Nancy J. Burke

Theorizing Social Context: Rethinking Behavioral Theory

Major behavioral theories focus on proximal influences on behavior that are considered to be predominantly cognitive characteristics of the individual largely uninfluenced by social context. Social ecological models integrate multiple levels of influence on health behavior and are noted for emphasizing the interdependence of environmental settings and life domains. This theory-based article explains how social context is conceptualized in the social sciences and how the social science conceptualization differs from and can broaden the analytic approach to health behavior. The authors use qualitative data from the Behavioral Constructs and Culture in Cancer Screening study to illustrate our conceptualization of social context. We conclude that the incorporation into health behavior theory of a multidimensional socioculturally oriented, theoretical approach to social context is critical to understand and redress health disparities in multicultural societies like the United States.

Hepatitis B awareness, testing, and knowledge among Vietnamese American men and women.

Southeast Asians have higher rates of liver cancer than any other racial/ethnic group in the United States. Chronic carriage of hepatitis B virus (HBV) is the most common underlying cause of liver cancer in the majority of Asian populations. Our objectives were to describe Vietnamese Americans’ awareness of hepatitis B, levels of HBV testing, and knowledge about hepatitis B transmission; and to compare the HBV knowledge and practices of men and women. A community-based, in-person survey of Vietnamese men and women was conducted in Seattle during 2002. Seven hundred and fifteen individuals (345 men and 370 women) completed the questionnaire. Eighty-one percent of the respondents had heard of hepatitis B (76% of men, 86% of women) and 67% reported HBV testing (66% of men, 68% of women). A majority of the participants knew that HBV can be transmitted during sexual intercourse (71% of men, 68% of women), by sharing toothbrushes (67% of men, 77% of women), and by sharing razors (59% of men, 67% of women). Less than one-half knew that hepatitis B is not spread by eating food prepared by an infected person (46% of men, 27% of women), nor by coughing (39% of men, 25% of women). One-third of our respondents did not recall being tested for HBV. Important knowledge deficits about routes of hepatitis B transmission were identified. Continued efforts should be made to develop and implement hepatitis B educational campaigns for Vietnamese immigrant communities. These efforts might be tailored to male and female audiences.

Intention, Subjective Norms, and Cancer Screening in the Context of Relational Culture

Research targeting disparities in breast cancer detection has mainly utilized theories that do not account for social context and culture. Most mammography promotion studies have used a conceptual framework centered in the cognitive constructs of intention (commonly regarded as the most important determinant of screening behavior), self-efficacy, perceived benefit, perceived susceptibility, and/or subjective norms. The meaning and applicability of these constructs in diverse communities are unknown. The purpose of this study is to inductively explore the social context of Filipina and Latina women (the sociocultural forces that shape people’s day-to-day experiences and that directly and indirectly affect health and behavior) to better understand mammography screening behavior. One powerful aspect of social context that emerged from the findings was relational culture, the processes of interdependence and interconnectedness among individuals and groups and the prioritization of these connections above virtually all else. The authors examine the appropriateness of subjective norms and intentions in the context of relational culture and identify inconsistencies that suggest varied meanings from those intended by behavioral theorists.

Health care access and sociodemographic factors associated with hepatitis B testing in Vietnamese American men.

Chronic hepatitis B viral (HBV) infection greatly increases the risk for cirrhosis and hepatocellular carcinoma. HBV serologic testing is important for the identification of chronically infected individuals, who may benefit from antiviral treatment and regular monitoring for disease sequelae. Elevated rates of cirrhosis and hepatocellular carcinoma among Vietnamese American men can largely be attributed to high rates of chronic HBV infection. We surveyed 509 Vietnamese men aged 18–64 years in Seattle, Washington and examined sociodemographic and health care access factors associated with HBV serology testing. Nearly two-thirds (65%) reported past testing. The following were among those factors associated with HBV testing in bivariate comparisons: older age; short proportion of life in the US; low English fluency; private health insurance; identifying a regular source of medical care; reporting no long waits for medical appointments; and having access to interpreter services. The following were independently associated with HBV testing in multiple logistic regression analysis: older age; college education; low English fluency; private health insurance; having a regular medical provider; and reporting no long waits for medical appointments. Younger and less educated men, and those with difficulty accessing medical care may be at particular risk for never having had HBV testing. Programs to reduce HBV transmission and sequelae should make special effort to target these vulnerable Vietnamese Americans.

Social and Cultural Meanings of Self-Efficacy

This article describes the influences of social context on women’s health behavior through illustration of the powerful influences of social capital (the benefits and challenges that accrue from participation in social networks and groups) on experiences and perceptions of self-efficacy. The authors conducted inductive interviews with Latino and Filipino academics and social service providers and with U.S.-born and immigrant Latinas and Filipinas to explore direct and indirect influences of social context on health behaviors such as mammography screening. Iterative thematic analysis identified themes (meanings of efficacy, spheres of efficacy, constraints on efficacy, sources of social capital, and differential access to and quality of social capital) that link the domain of social capital with the behavioral construct perceived self-efficacy. The authors conclude that social capital addresses aspects of social context absent in the current self-efficacy construct and that these aspects have important implications for scholars’ and practitioners’ understandings of health behavior and intervention development.

