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INTRACULTURAL VARIATION IN BLOOD PRESSURE IN BEIRA,
NANETTE LOUISE BARKEY
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
Many people in Mozambique and the U.S. helped to make this dissertation
possible. At Eduardo Mondlane University I owe a debt of gratitude to Drs. Paula, Ana,
Teresa, Rafael, Mate, Maria Jose, Zonjo, and Tino. My anthropology students in 2000
and 2001 taught me about life in Mozambique and medical anthropology, especially
Emidio, Maria Ivonne, Fransisca, Katia, Aurelio, and Salvador. Also in Maputo, I want to
thank Harriet McGuire who made so many good things happen for me, as did Esmerelda
and Joao, Steve and Michelle, Jill and Richard, Karen, Chad, and Annie. Olanda Bata and
Marcos Freire have been friends since Gainesville, and their continued friendship in
Mozambique is a joy.
In Beira there I had more friends and colleagues. At the Catholic University:
Father Mike, Father Elias, Dawndra, Rose, Greg, and Silvestre were all helpful. At the
UP: Dr. Uacane, and at ARPAC: Dr. Chuva.and Joao Joaquim were supportive. At the
Provincial Ministry of Health: Drs. Amos, Cristina, Selma, and Mussa participated.
Bizeque, Aguida, and Fransicso were outstanding research assistants, and I thank them.
We had good friends to keep us company in Beira, including Janet, Nicky, Maureen,
Christy, Bill and Tara. A million thanks go to Dona Fatima and Dona Emelia for
everything they did.
At the University of Florida, I owe a debt of gratitude to my colleagues in the
Center for African Studies and the Anthropology Department, especially Peter, Parakh,
Andy, Elli, Paige, George, Isaac, Dave, Hank, Ken, Rachel, and Lance. Beth was the kind
of friend and academic colleague we all dream of having. She helped in ways too
numerous to list. I owe Russ and Carole my unending gratitude for all of their help and
support over these five years. From Dr. Chege I learned about Africa, teaching, research,
and writing. I thank him and Annie for all their support, and for having encouraged me to
visit Mozambique. Jim Stansbury and Leslie Lieberman served as outstanding committee
members and supporters. Hunt and Jeanne Davis always provided a place to live when I
was in need, and made sure I was working hard. Marvin Harris shared with me his
passion for Mozambique before he passed away.
Kathy and Bill are always there for advice and encouragement. Jeannine has been
a great source of support and a friend since we met. To my parents and my husband, I
owe the largest debt. Their support helped me make it through all the tough spots and
their love has been wrapped around me at all times.
TABLE OF CONTENTS
ACKNOWLEDGMENTS........................ ..................................................................... ii
ABSTRACT .................................................................................................................... vi
1 INTRODUCTION ................................. ......................................... 1
Culture Change and Intracultural Variation................................................................ 2
Cultural Consensus Modeling to Study Variation .............................. ...................... 6
The Effects of Culture Change on Health............................................. .................... 9
High Blood Pressure in Africa: An Overview ...................... ......... .......................... 11
The Research Project.................................................. ............................................. 12
2 SETTING......................................................................................... .......................... 16
Mozambique........................... .................................... ..................... 16
T he C ity of B eira................................................................................. ....................... 28
P o n ta G ea ...................................................................................................................... 3 8
3 REVIEW OF THE LITERATURE............... ................................................... 44
Intro du action .......................................................... ....................................... ............ 4 4
An Overview of Hypertension in Africa............................................. .................... 45
Defining and Measuring Psychosocial Stress ............................................................ 63
Cultural Consensus Modeling to Study Psychosocial Stress and Social Support......... 74
S u m m ary ............................................................................................... ....................... 84
4 HYPOTHESES....................................................... ................................................ 86
Introduction .............................. .................................................. .......................... 86
Phase One Hypotheses ................................................ ............................................ 88
Phase Two Hypotheses.......................................................................... ..................... 89
5 PHASE ONE: ETHNOGRAPHY ............................................................................. 90
Consensus Modeling: Reprise............................ ..................................................... 90
Methods Used in Phase One .......................... ........................... 91
Freelist and Rankings Findings............... ................................................... 102
D discussion of the Findings ............................... .................................................... 110
