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This article was downloaded by: [Temple University Libraries] On: 21 November 2014, At: 20:11 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Mental Health, Religion & Culture Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cmhr20 Cross-cultural differences in explanations for health and illness: A British and Ugandan comparison Adrian Furnham a & Peter Baguma b a Department of Psychology , University College London , b Department of Psychology , Makerere University , Published online: 08 Nov 2007. To cite this article: Adrian Furnham & Peter Baguma (1999) Cross-cultural differences in explanations for health and illness: A British and Ugandan comparison, Mental Health, Religion & Culture, 2:2, 121-134, DOI: 10.1080/13674679908406341 To link to this article: http://dx.doi.org/10.1080/13674679908406341 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions

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Page 1: Cross-cultural differences in explanations for health and illness: A British and Ugandan comparison

This article was downloaded by: [Temple University Libraries]On: 21 November 2014, At: 20:11Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,37-41 Mortimer Street, London W1T 3JH, UK

Mental Health, Religion & CulturePublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/cmhr20

Cross-cultural differences in explanations for healthand illness: A British and Ugandan comparisonAdrian Furnham a & Peter Baguma ba Department of Psychology , University College London ,b Department of Psychology , Makerere University ,Published online: 08 Nov 2007.

To cite this article: Adrian Furnham & Peter Baguma (1999) Cross-cultural differences in explanations for health and illness: ABritish and Ugandan comparison, Mental Health, Religion & Culture, 2:2, 121-134, DOI: 10.1080/13674679908406341

To link to this article: http://dx.doi.org/10.1080/13674679908406341

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) containedin the publications on our platform. However, Taylor & Francis, our agents, and our licensors make norepresentations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions and views of the authors, andare not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon andshould be independently verified with primary sources of information. Taylor and Francis shall not be liable forany losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoeveror howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use ofthe Content.

This article may be used for research, teaching, and private study purposes. Any substantial or systematicreproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Page 2: Cross-cultural differences in explanations for health and illness: A British and Ugandan comparison

Mental Health, Religion G, Culture, Volume 2, Number 2, 1999 121

Cross-cultural differences in explanations for health and illness: a British and Ugandan comparison

ADRIAN FURNHAM' & P E T E R BAGUMA2 'Department of Psychology, University College London; 'Department of Psychology, Makerere University

ABSTRACT Two groups of student particapants-one from Great Britain, the other Uganda- completed a four-pan questionnaire on lay perceptions of current and future health, the causes of illness, and the nature of recove y. Demographic differences between the two groups, totalling 335 subjects in all, were co-varied out statistically. As predicted the most consistent and strongest difference between the groups was the Ugandans' belief that supernatural factors influenced their health to a limited extent, while the British believed this factor to be irrelevant to current and future health status. The other major difference between the groups indicated that the Ugan- dans, more than the British, rated the importance of Western medicine as a contributor to their current and future health. The results could be explained by the main causes of mortality and the health services available in the two countries. Limitations of studies such as this are discussed.

Introduction

Over the past twenty years there has been a considerable increase in cross- cultural studies of health and illness attributions and beliefs (Airhihenbuwa, 1995; Chalmers, 1996; Helman, 1989; Kleinman, 1980; Landrine & Klonoff, 1992, 1994; Williams & Jackson, 1997). Medical anthropologists and sociolo- gists have been working in this area for many years, but it is not until comparatively recently that cross-cultural and medical psychologists have at- tempted this research from their particular perspective and methodological preference. Young (1993) argued that beliefs about sickness and health persist in a society because people find them useful in deciding on a course of action to arrest, reverse, moderate or prevent illness and exculpating the putatively sick from the stigma of deviance. He argues that the content and organisation of health beliefs are the product of biophysical and cultural realities and it is culture that determines which particular physical signs are selected and ignored. This study is a cross-cultural extension of studies done by Furnham (1994) aimed at examining the difference in health beliefs in developed and developing countries.

~ ~~

Correspondence to: Prof. Adrian Furnham, Department of Psychology, University College London, 26 Bedford Way, London WCl, UK.

