Author: Cartwright, Brenda Y
Date published: April 1, 2010
Journal code: PJRE
In an increasingly diverse society, one of the many challenges that confront rehabilitation counselors is understanding the association between health beliefs and health-related behaviors. This is particularly significant since beliefs about the cause of illness appear to be important determinants of health-related behaviors (e.g., strategies for self-care, treatment and health-seeking).
There has been a growing interest in research focused on people's views about illness in health psychology, anthropology and sociology over the last two decades (Affleck, Tennen, Croog & Levine, 1987; Cope, David, & Mann, 1994; de Valle & Norman, 1992; Fortune, Richards, Main, & Griffin, 2000; Hodgetts & Chamberlain, 2000; Michela & Wood, 1986; Shiloh, RashukRosenthal & Benyamini, 2002; Taylor, Lichtman & Wood, 1984; Weinman, Pétrie, Sharpe, & Walker, 2000. Helman (as cited in Fung & Wong, 2007) identified four domains into which most people attribute as causes of illness (1) factors within the individual, such as their habits, behaviors, emotions and heredity; (2) factors within the natural environment, including the weather, pollution, bacteria and germs; (3) factors caused by the actions of others, such as interpersonal stress, catching illnesses from others and the careless actions of others; and (4) supernatural factors, including God's punishment, destiny and karma, as well as sinful thoughts, witchcraft, the Evil Eyes and hexes, or any disruption in balance or harmony of the person or his/her surroundings. On the whole, research indicates that people tend to attribute illness to the first domain (i.e., natural factors, including poor diet, smoking, alcohol use, lack of exercise, stress, weight, heredity).
One area of special interest within this research domain is the view that individuals from racially, ethnically and linguistically diverse groups tend to attribute illness to the fourth domain (i.e., supernatural) as well as natural factors. For example, Specter's (as cited in Valdez, 2001) research findings indicated that among Hispanics, illness is believed to be caused by an imbalance in a person's body (i.e., disease of hot and cold, dislocation of body parts or organs, diseases of magic or supernatural causes, diseases of emotional origin and envy. Nguyen and Rosengren (2004) found that Vietnamese-American children and adults tend to use and endorse both biological and magical explanations for illness. These findings supported Yee and Weaver's (1994) previous research involving individuals from culturally diverse groups. For example, among Latino/a Americans, illness is often ascribed to upsetting emotions, such as shame, disillusionment, anger or envy. In the African American culture, natural causes of illnesses are often attributed to ingesting impurities, following inappropriate diet, or exposing oneself to cold air. Additionally, Yee and Weaver noted that African American elders may delay or not seek help because they believe they cannot do anything about illness caused by "thin blood." A prevalent view among Native Americans is the belief that illness results from disharmony between the person, nature and the universe. Similarly, many Asian Americans believe that illness results from a state of disequilibrium between man, society and the cosmic forces of the universe, while many Native Hawaiians consider illness a punishment for wrongdoing (Yee & Weaver).
Guidance for the current study was provided by Landrine and Klonoff (1994) who conducted one of the first empirical studies investigating cultural diversity in causal attributions for illness. Based on their review of anthropological, sociological, and psychological literature, these researchers (1992) were concerned whether free-form methodologies asking participants to generate causes would inhibit People of Color to volunteer their belief in supernatural causes to researchers, who were informed by Western cultural traditions and were likely to view such attributes as "superstitious." Therefore, Landrine and Klonoff examined whether a change from the customary free-form surveys was warranted with participants from culturally diverse groups. These researchers conducted a two-part study, in which the first part elicited participants' views on the causes of illness and ratings of importance. The second part provided a list of both supernatural and natural causes for the research participants to rate in terms of their importance. Their study included 149 participants, of which 79 were European Americans and 70 were People of Color (i.e., 35 African Americans, 23 Latino/Latina Americans, and 12 Asian/Pacific Islanders).
As predicted, when asked to generate and rate causes of illness in terms of importance, no significant differences were found between European Americans and People of Color in terms of the number or type of cause generated, nor in the importance rating assigned. However, when these same participants were provided with a list consisting of both natural and supernatural causes to rate in terms of importance, People of Color endorsed and rated supernatural causes significantly more important than did European Americans.