Preparing the Questionnaire for Phase Two............................. .......................... 122
6 PHASE TWO:MODEL TESTING................................................................. 126
Phase Two: Survey Methods................. ................................ 126
Presentation of Preliminary Results...................................... 142
Survey R esults....................................................... ................................................ 144
7 CONCLUSION................. .......................................... 177
A LEGEND AND MAP OF PONTA GEA ............................................................. 187
B LIFESTYLE ITEMS FROM TWENTY TWO FREELISTS.................................. 189
C QUESTIONNAIRE IN ENGLISH............... ................................................ 192
D QUESTIONNAIRE IN PORTUGUESE................................... ........................ 197
E ORAL CONSENT INSTITUTIONAL REVIEW BOARD....................................202
F TABLE OF EDUCATIONAL CATEGORIES FROM THE MOZAMBICAN
CEN SU S ............................. ........................................................... 209
R E FER E N C E S ........................................................ .................................................. 2 10
BIOGRAPHICAL SKETCH ......................................................... 225
Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
INTRACULTURAL VARIATION IN BLOOD PRESSURE IN BEIRA,
Nanette Louise Barkey
Chair: H. Russell Bernard
Major Department: Anthropology
The research described in this dissertation evaluates the role of psychosocial
stress and social support in the development of high blood pressure in a neighborhood in
Beira, Mozambique. It uses consensus modeling to develop culture-specific models of
lifestyle and social support, and tests whether consonance with these models is predictive
of high blood pressure or buffers against it. Blood pressure was measured as an
expression of psychosocial stress, as well as an indicator of a chronic disease.
Mozambique has been experiencing rapid social, political and economic change
in recent years. The research was conducted in the middle class neighborhood of Beira,
Mozambique, the country's second largest city. The neighborhood of Ponta Gea is home
to people from a variety of ethnic backgrounds, ages, somatic types, and socioeconomic
and educational levels. All participants were adults over the age of thirty who are
Mozambican citizens currently living in Ponta Gea.
The research was conducted in two phases: the first ethnographic and the second a
house-to-house survey. The cultural models of lifestyle and social support were
developed in the ethnographic phase. There was strong consensus among the Ponta
Geans about the elements of these two models. The research team interviewed 261 people
in the survey during the second phase. At the end of the interview, participants had their
height, weight and blood pressure measured.
The survey data suggest that consonance with the model of a successful lifestyle
was predictive of higher blood pressure, as was age and obesity. Wealthier Mozambicans
had higher blood pressure than their poorer counterparts. Social support had a mild
buffering effect on blood pressure, controlling for lifestyle, age and obesity. The results
suggest that more research is needed to understand the mechanisms through which
psychosocial stress leads to negative health outcomes and work is needed to develop new
methods for measuring this connection.
The study presented here emerges at the intersection of two large endeavors
within anthropology: the study of societies in transition and the study of health within its
cultural context. Two related universals in the human experience form the foundation of
this research: cultures are constantly changing and all humans experience illness. The
research question is based on these universals and contributes to these two endeavors.
The research project described in this dissertation examines how psychosocial stress
arising from culture change leads to ill health, specifically high blood pressure.
Mozambique is an ideal setting for this research because it has undergone
tremendous social, economic, and political changes in the last decade and a half. I chose
high blood pressure as the health outcome for four reasons. 1) Blood pressure readings
are a non-invasive measure of stress that can be collected easily in field settings without
the need for laboratories and refrigeration. 2) The incidence of chronic diseases,
including hypertension, is increasing across Africa and to slow this increase we have to
have a better understanding of the causes of hypertension. 3) On a predissertation visit,
Mozambicans told me that high blood pressure is becoming more of a problem in recent
years, which they attribute to the changes taking place there, and they asked me to study
it. 4) Finally, there is a substantial amount of research on blood pressure in both
anthropology and public health, providing a solid comparative basis for my research.
Culture Change and Intracultural Variation
In order to present topics like culture change and intracultural variation, I start
with a brief discussion of culture. In this dissertation I use a definition of culture that
draws on the work of Shore (1996), D'Andrade (1984), Handwerker (2002), and others,
who emphasize the cognitive nature of culture, with less emphasis on behavior.
Handwerker (2002) summarizes Edward Tylor's 1871 definition of culture as "the
knowledge people use to live their lives and the way that they do so" (p. 107).
