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One enduring contribution comes from Emile Durkheim, a pioneer of the discipline of sociology. In his Rules of Sociological Method, first published in 1895, Durkheim (1938) proposed guidelines for the study of social phenomena as social facts. He argued that social facts are “representations” of society in the mind of the individual. They are ways of thinking, feeling, and acting external to the person. Such “facts” include myths, popular legends, religious conceptions, moral beliefs, and social beliefs and practices in general. By treating social values, beliefs, and customs as social facts, Durkheim promoted the systematic study of culture. He introduced his concepts of social solidarity and, particularly, a collective consciousness, as reflective of culture and concurrently present within and external to the individual. Taylor and Ashworth (1987: 43) propose that these concepts are applicable to the study of medical sociology phenomena, such as attitudes toward death and the link between “changing forms of social solidarity and changing perceptions of health, disease, and medicine.”

Another key pioneer in the study of culture was Max Weber. His research during the first two decades of the twentieth century brilliantly marked the initiation of the sociological analysis of culture. Among his voluminous work, two studies are particularly relevant: The Protestant Ethic and the Spirit of Capitalism (1904–5) and Economy and Society (first published in English in 1968). Weber highlighted the importance of culture as values and beliefs coexisting and shaping social action within the micro-cosmos of the individual actor as well as at the level of collectivities, institutions, and the larger society. Weber’s conceptualizations of ethnic group and traditional action offer the most relevant insights to the study of culture.

Weber defined ethnic groups as human groups characterized by a “subjective belief in their common descent” given their real or perceived similarities in one or more characteristics (physical types or race, customs, language, religion), and in “perceptible differences in the conduct of everyday life” (Weber 1978: 389–390). The impact of these subjectively perceived similarities on social action is heightened by yet another essential feature of ethnicity: “the belief in a specific honor of their members, not shared by outsiders, that is, the sense of ethnic honor” Weber 1978: 391) explained:

palpable differences in dialect and differences of religion in themselves do not exclude sentiments of common ethnicity… The conviction of the excellence of one’s own customs and the inferiority of alien ones, a conviction which sustains the sense of ethnic honor, is actually quite analogous to the sense of honor of distinctive status groups.

Weber’s concept of traditional action (one of four in his typology of social action) is also relevant to the link between culture and health. Weber defines traditional action as social action “determined by ingrained habituation.” Traditional action, he wrote, “is very often a matter of almost automatic reaction to habitual stimuli that guide behavior in a course which has been repeatedly followed. The great bulk of all everyday action to which people have become habitually accustomed approaches this type” (Weber 1978: 4). The concepts of ethnicity and traditional action, as defined by Weber, elucidate the pervasiveness of customs, beliefs, and practices of different ethnic or cultural communities upon their health-related behavior. Weber’s analyses have inspired subsequent research and contributed to the understanding of the pervasiveness of culturally inspired and culturally sustained health practices. Probably because of the profound influence and widespread incorporation of his conceptual insights into the body of general knowledge of sociology, these Weberian contributions are seldom cited directly in current medical sociology research. Two notable exceptions are the analysis of Weber’s legacy in medical sociology (Gerhardt 1989) and his concept of lifestyles (Cockerham 2021a, 2021b).

This interest in culture continues among subsequent generations of social scientists. By 1951, Clyde Kluckhohn reported many different definitions of culture and many more have appeared since. Yet, in spite of the plurality of definitions, some common strands that make up the fundamental fabric of this important concept are found in the cumulative work of anthropologists and sociologists. Kluckhohn (1951: 86) defined “culture” in the widest sense, as a community’s “design for living.” He pointed out that despite the wide variety of definitions he and A. L. Kroeber (Kroeber and Kluckhohn 1952) found, an “approximate consensus” could be developed, in which:

Culture consists in patterned ways of thinking, feeling, and reacting, acquired and transmitted mainly by symbols, constituting the distinctive achievements of human groups, including their embodiments in artifacts; … traditional (i.e., historically derived and selected) ideas and especially their attached values. (Kluckhohn 1951: 86)

Kluckhohn proposed that this definition of culture be used as “a map” or “abstract representation” of the distinctive features of a community’s way of life. This method is akin to the ideal type, the analytical tool introduced by Weber (1946) to identify general characteristics, patterns, and regularities in social behavior.