1367-4676/99/020121-14 0 1999 Taylor & Francis Ltd

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122 Adrian Furnham Cj. Peter Baguma

Lay health beliefs are complex and are fairly coherent and stable over time (Furnham, 1988; Fumham & Kirkcaldy, 1996). These health beliefs can be highly idiosyncratic being derived and adapted from a wide variety of sources. Cross-culturally specific health beliefs often reflect particular social, economic and political circumstances (Fitzpauick, 1984). Yet these beliefs form a ‘sys- tem’, in the sense that they are interconnected to other non-illness-related beliefs, and also because they are connected to the beliefs of other people in the community (Furnham, 1988).

Fitzpatrick (1 984) has also stressed the importance of cultural determinants of lay concepts of illness. They demonstrated the survival of forms of explana- tions of illness quite different from those found in Western medicine. Cultural factors influence the perception, labelling and explanation of illness (Herzlich, 1979). These health beliefs form part of the more general system of beliefs that provide a ‘coherent philosophy of misfortune’. People in the West apparently seek out explanation for illnesses, such as disease, environment factors, and stress, much more than people in non-Western societies (Lewis, 1993). Whilst there is evidence that there may well be interesting and subtle differences between the health beliefs of people from different developed Western countries (e.g. France and Britain), it is much more likely that the differences are much more apparent between those in developed countries and those in the poorer, less-developed Third World countries (Young, 1993).

Landrine and Klonoff (1994) in a review of causal attributions for illness in African, Asian and Latin-Americans found illness is often attributed to super- natural variables. They argue that belief in the primacy of supernatural causes may ‘account for the multitude of ethnic differences in health-related behaviour’ (p. 182). In their questionnaire subjects were required to rate the importance of 37 possible causes of illness which factor analysis reduced to eight interpretable factors: supernatural, interpersonal stress, lifestyles, personality, chance, sub- stance use, natural and weather. The only significant difference they found between whites and ‘people of colour’ was on the supernatural factor.

Others have stressed underlying similarities between cultures. Thus Snow (1974) in a study of the health beliefs of poor women from various ethnic minorities in Arizona compared her results to the working-class British patients studied by Helman (1989). She found that while it seemed the case that women from ethnic minorities held more beliefs about supernatural forces influencing health, compared to the British samples, there were more similarities than differences, in that both groups regarded themselves as vulnerable and in need of help from a healer.

Furnham (1994) found religious and political beliefs, but more noticeably attitudes to alternative medicine, to be related to lay beliefs about health and illness. Clearly, religious beliefs relate to how people think about health and illness (Furnham, 1990). Socio-religious and medical beliefs are clearly closely related and culturally determined (Helman, 1989). Actual experience of ortho- dox, Western medicine (as well as more traditional therapies) is to a large extent determined by the country in which one lives and its relative wealth. Statistics

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Cross-cultural di#erences in health and illness 123

show many differences between countries in the number of (Western medicine) trained doctors per 1000 in the population. Similarly, statistics on life expect- ancy shows high gaps between, for example, Americans and British (both 70 years) and Nigerians and Ugandans (both 53 years) (The Economist, 1993). It may well be that where medical resources are scarce they are particularly valued and thought of as more important to preserving and restoring health than when they are more available to ordinary people.

A questionnaire, originally devised by Stainton Rogers (1991) to be used within a Q-factor analytic approach, was subsequently adopted by Furnham (1 994) for use within a conventional factor analytic approach. Stainton Rogers devised the IHI (Influences on Health and Illness) questionnaire using inputs from a number of individual and group interviews, from media analysis of novels, popular magazines and television programmes, and from a wider range of other sources including psychometric instruments such as the MHLC (Wall- ston et al., 1978). It is a questionnaire with 4 parts and 124 questions, based on the argument that people may well explain health and illness differently in different interpersonal contexts: what determines one’s present state of health; and on what affects the speed and likelihood of recovery. This questionnaire was adopted for the present study because of its comprehensiveness and the compre- hensibility of its language. Further, because the factor analytic study by Furn- ham (1 994) revealed such clear and replicated factors, these factor scores (rather than individual items) were used in the analysis of this study.