Handwerker also offers his own definition of culture as "the systems of mental
constructions that people use to interpret and respond to the world of experience, and the
behavior isomorphic with those systems of meaning" (p. 109).
Dresser (1999a) explains how D'Andrade's (1984) model of cultural meaning
systems is useful when studying intracultural variation.
This in essence is a cognitive model of culture, in which culture is viewed as the
knowledge that individuals learn in socialization and share with other members of
the society that enables individuals to resolve routine problems and to make sense
of one another's behavior. At the same time, this theory places considerable
emphasis on the meaning of events and circumstances and ideas. (p. 595) (italics
D'Andrade's "notion of culture as a shared and learned culture pool" is central to
both cultural consensus modeling and the study of intracultural variation (Romney et al.
1986), which are explained below. Culture is shared and learned by members of a group,
but it is not equally learned or shared by all members. As we study variation in cultural
knowledge, we leam about people's roles in a society, the flow of power and knowledge,
and the economic, health, and social outcomes of this diversity within one group.
Like D'Andrade, Shore (1996) builds his theory of culture on cultural models. For
Shore, there are three mental models, two personal and one conventional. The first two
models are at the individual level: psychological and cultural. Shore's third mental model,
"instituted models," is based on Geertz's notion of templates, which are held at the social
level. "Instituted models are the external or public aspect of culture, and represent
common source domains by which individuals schematicize conventional mental
models" (Shore 1996 p. 312). For Shore, the link between external cultural models and
the two types of individual mental models is meaning. According to him, humans can
retain individual knowledge bits, but they also assign meaning to these bits, and this
meaning is infused with culture.
Many forces affect culture change. For years, anthropologists, sociologists, and
other social scientists have studied modernization, the process by which "traditional"
people became "modem" (cf., Inkeles and Smith 1974, Barth 1967). Usually this process
is assumed to include the adoption of Western modes of production, reproduction and
consumption. This phenomenon was also referred to as acculturation or westernization.
Critics of these studies questioned the value or power associated with being
modem, challenged the assumption that western culture was the model of what was
modem, and asked whether all societies travel along the same trajectory on an inevitable
path toward modernity (F. Cooper 2001). Modernization studies have fallen out of vogue,
and have been replaced in the last decade by a growing interest in globalization.
Globalization commonly refers to the adoption of western economic systems and cultural
traits by non-western people, or "one-way flow of culture from the West to the rest" (Inda
and Rosaldo 2002 p. 35). A noted African historian notes the limitations of these studies
when applied to Africa, "Like modernization theory in the 1950s and 1960s, globalization
talk is influential--and deeply misleading--for assuming coherence and direction instead
of probing causes and processes" (Cooper 2001, p. 189).
Pelto and Pelto's (1975) descriptions of culture change and how new ideas and
behaviors are integrated into a cultural schema are highly relevant to my research in
Mozambique. In their discussion of the stereotype of peasant communities' opposition to
change and modernization, they state that some studies "show that there are significant
intracommunity variations in response to outside change agents and other forces of
modernization" (p. 5). The Peltos also write about culture change and the role of
individuals and small groups in instigating change. "[W] e can suggest that successful
innovations by individuals (sources of variation) may be noticed by others, who take up
the new patterns while discarding previous practices" (p. 15). Homogeneous models of
culture change do not allow for the possibility of change coming from within a culture,
unless innovations come from people who can be labeled as deviants. A model based on
intracultural variation allows for change from within and shows how new ideas are
adopted within a group. In Mozambique, there is intracommunity variation in the
adoption of new ideas and behaviors, which come from outside as well as from within the
Dressier (1999) reviewed the literature on modernization and blood pressure, and
found that "research has progressed from hypothesizing that culture change is stressful, to
trying to operationalize theoretical models of what it is about culture change that is
stressful" (p. 583). He found that "delocalization" is a better term for describing what is
usually termed modernization. Originally described by Pertti Pelto in 1973, delocalization
is the process whereby a community becomes increasingly dependent on energy and
information that comes from outside the community (e.g., gasoline engines and the
know-how to maintain them). Dresser envisions a number of changes that result from
delocalization, including "the adoption of non-local standards of behavior for awarding
social status" and the emergence of "marked socioeconomic inequities" (p. 586).