A direct connection between culture and health was articulated by Bronislaw Malinowski (1944: 37), who considered culture as a functional response to satisfy “the organic and basic needs of man and of the race.” He defined culture as “the integral whole” encompassing “human ideas and crafts, beliefs and customs … A vast apparatus, partly material, partly human and partly spiritual, by which man is able to cope with the concrete, specific problems that face him” (Malinowski 1944: 36). Malinowski saw those problems as human “needs” that prompted “cultural responses.” These needs were metabolism, reproduction, bodily comforts, safety, movement, growth, and health. However, in his view, health is implied in all the other six human basic needs, in addition to the explicit need for “relief or removal of sickness or of pathological conditions” (1944: 93). The “cultural response” which addresses the problem of health is “hygiene”, defined as all “sanitary arrangements” in a community, “native beliefs as to health and magical dangers,” “rules about exposure, extreme fatigue, the avoidance of dangers or accidents,” and the “never absent range of household remedies” (Malinowski 1944: 91, 108).

Another valuable contribution to the understanding of culture was provided by sociologist Talcott Parsons. Parsons was greatly influenced as a student by Durkheim and Weber. Among his colleagues, he acknowledged the influence of Kluckhohn concerning the problems of culture and its relation to society (Parsons 1970). He conceptualized social action as taking place within a three-dimensional context comprising personality, culture, and the social system. Parsons (1951: 327) defined culture as “ordered systems of symbols” that guide social action and are “internalized components of the personalities of individual actors and institutionalized patterns of social systems.” For Parsons (1951: 11), the shared symbolic systems are fundamental for the functioning of the social system and they represent “a cultural tradition.” Parsons (1951: 326–7) argued that a cultural tradition has three principal components or systems: value-orientations, beliefs, and expressive symbols.

His preoccupation with a balanced analysis of values and motives that would prevent us from falling into the extremes of “psychological” or “cultural” determinism, led him to invest considerable effort into the discussion of culture. Parsons (1951: 15) identified three main features:

First, that culture is transmitted, it constitutes a heritage or a social tradition; secondly, that it is learned, it is not a manifestation, in particular content, of man’s genetic constitution; and third, that it is shared. Culture, that is, is on the one hand the product of, on the other hand a determinant of, systems of human interaction.

Parsons’ concepts of culture and cultural traditions and his identification of culture as transmitted, learned, and shared, together with the contributions from Durkheim, Weber, Kluckhohn, and Malinowski form the classical foundation for the study of culture. An additional heritage of the study of culture is the cross-fertilization of insights and research between sociology and anthropology. Most current studies on culture and on the link between culture and health have developed from this rich foundation.

By identifying the fundamental components of culture, the collective wisdom inherited from the classics permit us to consider culture and ethnicity as the same phenomenon. Although Margaret Mead (1956) and Benjamin Paul (1963) proposed that cultural differences cut across racial and religious lines, these two factors are very much part of the cultural landscape within which individuals and groups operate. This idea is captured by Stanley King (1962: 79), who proposed that what constitutes an ethnic group is the combination of “common backgrounds in language, customs, beliefs, habits and traditions, frequently in racial stock or country of origin” and, more importantly, “a consciousness of kind.” Note that, from the perspective of individuals and collectivities, these ethnic similarities may be factual or perceived and may include a formal religion. The sharing of the same geographical settlement is not as important as it was once thought, mainly because large migrations (voluntary or not) of people from different ethnic groups have resulted in the formation of diaspora beyond their ancestral lands and the subsequent increase of multiethnic settlements. The process of assimilation (becoming a member of the host culture) is common when individuals settle in a new country. Living in close proximity to each other leads individuals from different ethnic groups into another process, pragmatic acculturation, that is, the process of culture borrowing motivated by the desire to satisfy specific needs (Quah 1989a: 181). Assimilation and pragmatic acculturation have been found to influence health behavior significantly, as discussed later. But first, let us review some of the contemporary leading ideas on culture and health.