The Q-factor analytic method used by Stainton Rogers is a variant of conventional factor analysis, based on the work of Stephenson (1935). It reverses the orientation in which data are entered into the analysis, with each subject’s responses entered into a column, rather than across a row. In this way, the factor analysis treats each person’s responses as a whole, integrated pattern of response and ‘compares it with the response patterns of all the other subjects in the study. The factors which emerge from this analysis thus consist of a number of orthogonally statistically independent alternative patterns of re- sponse. Her data were quite different from those subsequently produced in Fumham’s (1994) study and cannot be compared with them. Furnham’s psychometric study, however, based on data from 338 subjects and using conventional factor analysis was able to provide evidence of internal reliability, context and concurrent validity of the IHI scale.

This study compared the health and illness beliefs of two groups-one from the First World (Great Britain) and the other from the Third World (Uganda). Previous work comparing equivalent samples from these countries indicated that subjects had no difficulty completing and understanding questionnaires devel- oped in the West (Furnham 81 Baguma, 1994), though there are always problems with both equivalence of meaning and stylistic answer sets (i.e. yea-saying). This study focused exclusively on cultural differences in health beliefs. From the above research it was predicted that, compared to the British sample, the Ugandans would rate orthodox, Western medical treatment and supernatural powers (God’s will, a curse) as more important in the cause of

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124 Adrian Fumham & Peter Baguma

TABLE 1. Details of the participants

British Ugandan F level ( N = 195)’ (N= 140)’ x2

Sex

Age Marital Status

Education 1. Have you ever visited

a complementary practitioner?

2. How ill are you at the moment?

3. Have you ever been seriously ill?

Male Female

Single Married Years Yes No

Not at all (1) Yes No

35% 66% 65% 35% x2 = 40.32b

26.91 years 25.14 years F(1,334) = 6.42 48% 83% x2 = 42.72b

13.14 13.51 F(1,335) = 1.31 41% 38% x2 = 3.1 1 59% 62%

52% 17%

1.69 2.11 F(1,335) = 13.01b 37% 68% x2 = 30.87b 63% 32%

‘Numbers do not always add up to the total because of missing data. bChi-square results yield a different statistic, but similar patterns of significance.

current and future health and illness. It was predicted that these differences would be found in all four parts of the questionnaire. Specifically, it was predicted from Landrine and Klonoffs (1992, 1994) work that Ugandans would see supernatural, religious and fatalistic factors as more powerful in affecting aspects of their current and future health more than the British.

Method

Participants

There were 335 participants in this study. Participants were students, and participant panel participants a t the University of London and a t Makerere University, Uganda. Both were fairly homogenous in terms of their ethnicity and mother tongue. Ugandan participants were all students at the premier university in the country. They were not asked to specify tribal allegiance, religion or mother tongue, though they were thought to be representative of the students on the campus. Certainly, they were all competent English speakers and among the elite of the younger people in the society. The British sample comprised about 80% white native British and 20% second generation immigrant British stu- dents. For over 90%, their mother tongue was English. Their details are given in Table 1.

Retrospectively it was recognised that it may have been a good idea to measure participants’ type and seriousness of recent illnesses and their percep- tion of the type, cost and availability of healthcare intervention required. Further the meaning of ‘complementary practitioner’ is likely to be quite different in the two cultures.

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Cross-cultural dzyerences in health and illness 125

It is true that neither group is really representative of their country as a whole, because they are a select group. Subjects were volunteers who partici- pated for no fee but were given feedback on the results. There was a very small refusal rate (less than 5%) and very few of the questionnaires were spoiled. The fact that both samples were probably better educated and from a higher socio-economic group than the population as a whole means that the probability of finding differences between the groups is probably reduced. Hence, cultural differences that emerge may be considered to be accentuated in the population as a whole.

Questionnaire

The IHI scale used in this study was derived from Stainton Rogers (1991) who was interested in explanation of responsibility and blame in health and illness and dissatisfied with existent health locus of control studies. The 124-item questionnaire is divided into four sections:

1. Subject perceptions of their current state of health (27 items). For example, ‘My current state of health is due to: My emotions; My body’s natural defenses; The weather ...’.