Modernity and Culture Change
Weisner and Abbott (1978) studied rural and urban Kikuyu and Abaluyia women
in Kenya using an "overall modernity scale," and the psychosomatic symptoms test,
which were developed by sociologists Inkeles and Smith. They found important
differences between the two ethnic groups, with the Kikuyu scoring higher on the
modernity scale. Surprisingly, in both ethnic groups, rural women scored higher on the
second scale, leading the authors to conclude that "urban residence can be much less
stressful than rural residence" (p. 437). Ethnographic research suggested that stress
among rural women comes from taking over the responsibilities of men who worked in
the cities, loss of child labor because of schooling, unbalanced reciprocity with the
husband's family, and indirect involvement with modem urban institutions. Weisner and
Abott reviewed 22 other studies of stress which used cross cultural and comparative data,
and conclude that "regional and intracultural analysis of contexts should help in
understanding the relationships of stress, modernity and contextual variables" ibidd p.
The research presented here focuses on intragroup variation in blood pressure.
Anthropologists have traditionally relied on cross-cultural comparison in their research.
Yet focusing on intracultural variation draws our attention to the fact that, while culture is
shared and learned by members of a group, it is not equally learned and shared by all
Romney (1994) traces this approach to Edward Sapir (1938), an anthropologist
who was among the first to raise the problem of intracultural diversity. Sapir pointed out
that, with anthropology's focus on communities, the individual was often left out and
there appeared to be no allowance made for individual variation in cultures. Sapir's
seminal observation had not been incorporated into the discipline by the 1970s when
Pelto and Pelto (1975) observed that anthropologists continued to shy away from
informants who do not behave or think about their culture in normative ways. People who
do not follow the "rules" are usually considered deviant, and anthropologists have not
always adequately pursued the question of why these people are different. Perhaps the
way we ask questions prompts our informants to give us uniform or generalizable
descriptions. Maybe we suspect that informants who tell us something different than what
we expect to hear are lying, or making up their answers. Maybe they simply want to
tweak our general approach to their culture. However, there is more to intragroup
variation and deviant or unexpected answers than inaccurate informants. An intentional
examination of intragroup variation, designed to investigate the patterns that exist in
knowledge and behavior, provides anthropologists with a richer understanding of the
culture being studied.
Cultural Consensus Modeling to Study Variation
Boster (1986, 1987) found that knowledge about varieties of manioc varied by
gender and kin group among the Aguaruna Jivaro. Women in the group knew more than
men, and women within a particular kin network had patterns of knowledge that were
most similar to other women within their kin group. Earlier, Romney and D'Andrade
(1964) had asked high school and university students to take a triad test of kin terms and
tested the hypothesis that there is one cultural norm about kin terms. Reanalysis of the
data using multidimensional scaling (Wexler and Romney 1972) showed that two models
of kin terms were present, one used by approximately 70% of respondents and another
used by 30%. Wexler and Romney (1972) said that this was a "cautious, exploratory"
approach to the study of human variation, made possible by the advent of
multidimensional scaling and computer-based data analysis.
When intracultural variation is the focus of the research, anthropologists study
individuals and subcultures, rather than whole communities or culture groups. This does
not mean that we are reducing our explanations to psychological factors, nor are we
forgetting the larger social systems. The patterns that we find at the subgroup level must
be placed within the context of the culture. Pelto and Pelto (1975) cite Goodenough, who
states that since culture is learned, "its ultimate locus must be in individuals rather than in
groups" (1971 p. 20), and they urge anthropologists to focus on intracultural diversity.
Within one society we may find a number of subcultures that hold different
perspectives and have special knowledge. Handwerker (2002) writes that people are
affected by who they are, and how they have interacted with the world. Women and men,
for example, could belong to different subcultures, as could youth and senior citizens. In
his work in an African American community, Dressler (1991) found that younger people
had a model of social support more heavily biased toward nonkin than did their parents,
whose social support model favored kin members.
Applications of Cultural Consensus Modeling (CCM)
Cultural models created with consensus modeling can be compared across groups
(cf., Weller et al. 1993, Weller and Dungy 1986, Chavez et al. 1995, Hurwicz 1995), or
the models can be used to study intragroup variation (cf., Dressier, dos Santos, and Viteri
1986, Garro 1986, Garcia et al. 1998, Caulkins and Hyatt 1999, Weller 1983).
Sometimes there is less intragroup or across group variation than anticipated.
