Using Cultural Analysis to Improve Public Health Outcomes

Reflections on productively grappling with alterity in public health contexts

The current theoretical paradigm underpinning global public health initiatives frame undesirable health behaviors as a consequence of ignorance (Krumeich, 2001, 126). Such a framing implies that community health behaviors specialists seek to alter aren’t driven by a cultural logic that makes their health behaviors advantageous within their sociocultural context. When interventions that set out to “correct ignorance” through education fail, public health agencies often blame the failure on the local culture (Fairhead, 2016, 10). Culture in this context, becomes a reductionist explanatory crutch that obfuscates the rich interior logic driving health behavior (Fairhead, 2016, 10). The failure of these initiatives to produce desirable public health outcomes boils down to the ethnocentric logic that underpins their design. In a misguided liberalist attempt to bypass the human condition of difference, health initiatives inadvertently attempt to universalize Western “common sense” through education that bypasses the cultured sense-making devices of the local community (Fairhead, 2016, 10). The prevailing models of education in global public health ethnocentrically assume health behavior is driven by ignorance, rather than by a logical process of decision-making that suits the sociopolitical ecosystem individuals find themselves within. Within this landscape of ethnocentrism in public health, cultural analysis can serve as a corrective, sensitizing public health specialists to the intricate life worlds local populations inhabit. Through visibilizing the life world, cultural analysis reveals the sociopolitical landscapes that shape cultured sense-making. Using the case studies of AIDs prevention in South Africa and breast milk feeding in Dominica (Krumeich, 2001), I will demonstrate how cultural analysis can be mobilized to design successful public health interventions that reject ethnocentrism, engage local perspectives, and use the cultured sense of local populations as a motor to promote desirable health behaviors.

The condition of alterity is naturally prevalent in the field of global public health, where specialists often find themselves working with populations that do not share their same cultural background (Krumeich, et.al. 2001, 121). Within these conditions of difference, the pragmatic principle of cultural analysis is a useful framework for communicative exchange. Pragmatism as deployed in cultural analysis encourages public health specialists to frame community health behaviors as logical solutions to problems within a specific socio-cultural context (Fairhead, 2016, 25). In the case of Dominica, public health officials were faced with a population of mothers using infant formula more than breast milk (Krumeich, et.al. 2001, 124). Rather than seeing this health behavior as illogical, pragmatism encourages public health agencies to understand how this health behavior is advantageous in women’s lives (Fairhead, 2016, 25). Cultural analysis revealed that infant formula was integral to the maintenance of familial relationships in Dominica (Krumeich, et.al. 2001, 124). Men would use formula to publicly acknowledge paternity and affirm his relationship with the mother of his child (Krumeich, et.al. 2001, 124). For women, breastfeeding meant risking this acknowledgment of paternity (Krumeich, et.al. 2001, 124).With contextualization the rationality of using infant formula becomes clear. As a result of this analysis, local mothers suggested that linking breastfeeding to the cultural ideal of motherhood could make it appear as a choice that reaped social benefits similar to that of infant formula (Krumeich, et.al. 2001, 128). The case of this breastfeeding public health intervention in Dominica is an example of how cultural analysis can create public health initiatives that present certain health behaviors, such as breastfeeding, as desirable and pragmatic within the existing cultural logic.