2. Subjects’ perceived ability to achieve better health in the future (31 items). For example, ‘My capacity to become healthier in the future is due to: God’s power and influence; Taking vitamins or a tonic, My age ...’.

3. Subjects’ perceptions of whether they will become ill or not (31 items). For example, ‘Whether or not I become ill is due to: Feeling unhappy; Stresshl conditions a t home; Lack of proper medical care ...’.

4. Subjects’ perceptions of the speed and likelihood of recovery when they are ill (35 items). For example, ‘When I am ill, how quickly and effectively I recover is due to: The virulence of the disease itself; Prayers said for me; The quality of any conventional medical treatment’.

Stainton Rogers’ items were obtained from a series of in-depth interviews and from other published tests. Each item was responded to on a seven-point agree-disagree scale where 7 = strongly agree; 1 = strongly disagree (participants were required to circle the appropriate number). The developed questionnaire was also tested on 83 British subjects where concurrent validity was ascertained along with its internal reliability. This questionnaire, which is the same used in this study, was run on 338 British participants by Furnham (1994).

Each of these questionnaire sections had been factor analysed (VARIMAX rotation) by Furnham (1994) who found a clear interpretable structure within each of comparable factors, which is described in great detail in that paper. The first part (27 questions on current state of health) factored into eight inter- pretable factors with an eigenvalue greater than 1.00 and which accounted for nearly 60% of the variance (see Table 2 for factor titles). The second part (31 questions on future health) also factored into eight interpretable factors ac- counting for two-thirds of the variance (see Table 3 for factor titles). The third

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126 Adrian Furnham & Peter Baguma

part (30 items on whether one is likely to become ill or not) factored into seven interpretable factors accounting for two-thirds of the variance (see Table 4 for factor labels). Finally, the fourth part (35 items on recovery) factored into seven interpretable factors that accounted for over two-thirds of the variance (see Table 5 for factor labels). Thus, although subjects completed all 124 differences between the groups, was analysed at factor level. As is common with factor analysis, not all the items loaded on the extracted factors and two loaded on more than one. In all, 116 items from the original 124 individual questions loaded on more than one. Furnham (1994) found that each factor had an acceptable alpha (all greater than 0.70). Analysis of these factor scores, rather than individual items, should help to reduce the possibility of making Type I1 errors in this study.

Procedure

The co-authors have collaborated on a number of projects and aimed to obtain relatively similar, representative samples as possible from their prospective universities (Fumham & Baguma, 1994). The first author posted the question- naires to the second author who ran the study in Uganda. All analyses were done in London.

Results

Each of the four parts of the questionnaire has been subjected to VARIMAX factor analysis (Fumham, 1994) and been shown to produce a replicable and interpretable pattern not dissimilar to that of Landrine and Klonoff (1994). Hence items were combined into sub-scale scores and the two national groups compared by ANCOVA co-varying out those demographic and attitudinal factors upon which they differed (i.e. sex, age, marital status, current illness, reported illness). This follows the analysis of Vincent and Fumham (1996) and Vincent et al. (1995). It is possible that some of these demographic differences (i.e. sex) interact with the medical belief systems, but for the purposes of this comparative study, they were partialled out. The focus of the study was cultural differences but participants differed on various demographic factors (e.g. age), unless these differences were controlled for it is not possible to separate the cause of any significant differences, e.g. were attitudinal differences a result of culture or age differences in participants. To focus exclusively on culture then the ANCOVA controlled for other important demographic differences in health beliefs.