Caulkins (1998) expected to find variation in the advice given by different types of
business advisors, but found that government, university, and private business advisors
shared the same cultural model of what constitutes success. Likewise, Kempton, Boster
and Hartley (1995) sampled from five maximally diverse groups of Americans to find out
how much they differed on their views of the environment. There was higher consensus
than expected, even when comparing extreme environmentalists and political
conservatives. Handwerker (2002) found that patterns in parents' perceptions of what
constitutes a good parent-teacher relationship do not mirror our classification of
subcultures. Latino parents' perceptions do not cluster together as we might expect.
Instead, two distinct groups emerge, each including both Latino and Anglo parents.
How CCM Reveals Intracultural Variation
Cultural consensus modeling (CCM) is explained more fully in the third section
of Chapter 3. The goal of CCM, as I am using it here, is to identify a few highly
knowledgeable informants who can provide culturally appropriate descriptions about a
particular cultural domain like the rules of Major League Baseball, types of manioc
plants, or ways to treat malaria. Once the group model for the domain has been
elaborated by these informants, the next step is to measure how individuals deviate from
it. Dressier has used this two-step approach successfully in Brazil and the U.S. (cf., 1999)
to create cultural models of lifestyle and social support and to test for variation from
The Effects of Culture Change on Health
Health Outcomes Resulting from Culture Change
Urbanization is an important component of culture change. As people move from
rural areas into the cities the way they earn a livelihood changes dramatically, as does the
social structure in which they live their lives. I chose an urban community for my
research precisely because urban lifestyle is dramatically different from the rural
subsistence lifestyle in Mozambique, and because we usually see a shift from a kin-based
to a nonkin-based network for social support in urban areas. The epidemiological profile
is often transformed with urbanization and the concomitant changes in lifestyle, as
When societies change their modes of production, the pattern of disease also
changes. With the advent of agriculture and the introduction of a sedentary lifestyle, an
increase in communicable diseases is noted (MN Cohen 1989, Armelagos 1991). As
hygiene, sanitation, and nutritional status improve, many societies move from a health
profile dominated by infectious diseases to one made up primarily of noncommunicable
diseases and very few infectious diseases. The epidemiological transition from infectious
disease to chronic diseases has been noted in the U.S., Japan, and most western European
Most African countries have not undergone this second transition and are
challenging the notion that it is a universal process. Mozambique, like many of her
neighbors, is experiencing a double burden of infectious diseases accompanied by an
increasing frequency of chronic disease afflicting her citizens.
In this dissertation, my focus is on culture change and noncommunicable diseases
in a society that previously suffered primarily from infectious disease. Several
noncommunicable diseases are referred to as "diseases of civilization," including
cardiovascular disease and stroke, diabetes, and some types of cancer. Cardiovascular
disease, in particular, has been associated with changes in lifestyle that accompany
modernization: sedentary lifestyle, dietary changes, urbanization, and decreasing levels of
Lifestyle is the primary mediating factor between culture change and negative
health outcomes. Biomedical and social science researchers alike are interested in the
question "How does the way that people live influence their health?" Although we may
use the same terminology, there is a striking contrast in our meaning. For biomedical
researchers, lifestyle usually denotes individual decisions and behaviors that affect a
person's risk for disease e.g., smoking, diet, exercise patterns, and sexual practices.
Researchers who focus on these behaviors are interested in explaining the incidence of
disease and usually measure lifestyle at the individual level (cf., Kaplan 1990).
According to Coreil, underlying this use of lifestyle is "the notion that personal habits are
discrete and independently modifiable, and that individuals can voluntarily choose to
alter such behaviors" (1985 p. 428). Yet, lifestyle does not always hold a negative
connotation in biomedical research. Some behaviors (i.e., regular exercise) and decisions
(i.e., abstention from high-risk sex) are categorized as health promoting, and are held up
as examples to at-risk individuals who need to change their unhealthy lifestyle.
In contrast, anthropologists tend to focus on the way people live. We see lifestyle
in a broader sense, including behaviors that may not have a direct impact on health. For
my research, lifestyle is important within the context of culture change and stress. The
construct includes not only behaviors such as diet and exercise, but also how they
communicate and learn, what they think, dream, and worry about, relations with their
spouses, friends, and families, and strategies for adapting to the changing world in which
Anthropologists have been observing change in societies since they have been
studying them. As societies come into contact with each other, the lives of people in
those societies change. Whether we call this contact and its effects "culture change,"
"acculturation," "modernization," or "globalization," we know that having social cues,
rules, and expectations change is stressful.