The landmark Surgeon General's Report (Office of the Surgeon General, 2001) highlights the disproportionate service delivery outcomes among individuals from culturally diverse groups across the nation. Additionally, research findings indicate the mental health service outcomes among clients from culturally diverse backgrounds were less than those provided to European Americans in vocational rehabilitation programs over the past two decades (Atkins & Wright, 1980; Wilson, 2000; Wilson, Harley & Alston, 2001). Given these findings, it is imperative that rehabilitation counselors become better informed and develop skill sets necessary to integrate both their clients' and their own cultural backgrounds and beliefs into the vocational rehabilitation process. This line of inquiry may assist rehabilitation counselors to acknowledge the significant role that health beliefs play in shaping clients' health-related decisions and behaviors. Moreover, understanding the precursors to health behaviors can assist these professionals to: (1) work more effectively, ethically and respectfully with clients, (2) improve health and treatment outcomes, and (3) increase quality of life among all populations in an increasingly multicultural U.S. society.
This research expanded the diversity of the cultural groups used to validate Landrine and Klonoff 's (1994) study. The author investigated cultural differences in causal attribution for illness and examined the extent to which participants (i.e., African Americans, Asian Americans, Latino/Latina Americans, Native Americans, Native Hawaiian and other Pacific Islanders) are inhibited from expressing their beliefs in supernatural attributions for illness.
As in Landrine and Klonoff 's study, it was hypothesized that (1) there would be no significant differences among participants in the type and rating of importance when asked to generate their own ideas about the causes for illness, and (2) there would be significant differences in ratings of importance assigned to supernatural causes among People of Color, when provided with a list that included both natural and supernatural causes.
After obtaining approval from the host institutional review board, this researcher utilized purposive sampling methods. Electronic message requests were sent to targeted institutions (i.e., Historically Black Colleges and Universities [HBCUs], universities serving large numbers of Native Hawaiians and other Pacific Islanders and Latino/Latina students) and listserves (i.e., National Association of Multicultural Rehabilitation Concerns [NAMRC], Consortia of Administrators for Native American Rehabilitation [CANAR]) to invite participation of a culturally diverse sample. Since this research was web-based, the traditional response rate used for paper-pencil surveys is not applicable.
A total of 226 volunteers participated in this study. The gender distribution of the sample included 179 (79.2%) women, including 123 People of Color and 56 European Americans, and 46 (20.4%) men, of which 36 were People of Color, and 10 were European Americans.
Respondents ranged from 1 8 to 60+ years in age. Forty-eight (21.2%) were of traditional college ages 18-22, (i.e., 26 People of Color, 22 European Americans), and 178 (78.8%) were older (i.e., 23-60+ years of age), of which 134 People of Color and 44 were European Americans. One-hundred sixty (70.8%) respondents were People of Color, including 50 African Americans, 37 Native Hawaiians and other Pacific Islanders, 25 Asian Americans, 1 1 Native Americans, 7 Latino/Latina Americans, and 30 from other groups. Sixty-six (29.2%) participants indicated they were European Americans.
Educational level ranged from high school to graduate degrees. The majority were highly educated with 32.3% (i.e., 40 People of Color, 33 European Americans)reported having some college, while 27.4 % (i.e., 50 People of Color, 12 European Americans) had earned graduate degrees. Among the respondents 35.8% reported annual incomes of $50,000, or more (i.e., 56 People of Color, 25 European Americans), while 20.8% (i.e., 25 People of Color, 22 European Americans) reported earnings between $35, 001 and $50, 000 per year.
Among those identifying religious affiliations, 23.9% were Protestant (i.e., 92 People of Color, 34 European Americans) 21.7% Catholic (i.e. 26 People of Color, 24 European Americans); 3.5% Buddhist (i.e., 8 People of Color, 0 European Americans), 2.7 %Agnostic (i.e., 5 People of Color, 1 European American), .9% Jewish (i.e., 1 Person of Color, 1 European American), and 41.6% reported other affiliations (i.e., 16 People of Color, 6 European Americans). About 4.4% did not identify religious affiliation (i.e., 9 People of Color, 0 European Americans).
Recipients of the electronic messages were offered the opportunity to visit this researcher's webpage for access to a welcome letter and the online Perceptions of Illness (POI) Survey. The welcome letter described the purpose of the study, ensured anonymity and voluntary participation, and informed potential participants that by completing the questionnaire, they were providing informed consent to participate. Completed surveys were submitted as an email attachment from "Nobody."
The POI Survey requested demographic information, and consisted of a two-part questionnaire. In the first part, participants were instructed to list the things that they personally believed cause illness or caused people to get sick. Then, participants were instructed to rate each of these causes on a likert scale that ranged from 1 (not at all important) to 7 (extremely important). The second part of the questionnaire provided participants with 37 possible causes of illness, including a wide range of interpersonal, intrapersonal or natural, and supernatural causes as used in Landrine and Klonoff 's (1994) study. Participants were instructed to rate these researcher-provided causes in terms of how important they personally believed the causes serve as attributions of illness. These ratings were presented on the same 7-point likert scale.