Perceived Susceptibility to Illness and Perceived Benefits of Preventive Care: An Exploration of Behavioral Theory Constructs in a Transcultural Context

This article describes how the social context of transculturation (cultural change processes) and transmigration (migration in which relationships are sustained across national boundaries) can directly influence use of mammography screening. The authors conducted semistructured interviews with Latino and Filipino academics and social service providers and with U.S.-born and immigrant Latinas and Filipinas to explore direct and indirect influences of social context on health behavior (Behavioral Constructs and Culture in Cancer Screening study). Iterative analyses identified themes of the transcultural domain: colonialism, immigration, discrimination, and therapeutic engagement. In this domain, the authors examine two key behavioral theory constructs, perceptions of susceptibility to illness and perceptions of benefits of preventive medical care. The findings raise concerns about interventions to promote mammography screening primarily based on provision of scientific information. The authors conclude that social context affects behavior directly rather than exclusively through beliefs as behavioral theory implies and that understanding contextual influences, such as transculturation, points to different forms of intervention.

‘Honoring tradition, accepting new ways’: development of a hepatitis B control intervention for Vietnamese immigrants

Background. Chronic hepatitis B infection rates among Vietnamese‐American adults range from 7 to 14%. Carriers of HBV are over 200 times more likely to develop liver cancer than non‐carriers, and Vietnamese males have the highest liver cancer incidence rate of any ethnic group in the USA (41.8 per 100,000). Culturally and linguistically appropriate interventions are necessary to increase hepatitis B knowledge, serologic testing, and vaccination rates among Vietnamese immigrants. Methods. The authors engaged in qualitative data collection to inform the development of intervention materials including a video, pamphlet, and barrier‐specific counseling guidelines. Bilingual research assistants conducted 25 open‐ended qualitative interviews and six focus groups focusing on hepatitis B and liver cancer with a convenience sample of Vietnamese‐American men and women living in the Seattle area. Results. Qualitative findings include beliefs about liver illness and health influenced by traditional Vietnamese and traditional Chinese medicine theory; beliefs about hepatitis B transmission and causes embedded in personal experiences and socio‐historical circumstances; and the value of health and a positive attitude. The video portrays a Vietnamese immigrant family struggling with the new knowledge that their healthy‐appearing son is a hepatitis B carrier. Print materials address knowledge resources and misconceptions about hepatitis B revealed in the qualitative data. Discussion. Qualitative research provides valuable insight into unanticipated issues influencing health beliefs and behaviors relevant to specific populations and is essential to the development of effective health education materials, which necessarily draw upon local social and cultural contexts. The methods used in this study to develop culturally informed hepatitis B intervention materials for Vietnamese‐Americans translate well for the development of education outreach programs targeting Vietnamese and other immigrants elsewhere.

Slow Research: Thoughts for a Movement in Global Health

Slow research, like slow food, is good for health.The impetus for this article arises from a shared desire for rethinking our approach to Global Health. The field of Global Health, arising from the...

Knowledge about Cervical Cancer Risk Factors, Traditional Health Beliefs, and Pap Testing Among Vietnamese American Women

AbstractIntroduction: The objective of this paper was to examine knowledge about cervical cancer risk factors and traditional health beliefs in relation to Papanicolaou (Pap) testing among Vietnamese women. Methods: A population-based survey was conducted in Seattle (n<352, response rate=82%) during 2002. Results: The proportions of women who knew that older age, not getting regular Pap tests, and Vietnamese ethnicity are associated with an elevated cervical cancer risk were only 53%, 62%, and 23%, respectively. The majority (87%) incorrectly believed poor women’s hygiene is a risk factor for cervical cancer. Approximately two-thirds (68%) of the women had received a Pap test during the preceding three years. Knowing that lack of Pap testing increases the risk of cervical cancer was strongly associated (p<0.001) with recent Pap smear receipt. Conclusion: Our results confirm that Vietnamese women have lower levels of cervical cancer screening than non-Latina white women. Intervention programs addressing Pap testing in Vietnamese communities should recognize women’s traditional beliefs while encouraging them to adopt biomedical preventive measures into their daily lives.

Culture: The missing link in health research

Culture is essential for humans to exist. Yet surprisingly little attention has been paid to identifying how culture works or developing standards to guide the application of this concept in health research. This paper describes a multidisciplinary effort to find consensus on essential elements of a definition of culture to guide researchers in studying how cultural processes influence health and health behaviors. We first highlight the lack of progress made in the health sciences to explain differences between population groups, and then identify 10 key barriers in research impeding progress in more effectively and rapidly realizing equity in health outcomes. Second, we highlight the primarily mono-cultural lens through which health behavior is currently conceptualized, third, we present a consensus definition of culture as an integrating framework, and last, we provide guidelines to more effectively operationalize the concept of culture for health research. We hope this effort will be useful to researchers, reviewers, and funders alike.