Cassel (1976) acknowledges the difficulties in defining and operationalizing the
various forms of psychosocial stress caused by culture change. He reviews several studies
in which the concepts of social change and social and/or family disorganization were
measured and found to predict a number of different health problems. Henry and Cassel
(1969) note that stress is heightened when people are subject to new social expectations
and the behaviors they had learned as children are no longer the norm.Cassel (1976)
encourages intervention, in both reducing exposure to stressors and in strengthening
social support, to avoid the development of these illnesses. The nature of social support
often changes during the modernization process, as people move away from their kin and
begin to live more detached lives.
High Blood Pressure in Africa: An Overview
High blood pressure is an intriguing condition because it is multifactorial and the
contribution made by psychosocial factors is still in the process of being understood. I
review the literature on blood pressure in Africa in Chapter 3, but highlight a few of the
most important findings here. High blood pressure is universally found to increase with
age and obesity (usually measured by body mass index, weight divided by height),
including most African populations.
The relationship between socioeconomic status and blood pressure is different in
most of Africa compared to the West. Wealthier people in the western hemisphere and in
Europe are thinner than the rest of the population and tend to have lower blood pressure.
In most African populations, with the exception of South Africa, studies show that
wealthier people are heavier and have higher blood pressure than poorer people in the
same groups. The inverse pattern of socioeconomic status and blood pressure is an
important element of the present study and in the interpretation of my findings.
The Research Project
After visiting Mozambique in 1999, I became interested in the question of how
recent changes in Mozambique are affecting people's health. Mozambicans I interviewed
during that preliminary visit told me that they were suffering an increase in the frequency
of hypertension, or tensdo alta, and attributed it to the rapid transformations following
the end of the civil war (in 1992). I chose to approach the question by looking at
intracultural variation in access to culturally appropriate models of lifestyle and social
support. Dressier has developed this model for assessing cultural consonance, or the lack
of it, as a stressor and a cause of hypertension (Dressler 1999, Dressier and Bindon
2000). Dressier developed his model in Brazil and in the U.S., and encouraged me to test
it in urban Mozambique.
Mozambique, like Brazil, is a Portuguese-speaking country with historical ties to
Portugal and her history of colonization. Yet, Mozambique continued to be a colony for
nearly a century after Brazil had her independence. More than 99% of Mozambique's
citizens are of African descent, whereas Brazil is home to a mix of people who are
originally from Africa, Europe, and Asia, in addition to native Brazilians. More
importantly, the relationship between socioeconomic factors and hypertension is opposite
in Brazil and in Mozambique. In Brazil, high blood pressure is more common among
lower socioeconomic strata, while in Mozambique it is a condition primarily afflicting
In the first phase of the study, I used ethnography to build the models of lifestyle
and social support. I interviewed informants in the first phase of my research who were
identified by other people or by me as having a specialized knowledge of lifestyle and
social support. The methods and results of this phase are presented and discussed in
Chapter 5. In phase two, I tested the two models developed in phase one and measured
individual variation from them through a door-to-door survey of adults. The survey also
included questions about perceived stress and life events, family history of hypertension,
demographic questions, and anthropometric measurements. The methods and results of
phase two are found in Chapter 6.
I spent 21 months in Mozambique between June 1999 and November 2001.
During this time, there were three distinct periods of research. From June through August
1999, I defined the research question and studied Portuguese. During this time, I traveled
around the country interviewing people from all walks of life, questioning my academic
colleagues there, and observing urban and rural life. From January through June of 2001,
I lived in Maputo and taught medical anthropology at Eduardo Mondlane University
while also collecting preliminary data on stress and social support in that city through
interviews, participant observation and freelists. The main data collection period in the
city of Beira ran from October 2000 through November 2001 and is described in detail in
Chapters 5 and 6.
The calendar of activities below illustrates when the different parts of the research
were done and the length of time of each activity.
June- Jan.- Oct.- Jan- Mar.- May- June- Sept.-
Aug. June Dec. Mar. Apr. June Aug. Nov.