Two research assistants independently coded participants' freely-generated causes into 15 categories with a 98.9% inter-rater agreement. These categories were similar to those found in reviewed studies and included stress, lack of exercise, lack of rest, virus/bacteria, genetics, emotions, diet, environment, status, weight, supernatural, alcohol/substance use (i.e., smoking, drug use, drinking), hygiene, relationships, and other.
To address the first hypothesis, there would be no significant differences among participants in the type and rating of importance when asked to generate their own ideas about the causes for illness, a MANOVA analysis was run to assess racial/ethnic differences in the importance ratings assigned to the respondents' own generated causes. Since concerns were raised about the possibility that some of the differences in Landrine and Klonoff 's (1994) study related to demographic variables (i.e., gender, age, religion) may have been spurious, differences among these variables were not assessed in this study.
To address hypothesis two, there would be significant differences in ratings of importance assigned to supernatural causes among participants when provided with a list of causes, researcher-provided causes were first factor analyzed using a principal-components analysis with an oblique rotation for simple factor loadings and to observe whether the factors/principal components could be legitimately considered correlated . Factors were retained with an eigenvalue > 1 .00, and items were retained on a factor if the loading was > 0.5 for stronger congruent validity with common variance of 25%, with the exception of three items loading at 0.4 and sharing a common variance of 16%. The resulting factors were categorized somewhat differently from those in Landrine and Klonoff 's (1994) study. Specifically, in the earlier study, the eight factors were categorized as Supernatural, Interpersonal stress, Lifestyles, Personality, Chance, Substance Use, Natural and Weather, while factors in this study were categorized as Supernatural, Personality, Lifestyle, Susceptibility and Relations. These five factors rather than the 37 variables were used as dependent variables in the analysis of possible differences in causal attributions for illness.
MANOVA analyses were performed for racial/ethnic differences on the researcher-provided causes as in the Landrine and Klonoff (1994) study. For each participant, a total score for each of the factors was calculated by adding the ratings the participant had assigned to each cause loaded on that factor.
Participants generated an average of six causes of illness. Similar to findings in the Landrine and Klonoff (1994) study, the most frequently generated causes were diet (61.9%), alcohol/substance use (59.7%), stress (53.1%), environment (48.2%), virus/bacteria (47.8%), genetics 39.4%, lack of exercise 36.3%), and emotions (28.3%). Unlike Landrine and Klonoff's study, causes generated by large percentages of the sample rated as most important (mean importance rating on a 7-point scale) included diet (3.92), alcohol/drug use (3.80), stress (3.38), virus/bacteria (2.95), environment (2.90), and genetics (2.35).
A MANOVA analysis was run to assess racial/ethnic differences in the importance ratings that participants assigned to their own generated causes. As hypothesized, when participants were asked to generate their own causes of illness and to rate them in terms of their importance, no racial/ethnic differences emerged [F (15,210) = .663, ? = .819)].
The results of the factor analysis of the 37 causes provided by this researcher are shown in Table 1 . Five factors accounting for 62.3% of the variance emerged.
Each of the variables is clearly loaded on a single factor. Further, each of the five factors shows satisfactory discriminant validity. The proportion of variance shared between the supernatural and personality factors is approximately 1 .2% (r = 0. 1 1 ). The correlation between the supernatural and lifestyle factors is 0.04 with practically zero common variance between the two factors. The supernatural factor is correlated with the susceptibility and relations factors at r = 0.27 and r = 0.41 respectively, with about 7.3% and 16.8% of the variance in common.
The proportion of shared variance between personality and lifestyle is approximately 5.3% (r = 0.23). Personality is correlated with susceptibility at 0.05, suggesting that the two factors are independent of each other. The correlation between personality and relations is 0.23, with about 5.3% of the variance shared.
The correlation between lifestyle and susceptibility is 0.36, indicating only 1 .3% of the variance is shared between the two factors. Susceptibility is correlated with the relations factor at 0.26 with approximately 7% of the variance shared in common.
Finally, the correlation between the susceptibility factor and the relations factor is 0.17 with about 3% of the variance in common. As shown in Table 2, the inter-correlations are low enough for the factors to be considered distinct.
As predicted, racial/ethnic differences in causal attributions on the Supernatural factor emerged. The mean total score on each of the five factors for both People of Color and European Americans are shown in Table 3.