Perceptions of the current state of health

The 27 items of this questionnaire fell into eight clear factors labelled emotional well-being (‘my emotions’; ‘inner forces of my psyche’), work-home inreflace (‘my working environment’; ‘the circumstances of my home life’); liferyle (‘my overall

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Cross-cultural differences in health and illness 127

TABLE 2. Mean score and ANCOVA F levels on the eight factors relating to current state of health

ANCOVA ‘My current state of health is due to ...’ British Ugandan (F level)

A. Emotional well-being (7-49)’ B. Work-home interface (5-35) C. Lifestyle (5-35) D. Constitution (3-2 1) E. Societal Factors (2-14) F. Fate (2-14) G. Environment (2-14) H. Supernatural powers (2-14)

~~

20.56 (2.93)b 23.04 (4.60) 27.22 (5.44) 13.07 (6.53) 11.17 (3.72) 6.15 (3.07)

3.93 (1.96) 7.55 (3.77)

20.32 (2.90) 23.34 (5.26) 27.76 (5.55) 13.16 (6.58) 13.41 (4.47) 5.64 (2.82)

6.41 (3.20) 9.11 (4.55)

2.41 1.03 1.13 0.98 14.96‘ 0.34 7.22‘ 44.14‘

‘Range of scores. bThe number in parentheses is not the standard deviation but the mean score of all the items loading on that factor. ‘p < 0.0 1.

lifestyle’; ‘taking good care of myself); constitution (‘the constitution with which I was born’); societal factors (‘the society in which we live’; ‘the culture within which I live’); fate (‘simple probability’; ‘good or bad luck’); environment (‘the weather’); and supernatural powers (‘whether there is somebody “ill-wishing” me or not’; ‘God or some other supernatural power’). A MANCOVA ( F = 4.13, p < 0.05) showed a significant difference between the two groups. Table 2 shows that there were three significant differences on the eight ANCOVAs. Compared to the British, the Ugandan subjects rated societal factors, the environment and supernatural powers, as more important in causing their current state of health. Notice from the mean score on each factor that both groups rated their constitution, lifestyle and work-home interface as the major determinants of their current health. Interestingly the Ugandans rated supernatural powers above both fate and emotional well-being as important factors in determining their health.

Perceived ability to achieve better health in the future

The 31 items in this part of the questionnaire also factored into eight clearly interpretable sub-scales; psychological factors (‘promoting a positive attitude’; ‘tackling any unresolved inner conflicts’); environmental factors (‘improvements in my home environment’); medical treatment (‘getting medical treatment’; ‘seeking out preventive medical services’); self-medication (‘taking vitamins at home’); 1ifetyZe (‘giving up unhealthy habits’); fate (‘simple probability’; ‘good or bad luck’); constitution (‘the constitution with which I was born’); and religious factors (‘God’s power of influence’; ‘any other supernatural influence’). A significant MANCOVA ( F = 8.99, p < 0.01) followed by eight ANCOVAs showed five of the eight factors yielded significant differences. The biggest

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128 Adrian Furnham & Peter Baguma

TABLE 3. Mean scores on ANCOVA F levels on the eight factors relating to capacity to becoming healthier-the future

‘My capacity to become healthier in the future is due to ...’

A. Psychological factors (5-35)’ B. Environmental factors (5-35) C. Medical treatment (5-35) D. Self-medication (321) E. Lifestyle (3-21) F. Fate (3-21) G. Constitution (4-28) H. Religious factors (2-14)

British

29.40 (4.15)b 22.54 (4.50) 19.32 (3.86) 12.51 (4.17) 15.02 (5.00) 10.74 (3.58) 15.66 (3.91) 3.89 (1.94)

Ugandan

28.07 (4.07) 25.94 (5.18) 27.10 (5.42) 14.15 (4.71) 16.54 (5.51) 10.94 (3.64) 17.42 (4.35) 6.82 (3.41)

ANCOVA (F levels)

1.03 1 1 .22‘ 56.55‘ 6.05d 3.55 0.16 6.48‘ 46.74‘

%nge of scores. bThe number in parentheses is not the standard deviation but the mean score of all the items loading on that factor. ‘ p < 0.00 1. dp<o.ol.

differences lay in the provisionaVavailability of medical treatment (Table 3) which was rated much more highly by the Ugandans followed by religious/ supernatural factors. This supports the main hypothesis in this paper. Environ- mental factors, self-medication and one’s constitution were also rated as more important by the Ugandans than the British subjects. Both groups rated lifestyle as the most important factor and religious factors the least, though they differed significantly on the latter.