1999 2000 2000 2001 2001 2001 2001 2001
Pilot research I n h
Language Study DH -
Key Informant Interviews
Quantitative Data Management
Figure 1-1. Calendar of Activities.
The principal research on which this dissertation is based was done in the
neighborhood of Ponta Gea, in the city of Beira, in central Mozambique. Ponta Gea was
built by the Portuguese colonial authorities as a middle-class neighborhood, restricted to
whites and selected Africans. Currently, a wide range of people call Ponta Gea home,
people representing a cross-section of Mozambican society as well as foreigners. The
research setting is described in detail in Chapter 2.
Comparison with the Methodology in Dressler's Research
In addition to the data on consonance in lifestyle and social support,
anthropometric measurements, and blood pressure, Dressier and his colleagues in Brazil
collect other data that I did not collect. Dressier uses two 24-hour dietary recalls for the
data on the intake of calories, protein, fat, sodium, and other nutritional indicators. I do
not share his belief that 24-hour dietary recalls are useful in generating dietary
information. They take a long time to do properly (minimum one hour), and yield only
marginally useful information, which is, of course, subject to recall and social desirability
bias (Bernard et al. 1984). If nutritional data are the focus of a research project, I believe
that these shortcomings can be minimized and the efforts they require can be worthwhile.
Dressier also collects genetic information from his respondents, which I did not do. In
Brazil, Dressier works in four neighborhoods to compare socioeconomic levels. My
research was done in one neighborhood of Beira that is home to people from a range of
The Republic of Mozambique is located on the southeastern coast of Africa, and
is bordered by six English-speaking countries: South Africa, Swaziland, Tanzania,
Zimbabwe, Zambia, and Malawi. The country is long and narrow, running north and
south with a 2,500 km coastline along the Indian Ocean. The present capital, Maputo, is
in the extreme south of Mozambique, near its borders with South Africa and Swaziland.
The original Portuguese capital was on Mozambique Island from the sixteenth century
until 1902, in the northern province of Nampula.
The country covers an area of 800,000 square kilometers, making it about twice
the size of California (Nelson 1984). Mozambique is divided into ten provinces, which
are usually grouped into three areas: north, center, and south. As is the case in most
African countries, roads and railways were built to extract the wealth of the hinterlands to
the ports, traversing the country in an east-west direction. Thus, north-south travel
between the northern, center, and southern sections of the country is difficult at best, and
nearly impossible during the rainy season.
The country has a population of slightly over seventeen million (Instituto
Nacional de Estatistica-INE--1999). The population is concentrated in the northern
provinces of Zambezia (3.24 million) and Nampula (3.19 million), plus around one
million people living in the capital of Maputo ibidd). Like most developing countries,
Mozambique's population is young, with nearly 45% of the people under age 15 (INE
Ethnicity and Language
There are ten major ethnic groups in the country, which encompass numerous
subgroups with diverse languages, cultures, and history. The largest of the ten major
groups are the Makua, the Tsonga, the Lomwe, the Sena, the Makonde and the Ndau.
(CountryWatch.com 2002). Ethnic groups in the north are primarily matrilineal, while the
south is patrilineal, with the divide occurring roughly along the Zambeze River.
Portuguese is the official language in Mozambique, which also recognizes 13
other major languages: Emakhuwa, Xitsonga, Ciyao, Cisena, Cishona, Echuwabo,
Cinyanja, Xironga, Shimaconde, Cinyungue, Cicopi, Bitonga, and Kiswahili ibidd).
English is taught in many of the country's secondary schools. According to the 1997
census, 40% of adult Mozambicans report being able to speak Portuguese (INE 1999).
There is a striking difference between the urban areas where 72% of adults speak
Portuguese, and the rural areas, where just 25% can speak it ibidd).
The inhabitants of Mozambique are primarily of African descent (99%), with
.08% of the population of Portuguese or European descent, and .08% originating from
India or Pakistan (INE 1999). The majority of non-African citizens are concentrated in
the urban areas, principally the cities of Maputo, Beira, Nampula, and Quilemane.