Another theory that demonstrates the efficacy of cultural analysis is Clifford Geertz framework of ‘thick description’ (Geertz, 1973). When framing problems, contemporary public health agencies often engage in what Clifford Geertz refers to as ‘thin description’ (Geertz, 1973, 2). A ‘thin description’ simply explains a situation on the surface, providing no context revealing the meaning behind the actions described (Geertz, 1973, 2). An example of a thin description in the arena of public health is of the AIDs threat in South Africa where public health officials problem analysis was as follows: the local Xhosa and Zulu population are not using condoms to protect themselves against AIDs and STDs (Krumeich, et.al. 2001, 125).. With thin descriptions, there is a risk of casting local populations as irrational or without sense, because these thin descriptions erase the sense and meaning that shape the rejection of condom use. Using ‘thick description,’ cultural analysis reveals that condom use is disadvantageous for gender relations between Xhosa and Zulu men and women. For women, bringing up condom use to their partner could be interpreted as confrontational or as an admission of promiscuity, both of which could jeopardize her performance of femininity and hence her relationship with a man (Krumeich, et.al. 2001, 125). Furthermore, condoms prevent the possibility of pregnancy, which is also disadvantageous in a context where motherhood gives women prestige (Krumeich, et.al. 2001, 125). For men, using condoms interferes with the gendered responsibility of procreation and continuation of the clan (Krumeich, et.al. 2001, 125). ‘Thick description’ of condom health behavior illuminates the complexity of encouraging condom use in a context where condoms threaten to disrupt gender relations. Using the cultural analysis of condom use, local nurses suggested telling men that condom use could reduce STDs and lead to the continuation of a healthy clan (Krumeich, et.al. 2001, 128). In collaboration with the community, anthropologists and health specialists were able to devise a strategy of intervention that framed condom use as fulfilling masculine ideals (Krumeich, et.al. 2001, 128). The case of South Africa demonstrates how a successful health intervention uses cultural logic to make positive health behaviors appear desirable and advantageous to the local community. 

Cultural analysis is an essential component of public health initiatives, particularly in the context of global health where conditions of alterity necessitate robust pathways of cross-cultural exchange. As it stands, the current ethnocentric paradigm of global public health intervention views problematic health behaviors as devoid of rational logics (Krumeich, et.al. 2001, 126). Pragmatism, on the other hand, present health behaviors as rational and advantageous solutions within respective sociocultural contexts (Krumeich, et.al. 2001, 126). Rather than conceptualizing undesirable health behaviors as a product of irrationality or ignorance, public health specialists can use the pragmatic framework of cultural analysis to sensitize themselves to the cultured sense-making of local communities (Fairhead, 2016, 25). With knowledge of local sense-making, health agencies can motivate new health behaviors using arguments that appeal to the cultural logics of the population. Working within rather than against local logics is proven to lead to more success (Krumeich, et.al. 2001, 128), both in the implementation of initiatives as well as in cultivating an engagement that is enriching rather than pejorative and otherizing. Important to note however that cultural analysis doesn’t automatically safeguard against ethnocentric and otherizing interventions. In the case of Dominica or South Africa, if a health specialist were problematize the gender relations motivating health behavior, rather than work with the local gendered logics, the intervention would be operating with ethnocentric principles (Krumeich, et.al. 2001,128). Interventions in public health should seek to shift health behavior, but not cultural logics such as gender relations. A dialogical approach, as laid out by anthropologist Krumeich, helps ensure a mutually respectful encounter (Krumeich, et.al. 2001,128). Through the dialogical approach, an anthropologists’ cultural analysis is presented to the community and in collaboration with public health specialists the community suggests interventions that work within the sociocultural climate (Krumeich, et.al. 2001,128). With this approach, cultured sense-making is not problematized, rather it is used to motivate health behavior and these initiatives are also done in partnership with the communities. In the case of Dominica and South Africa, gender norms are not ethnocentrically “corrected” rather they are used to motivate the health behaviors public health specialists deem as advantageous. Ultimately, through applying cultural analysis in a dialogic approach with communities, public health initiatives will safeguard against ethnocentrism and create health interventions that attempt to work with, rather in dismissal of, local cultured logics.

Bibliography

Fairhead, James (2016) Understanding social resistance to the Ebola response in the Forest Region of the Republic of Guinea: An anthropological perspective, African Studies Review 59, 3: 7-31. 

Geertz, Clifford (1973). Thick Description: Towards an Interpretive Theory of Culture.

Krumeich, Anja. et.al. (2001) The benefits of anthropological approaches for health promotion research and practice. Health Education Research: Theory & Practice 16, 2: 121-130.