Perception of whether one will become ill or not

The 31 items that made up this part of the questionnaire had seven sub-scales: stress (‘stres~ful, nasty and unsettling events in my life’; ‘rows with people at work’); poor treutment (‘uncaring or unsympathetic treatment by my doctor’); exposure (‘the virulence of infective organisms’); environment (‘working in a poor environment’; ‘exposure to harmful chemicals’); fate (‘simple probabil- ity’; ‘bad luck’); l$estyZe (‘adopting a lifestyle that is unhealthy’); and supernatural forces (‘a curse or ill-wishing’; ‘God’s will’). The MANCOVA on this seven- factor scale were statistically significant (F = 6.62, p < 0.01) and four of the six ANCOVAs were significant, though only two at the p < 0.00 1 level. Compared to the British, the Ugandans believed supernatural forces, poor medical treat- ment, the environment and exposure to infections, were more important in determining whether they will become ill or not. Lifestyle, exposure and environment were thought to be among the most important factors in prevent- ing illness.

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Cross-cultural differences in health and illncs:, 129

TABLE 4. Mean scores and ANCOVA F levels on the seven scales referring to hture illness ~ ~~

‘Whether or not I become ill is due to ,..’ British Ugandan ANCOVA (F level)

A. Stress (9-63)’ 38.99 (4.33)b B. Poor medical treatment (4-28) 16.54 (4.13) C. Exposure (4-28) 20.01 (5.00) D. Environment (4-28) 18.36 (4.59) E. Fate (5-35) 17.56 (3.51) F. Lifestyle (2-14) 10.75 (5.37) G. Supernatural forces (3-21) 5.21 (1.73)

38.68 (4.29) 21.24 (5.31) 21.63 (5.40) 20.62 (5.15) 15.97 (3.19) 10.25 (5.12) 9.33 (3.1 1)

1.41 39.61‘ 5.04d 7.52’ 0.22 1.93 53-24‘

‘Range of scores. bThe number in parentheses is not the standard deviation but the mean score of all the items loading on that factor. ~pc0.001. ‘p < 0.05. ‘p < 0.0 1.

Perception of the speed and likelihood of recovey

The 35 items concerning the perception of recovery had a seven-factor struc- ture. These were labelled medical treatment (‘the quality of medical treatment I received’); Zrj’estyZe (‘being careful about my day to day behaviour’); psychoZogicaZ factors (‘finding ways to make myself feel happier’); recovey factors (‘an environ- ment which is conducive to recovery’); religious factors (‘prayers said for me’; ‘God’s will’); supernatural forces (‘some other supernatural power’); and fate (‘good luck’). The MANCOVA on this final part of the questionnaire was also significant ( F = 3.10, p < 0.05). Three of the seven factors showed significant differences. Ugandans rated religious factors, supernatural forces and medical treatment as more important factors in causing recovery. Both groups rated lifestyle, medical treatment and recovery factors as the most important factors in determining recovery.

Higher order factor analysis

Given the overlap of questions and the similarity in emergent factors in each of the four sections in the questionnaire it was decided to perform a ‘high-order’ factor analysis of the 30 factor scores found in Tables 1-4. This would ensure a more parsimonious examination of the cultural differences. Because of the overlap in factors in parts 1-4 of the questionnaire, it is possible that various Type I1 errors occurred. Table 6 shows the seven factors that emerged from this analysis and which together accounted for 70% of the variance.

