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Preventive health behavior refers to the activity of a person who believes he or she is healthy for the purpose of preventing illness (Kasl and Cobb 1966: 246). In addition to the study of healthy individuals, relevant research on preventive health behavior also covers studies on substance addiction or abuse (drugs, alcohol, cigarettes), which seek to understand the path toward addiction and to identify the factors involved. The subjective evaluation of one’s own health status may propel or retard preventive action against disease. Many studies on preventive health behavior report data on self-health evaluation but it is uncommon to report variations in the cultural meaning attached to health status. As health status is, in many respects, a value, cultural variations are common in people’s evaluation of their own health status and the way in which they evaluate it.

An illustration of this phenomenon is the traditional Chinese notion of “ti-zhi” (Lew-Ting et al. 1998). “Ti-zhi” or “constitution” denotes “a long-term, pervasive characteristic that is central to their sense of self” and clearly different from the Western concept of health status. The latter is “a more temporal, fluctuating state” that varies with “the experience of illness” (Lew-Ting et al. 1998: 829). Their study illustrates the cultural similarity in the definition of constitution among people of the same ethnic group (Chinese elderly) living in two different parts of the world, Taipei and Los Angeles. In contrast, residing in the same geographical location does not secure a common meaning of health status. For example, significant cultural differences in self-evaluated health status were observed among three cultural groups living in close proximity of each other in south-central Florida (Albrecht et al. 1998).

Among the studies relevant to the prevention of substance abuse, is the work of Gureje et al. (1997). People in nine cities were interviewed on their values and perceptions concerning the meaning of drinking alcohol. The nine cities were Ankara (Turkey), Athens (Greece), Bangalore (India), Flagstaff (Arizona), Ibadan (Nigeria), Jebal (Romania), Mexico City, Santander (Spain), and Seoul (South Korea). These authors reported a “remarkable congruence” in the practitioners’ criteria to diagnose alcoholism. But they found significant variations among people across the nine cities concerning “drinking norms, especially with regard to wet and dry cultures” (1997: 209). A wet culture, they stated, is that where alcohol drinking is permitted or encouraged by the social significance attached to the act of drinking and to the social context within which drinking takes place. In a dry culture, alcohol drinking is discouraged or prohibited altogether. Their study is part of the increasing body of research findings showing that the difficulties encountered in the prevention of alcoholism and other types of substance abuse are greater in some cultures than in others (e.g. Nelson and Wilson 2017).

The investigation into the relative influence of culture upon alcohol abuse was found by Guttman (1999) to be equivocal in situations where acculturation takes place. Guttman refers to the common definition of acculturation that is, “the process whereby one culture group adopts the beliefs and practices of another culture group over time” (1999: 175). His study of alcohol drinking among Mexican immigrants in the US highlighted several problems. He found it difficult to identify clearly the boundaries between cultures sharing the same geographical area. Some studies overcome this problem by following the symbolic-interaction postulate of the importance of subjective definition of self and of the situation and correspondingly accepting the subjects’ self-identification as members of a given culture (e.g. Quah 1993). Some researchers assume that the length of time spent in the host country leads to acculturation and thus use other indicators, such as the proportion of the immigrant’s life spent in the host country (i.e. Mandelblatt et al. 1999).

A second and more critical difficulty in the study of preventive and other types of health behavior involving alcoholism and other health disorders among immigrants and ethnic minorities is their concurrent exposure to multiple cultural influences. In this regard, Guttman’s finding in the US is similar to findings in other countries. He observed that immigrants “are participants not only in the dissolution of older cultural practices and beliefs but are also constantly engaged in the creation, elaboration, and even intensification of new cultural identities” (Guttman 1999: 175). However, the presence of multiple cultural influences does not necessarily lead to the creation of new identities. Other outcomes are possible, such as one outcome I label pragmatic acculturation: the borrowing of cultural elements (concepts, ways of doing things, ways of organizing and planning) and adapting them to meet practical needs. Pragmatic acculturation is practiced in the search for ways to prevent illness, or trying different remedies to deal with symptoms (illness behavior), or seeking expert help from healers from other cultures (Quah 1985, 1989a, 2003, 2008). Individuals “borrow” healing options from cultures other than their own, but they may or may not incorporate those options or more aspects of the other cultures into their lives permanently. The borrowing and adapting is part of the ongoing process of dealing with health and illness. Solutions from other cultures tend to be adopted, or adapted to one’s own culture, if and for as long as they “work” to the satisfaction of the user.

Yet another angle of analysis in the study of culture and health is the identification of cultural differences in health behavior among subgroups of a community or country assumed to be culturally homogeneous. Such is the case of differences commonly found between “rural” and “urban” ways of life and ways of thinking in the same country. Lyttleton’s (1993) study of preventive health education on AIDS in Thailand illustrates well the urban–rural divide. The message of public preventive information campaigns designed in urban centers was not received as intended in rural villages. The concept of promiscuity that was at the center of the Thai AIDS prevention campaigns was associated by the villagers with the visiting of “commercial sex workers” only and not with the practice of “sleeping with several different village women” (1993: 143). The misperceptions of preventive public health campaigns occur between the rural, less educated, and dialect-speaking groups on the one hand, and the urban, educated civil servants and health professionals who design the campaigns, on the other hand. The misperception of the campaign message is not the only problem. An additional serious obstacle to reach the target rural population is the medium used to disseminate preventive health information. The Thai villagers perceived new technology including television broadcasts from Bangkok as “belonging to a different world – both physically and socioculturally” and, consequently, “increased exposure to these messages simply reinforces the [villagers’] perception that they are not locally pertinent” (Lyttleton 1993: 144). The search for, and testing, of effective approaches to “culturally tailored” health interventions continues (e.g. Galbraith et al. 2016; Kikuzawa et al. 2019; Miller et al. 2019).