To compare findings with those of Landrine & Klonoff (1994), a MANOVA analysis was conducted. The omnibus F was significant with 6% of the generalized multivariate variance attributable to racial/ethnic differences [F (5,220) = 3.06, ? = .011, ? + 0.94]; the supernatural factor was the only significant factor [F (1, 225) = 12.298, ? = .001]. Subsequent analysis with t-tests was significant only on the supernatural factor (t = 3.51, ? = .001, 95% CI: 4.14, 14.75) indicating that the mean for People of Color is significantly higher than the mean for European Americans.
The results of this study resonate with those found by Landrine and Klonoff (1994). First, the methodological approach used to assess causal attributions for illness may have in part, influenced the nature of the results. In the first part of the survey, neither People of Color nor European Americans generated supernatural causes. Yet when provided a list that included supernatural causes in the second part of the survey, both People of Color and European Americans rated these causes as important. These differences suggest that culture may influence free-form versus forced choice survey behavior. Perhaps, future research on health beliefs may necessitate a change in methodology to obtain more accurate data from participants, particularly members of culturally diverse groups.
Second as predicted when provided a list of causes including both natural and supernatural causes, People of Color were more likely to attribute greater importance to supernatural causes for illness than did European Americans. These findings suggest there was considerable diversity in causal attributions for illness. It is important to note that large percentages of college-educated participants from culturally diverse groups in this study endorsed supernatural causes, therefore suggesting the possibility that such beliefs may be largely independent of education.
Given that most respondents reported affiliations with varied religions, future research should also address the roles that spirituality and personal religious beliefs about coping may have on health beliefs of individuals from culturally diverse groups in this country. Further, variations exist among immigrants as well as People of Color who were born in this country in their attempt to socialize to Western ways and assimilate or retain traditional health values, beliefs and practices. Therefore, future studies should give consideration to the role that acculturation and assimilation may have on perceptions related to causal attributions of illness.
The study is limited by it the sample size. The small numbers of participants within each culturally diverse group did not permit an analysis of the variability within and among these groups. Future research with larger samples would permit comparisons to strengthen the generalizability of results. A further limitation is related to the sample's representativeness. Findings in this study were based largely on college educated female respondents. Samples of males and individuals with less education may possibly yield different results. Selection bias may have also influenced the results, particularly since individuals who chose not to participate in this study may have responded differently. Despite sampling limitations, the results from this study add to the body of knowledge examining beliefs about causes of illness as mediators of health-related behaviors in a cultural context
Hopefully, this research has expanded rehabilitation counselors' thinking about how beliefs may influence health- related behaviors, particularly those of clients' from culturally diverse groups. To assist counselors to work more effectively, ethically and respectfully with these clients, specific guidelines are offered. These guidelines are based on the Association for Multicultural Counseling and Development (AMCD) multicultural competencies (Arredondo et al., 1996) which integrate multicultural and culture-specific awareness, knowledge and skills into interpersonal counseling interactions.
First, rehabilitation counselors must recognize how their own beliefs and assumptions about human behavior may be reflected in their counseling and work with clients from culturally diverse groups. Counselors cannot afford to allow their biases, worldviews, and values interfere with their ability to work with their clients.
Second, rehabilitation counselors must actively attempt to understand the worldviews of clients from cultures other than their own and accept the differences as equally legitimate perspectives. Greater attention should also be given to acknowledging the significance that health beliefs have in shaping lifestyles and health-seeking behaviors which ultimately impact health care and service outcomes among clients from culturally diverse groups. Rehabilitation counselors should encourage their clients to talk about their health beliefs, values and practices. For many of these individuals, an encounter with their counselors may be their first opportunity to share fears and concerns about their illness or disability. This sharing process can offer the opportunity to understand clients' distrust and fears about medical systems, their level of knowledge about being vulnerable to illnesses, their attitudes about seeking information, engaging in preventive practices and turning to others for help. This sharing of valuable information not only enhances the communication process, it ultimately assists in promoting health behavior changes for these clients.
Third, rehabilitation counselors should actively develop and practice appropriate, relevant, culturally-sensitive strategies and skills in working with clients from culturally diverse groups. Rehabilitation counselors must work together with their clients to identify mutually acceptable goals and enhance overall outcomes. This includes engaging in service delivery and consultative practices with family members, traditional healers, religious and spiritual leaders, as well as practitioners.
The author thanks Judy Daniels, Michael D'Andrea, Bob McConnell, Pina Lemusu, Mia Sutter, Shuqiang Zhang, and Paul Kingery for their support and assistance.
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Brenda Y. Cartwright
University of Hawaii at Manoa
Brenda Y. Cartwright, EdD, Department of Kinesiology & Rehabilitation Science, College of Education, University of Hawaii at Manoa, 1337 Lower Campus Road, PE/A 217, Honolulu, HI 96822.