The seven factors that emerged are very clear. These factor scores were then arithmetically combined into a total score for each of the seven factors. Thereafter, an ANCOVA was performed on each, comparing the two cultural

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130 Adrian Furnham &.+ Peter Baguma

TABLE 5. Means and ANCOVA F levels for the seven sub-scales concerned with recovery

‘When I am ill, how quickly and effectively I recover is due to ...’ British Ugandan (F level)

ANCOVA

~~ ~

A. Medical treatment (5-35) B. Lifestyle (6-42) C. Psychological factors (5-35) D. Recovery factors (5-35) E. Religious factors (2-14) F. Supernatural forces (3-21) G. Fate (2-14)

24.56 (5.09)b 27.93 (5.58) 9.16‘ 32.12 (5.35) 31.66 (5.27) 0.15 22.91 (4.58) 22.52 (4.50) 0.5 1 26.05 (5.21) 25.66 (5.13) 1.68

5.16 (2.58) 9.26 (4.63) 57.79d 5.33 (1.77) 7.88 (2.63) 1 1.61d 5.99 (2.99) 6.16 (3.08) 0.85

“Range of scores. bThe number in parentheses is not the standard deviation but the mean score of all the items loading on that factor. Cp<O.Ol. dp<O.OOl.

groups. The first factor contains all religioudsupernatural factors and showed, as expected, that Ugandans rated them more highly. The second factor concerned psychological and emotional factors but showed no significant differences between groups. The third factor contained five lifestyle factors and the fourth ‘superfactors’ all the fate factors, but neither showed a significant difference between the two groups. The fifth factor concerning medical treatment showed a large difference between the groups with Ugandans rating this more highly. Similarly the Ugandans rated the environment as more important than Britons. There was also a marginally significant difference on the role of personal constitution in leading to health with the Ugandans rating this slightly more highly. However, given the number of analyses performed, it is probably only safe to interpret significant differences at p < 0.001.

Discussion

The results from the various parts of the questionnaire, which indeed may be looked upon as part replications, were very consistent. They showed that both Britons and Ugandans rated psychological factors (i.e. well-being, stress, emotional upheavals) and lifestyle factors (habits) as important to maintaining current and ensuring future health, as well as facilitating recovery. Further, they were not fatalistic in the sense they either believed luck or chance were major determinants of their health. Overall results were similar to Furnham’s (1 994) British adult sample.

They did, however, disagree significantly on one factor both rated as important and one both rated as relatively unimportant. The Ugandans rated the quality and quantity of (presumably Western) medical treatment as a much more important factor than did Britons. This may be due to a number of

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Cross-cultural diflerences in health and illness 13 1

TABLE 6. Overall high-order factor analysis and ANOVAs between the group

ANCOVA Loading British Ugandan (F level)

1 (H) Supernatural factors 2(H) Religious factors 3(G) Supernatural factors 4(E) Religious factors 4(F) Supernatural factors Eigenvalue 8.37; Variance 28.0%

1 (A) Emotional well-being 2(A) Psychological factors 3(A) Stress 4(C) Psychological factors Eigenvalue 3.77, Variance 12.6%

1 (C) Lifestyle 3 (C) Exposure 3(F) Lifestyle 4(B) Lifestyle 4(D) Recovery factors Eigenvalue 3.19, Variance 10.7%

1(F) Fate 2(F) Fate 3(F) Fate 4(G) Fate Eigenvalue 2.34, Variance 7.8%

1 (E) Societal factors 2(C) Medical treatment 2(E) Lifestyle 3(B) Poor medical treatment 4(A) Medical treatment Eigenvalue 1.52, Variance 5.1%

1 (B) Work-home interface 1 (A) Environment 2(B) Environment factors 2(D) Self-medication 3(D) Environment Eigenvalue 1.13, Variance 3.8%

1 (D) Constitution 2(G) Constitution

0.85 0.91 0.90 0.84 0.71

0.83 0.85 0.80 0.76

0.68 0.65 0.74 0.57 0.65

0.86 0.87 0.69 0.84

0.50 0.80 0.46 0.63

0.63 0.76 0.54 0.49 0.52

0.87 0.77

22.64 39.84 47.86'

112.15 110.78

1 16.57 117.70

40.56 40.94

0.38

1.29

0.29

87.77 106.98 44.5 1'

83.83 92.29 6.67b

41.68 43.34 3.76'

ap<0.001. bp < 0.0 1. ' p < 0.05.

