Culture may be likened to physical magnetism in the power that all of these forces exert on everything we do and their seamless and mainly unconscious integration into our lives. To understand the role of culture and social context in health behavior, we must apply methods that reveal the dimensions of these phenomena. Neither surveys nor simple focus groups can achieve this. The report by Stewart et al. (2009)
that the all-important construct of intention predicted mammography only for White women in a study of five ethnic groups is sobering. Yet when juxtaposed with Pasick et al.’s (2009)
elucidation of the many ways that relational culture can influence intention, the quantitative data are supported and explained. For this study, we went beyond direct (focusing explicitly on the constructs) quantitative and/or focus group research by inductively exploring the sociocultural context in which the behaviors of interest take place. Our multimethod approach allowed us first to determine how standard quantitative indicators of the five constructs performed across cultures and languages and then to broadly and inductively explore the “how” and “why” dimensions of cancer screening, that is, the more subtle, distal forces that come into play. The combination of approaches functioned as intended in at least four important ways. First, as mentioned, our qualitative findings added rich explanatory dimensions to our quantitative data. Washington et al.’s (2009)
case for new dimensions of subjective norms illustrates the potential of direct observation in contributing to meaningful theoretical concepts, particularly where complex interactions are involved.
Second, varied sources of knowledge (KI scholars, community GKs, and lay women) yielded complementary and expository findings. For example, the sequence of quotes presented earlier illustrating the social capital domain exemplifies the synergy of data from varying perspectives. A KI outlined the broad phenomenon of social capital, a GK described community-level manifestations, and a lay woman provided an illustration of the concept from everyday life. Similarly, we learned about relational culture from our KIs, who described this interconnectedness in many ways. Women themselves, however, had a difficult time explaining this phenomenon, saying that they preferred the company of others “so we don’t look stupid” or “to know what’s going on … to know everything.” None of these perspectives alone could have the power of this combination.
Third, we would have missed the relationships of social capital, transculturation, and relational culture with breast cancer screening had we followed common public health methods, directly querying community women either quantitatively or qualitatively about the constructs and/or influences proximal to mammography use rather than exploring life more broadly. In fact, when our questions were more cognitively focused, women’s responses were consonant with the theories and constructs. Does this negate the contextual influences and our interpretation of their role in behavior just as we suggest that our broader data negate some aspects of the constructs? The complexity of human behavior and its origins suggests otherwise and points more to the rejoinder that simple questions yield simple responses and afford a natural fit with long-standing health behavior paradigms. But we have shown that the context of the same respondents, when scrutinized from varying perspectives, yields highly plausible alternative understandings that would not be obtained from an exclusive focus on the women themselves.
Fourth, the transdisciplinary approach was key because this study would not have been possible exclusively in psychology or behavioral science (the bases for behavioral theory) nor in anthropology or sociology (which provided the methods for exploring sociocultural context) alone. Literature on transdisciplinary research (Stokols, Hall, Taylor, & Moser, 2008
) has not as yet considered the need, potential, and challenges of transdisciplinarity across and within the social and behavioral sciences. Instead, recent writings on this topic address broader integration of basic, clinical, behavioral, environmental, and policy research. In public health, this is based on the “socioecological model” (Smedley & Syme, 2001
), a widely regarded and important framework that has successfully advanced the field beyond decontextualized determinants of health and health behavior by explicating organizational, socioeconomic, and political influences (“social determinants”; Hiatt & Breen, 2008
), leading to interventions that target institutions, communities, and policies in addition to individuals (Emmons, 2000a
). Still undeveloped, however, are the cultural aspects of context and their integration with socioeconomic and political forces. Reasons for this likely include lack of consensus on what culture is (Kagawa-Singer, 2009
) and the fact that much socioecological research remains anchored in the quantitative realm. Although qualitative research is regarded as an appropriate component of transdisciplinary research, anthropologic methods such as ethnography are as yet rarely used in behavioral research.
To more effectively understand and address cancer and other health disparities, transdisciplinary research within the behavioral and social sciences should be pursued with a specific focus on integration of social context and health behavior. In this process, the ideal mixed-methods approaches will be iterative where qualitative methods inform quantitative measurement, the results of which are explicated with additional qualitative research. Intervention trials, informed by both forms of data, can also be best evaluated with variations of the same combination of methods.
Implications for Research
The 3Cs study has taken only a small but first step toward empirically testing the meaning of current behavioral theory constructs across cultures. It does, however, raise important questions regarding the validity, universal applicability, and the appropriateness of current methods for devising, testing, and using extant cognitive theories. Proverbially, further research is needed. Several lessons from this study can guide subsequent research.
Clear findings are that much can be learned by venturing beyond the usual individually focused and deductive methods and that exploration of sociocultural contextual influences requires the best of both qualitative and quantitative paradigms (Kagawa-Singer & Chung, 2002
). Indeed, the persistent and intractable nature of health disparities, which overwhelmingly affect populations that have not been the focus of basic theory development and testing, is a call to reevaluate the study of health behavior from a purely psychological, quantitative, deductive, decontextualized perspective. Navigating our way toward that end will require researchers who are cross-trained in inductive and deductive paradigms and/or trained to work effectively as part of a transdisciplinary team. Critically, the gatekeepers of scientific discovery, scientific peer reviewers, must come to understand, value, and promote inductive and mixed-methods research.
Can new constructs be developed that capture sociocultural influences on health behavior? Kagawa-Singer and Valdez-Dadia (2009)
persuasively argue that better measures of culture can and will improve predictors of the risk and protective factors, improving variance across the cancer continuum from the development of cancer to treatment outcomes.
Further basic research is needed to refine efficient methods for developing more contextualized constructs. Our study took many years, but in large part this was because of a lack of a road map. Hopefully, efforts to build on this work or to replicate it with other ethnic groups can go more quickly. Attention to context in the development of constructs would be expected to improve validity. Whether complex and dynamic processes can be adequately captured by static measures remains a question. Possibly even more challenging will be measurement of factors that are not consciously accessible. Thus, it is likely that qualitative methods will always be needed to bring an essential dimension to quantitative studies.
Implications for Practice
It is always desirable for practitioners and program planners to rely on research-tested approaches if they are available as opposed to spontaneous instinct-driven invention or reinvention. The admonition is increasingly heard that the best evidence is “theory based.” This advice remains true but with some qualification. Practitioners should take note of the theoretical origins of a tested intervention and the populations that participated in the research. Questions of comparability or appropriateness should be addressed through community input to an adaptation process. This will ideally include scholars and community leaders along with lay individuals. Careful process evaluation is also important to continually assess impact. More than ever, we believe the results of our multiperspective inquiry support the value of community-based participation in program development and adaptation from the outset of an initiative. It is important, though, that this alone does not constitute “cultural competence.” Rather, a purposeful effort to recognize and respond to the key contextual factors of people’s lives should garner credibility, resonate with community members, and effect desired change.