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132 Adrian Furnham & Peter Baguma

different reasons. First, it may be because being in relative short supply it is valued more by the Ugandans. Secondly, it may be that Britons are more sceptical about the value of medicine and more used to hearing stories about bad treatment (Vincent & Fumham, 1997). Thirdly, and related to the first issue, it may be that due to limited resources Ugandans ensure that mainly acute cases are treated, making Western medical treatment seem more successful, than if they were exposed to the inability of modem treatments to deal with common chronic problems like back pain (Fumham & Briggs, 1993). However, these interrelated speculations warrant empirical testing to see which is true.

The most dramatic and consistent difference between the two cultural groups, however, concem’ed the rating of supernatural forces (God, curse, spiritual healers’ intervention) on health. The Britons rated this very low, well below fate on all the different parts of the questionnaire suggesting it was essentially irrelevant to health and illness. The Ugandans, on the other hand, rated it much higher as predicted and as found in previous cross-cultural studies on health beliefs (Landrine & Klonoff, 1992, 1994). Whilst it is true that the Ugandans rated supernatural forces amongst the least important factors in determining their health overall, there was still a big difference between them and the British who rated these factors as almost totally irrelevant. Landrine and Klonoff (1994) also found supernatural causes to be the best discriminator between American whites and ‘people of colour’. The latter rated particularly such ideas as sinful thoughts, and acts and punishment from God, as well as a payback for wrong-doing as causes for illness. There appeared to be a mixture of dour Protestant solutions to the problem of evil mixed up with more traditional religious beliefs (Fumham, 1990). Landrine and Klonoff (1 994) found that endorsement of supernatural factors was independent of education, but that there were differences between various sub-groups. Certainly in eluci- dating health beliefs and encouraging specific health-related behaviours, it seems important to take into consideration the religious beliefs of groups particularly those from the Third World (Fumham, 1994).

Fatalism has been associated with both poorer mental and physical health. Certainly trusting in fate may be seen as a psychologically unhealthy strategy for maintaining physical health. Indeed ideas about the cause and maintenance of mental and physical health may be very similar and also self-fulfilling. However it is possible that there are greater cultural differences in beliefs about mental rather than physical health though it is not always possible to clearly distinguish between the two.

The Ugandans rated environmental factors as more important than Britons despite the latter concern with Green issues. Both rated environmental factors highly though they were no doubt referring to different features. Britons seem more concerned about pollution while the Ugandans worry about the quality of their home and work environment. Given that Uganda is a tropical country, it is quite possible that the inhabitants are exposed to more diseases and dangers than Britons who live in a temperate climate (The Economist, 1993).

This study aimed to examine cultural differences in health beliefs indepen-

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Cross-cultural differences in health and illness 133

dent of demographic differences and health status. Such differences as found between the groups were statistically co-varied Out, but it could be argued that neither of these groups were properly matched nor representative of their society. Indeed, the former precludes the latter. Yet, if the groups were relatively similar and the Ugandans educated in the Western system, this would presumably lead to differences between the groups being minimised rather than maximised. It could be argued that the differences found in this study would be accentuated rather than reduced when examining bigger more representative samples.

There are always very serious problems in cross-cultural work, even without involving translations, concerning the differences in meaning. Further, there is a tendency for people in certain cultures to answer positively (in the direction of agree) rather than disagree. These problems are not easily overcome and pose a serious issue in interpreting data such as found in this study.

There remains a limited, but growing psychological literature on cultural differences in illness beliefs (Currer & Stacey, 1993). This study showed that there were predictable and explicable differences between people from two widely different cultures. To some extent it may be surprising to observe how few differences there were, or at any rate the extent to which the cultures rank-ordered the factors in similar ways (Snow, 1974). On the other hand, it is important to recognise that illness beliefs are shaped by cultural and sub-cultural forces (Herzlich, 1979). This is naturally relevant when considering differences in the uptake of medical facilities by different migrant groups, and the native population in the same country (Fumham & Bochner, 1994). Modem science and medicine have rejected the idea of supernatural forces affecting personal health as fallacious and dangerous. But if these beliefs effect to illness-related behaviours, it behoves educators and clinicians at least to acknowledge, to access, and, where appropriate, attempt to change them.

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