Catholic missionaries were an integral part of the Portuguese colonial scheme,
and today Roman Catholics make up about one quarter of the population. Nearly as many
Mozambicans say that they belong to no religion (23.1%). During the socialist period
(1975 through the late 1980s), organized religion was strongly discouraged, which
explains the high number of people in this category. The seventeen percent of
Mozambicans who are Muslim mostly live in the northern, coastal provinces. Several
mainstream Protestant denominations have been present in Mozambique for the past
century, and their members comprise eight percent of the population. In the last decade,
independent evangelical protestant churches have been growing rapidly, and today about
18% of all Mozambicans belong to these churches. (CountryWatch.com 2002).
Arab traders had been coming to Mozambique since 600 A.D., landing in the
northern provinces of Nampula and Cabo Delgado where they established small trading
posts. Vasco da Gama is usually given the credit for being the first European to land in
Mozambique while sailing to India in 1498. But, in 1487, Pero da Covilha landed in
present-day Beira (Sofala), and sent back reports of great gold riches to Portugal.
The Portuguese began to settle and trade in Mozambique in the 17th century, and
they established a system of land concessions (prazo), to encourage Portuguese
settlement. Throughout the 19th and early 20th centuries, the Portuguese struggled with
the British over control of Mozambique. The British were interested unregulated access
to ocean ports for goods from Zambia, Zimbabwe (Northern and Southern Rhodesia), and
Malawi, through rail and land connections to the coast of Mozambique. The Portuguese
wanted to join their largest African colonies (Angola and Mozambique) into one large
colony, but the British colony of Rhodesia stood in the way of this goal.
The Portuguese have long claimed that their colonization policy was nonracial,
that all Mozambicans were citizens of Portugal, regardless of their skin color. Marvin
Harris (1958, 1966), among others, has pointed out that some of these citizens were more
equal than others. The Portuguese colonial government did not make this hierarchy
explicit, however. The division between the races was so thoroughly ingrained that "in
Mozambique "Europeans Only" notices are not needed in order to maintain an almost
perfect separation between the African mass and the Europeans" (Harris 1958 p. 4).
Newitt (1995) describes the colonial racial classification system used to determine who
was exempt from contract or forced labor. In 1917 a system was created whereby an
African could be certified as assimilado (non-indigeneous), and thus fall into a protected
category. In order to qualify as assimilated, an applicant had to show that s/he had
incorporated Portuguese culture (including language and the Catholic religion), and had
completed several years of formal schooling.
Forced labor was a cornerstone of Portuguese colonial rule because the colonial
government earned a significant amount of money by selling contracted Mozambicans as
laborers to the South Africa mines. Miners were required to work for a specified period
of time, housed in barracks under poor health conditions. Harris details the agreement
between the Union of South African and the Portuguese colonial government in the
1950s. "The South Africans pay the Portuguese government $5.25 per recruit, permit the
Portuguese to maintain tax collecting posts within the Union, deliver about half of the
recruits' wages to the Portuguese authorities for payment when the laborer returns to
Mozambique, restrict the maximum consecutive contract time to eighteen months, and
guarantee repatriation" (1966 p. 27).
Portuguese policy inside Mozambique insured a steady stream of recruits for
South Africa and Rhodesia. Mozambican men between the ages of 18 and 55 were
assumed to be unemployed and thus forced to work in service to the government unless
they could provide proof of current employment, or proof of recently completing either
military service or a labor contract in South Africa or Rhodesia. In order to avoid forced
labor in Mozambique, many men took contracts in neighboring countries, returning home
for six months, and leaving again before they were swept up and forced to perform
unpaid labor in the colony (Harris 1958). Many of the migrant laborers used their wages
to buy goods not available to other Mozambicans at the time, such as watches, bicycles,
Expatriate Mozambicans learned of the nationalist movements in other African
countries in the 1950s, and were able to organize in Malawi, Kenya and Tanzania. Inside
Mozambique, the Portuguese state security forces successfully squashed any nationalist
organizations that attempted to organize there (Newitt 1995). Three nationalists groups
joined together in 1962 to become FRELIMO (Front for the Liberation of Mozambique)
in Dar es Salaam, Tanzania. FRELIMO first leader was Dr. Eduardo Mondlane, an
American-trained sociologist, who was working for the U.N. in New York. The armed
struggle for the liberation of Mozambique from Portuguese rule began in the mid-1960s
in the northern provinces along the border with Tanzania. The fight spread to the
central/west province of Tete, which borders on Malawi and Zambia, in the early 1970s.
Independence from Portugal was granted following a military coup in April 1974
that overthrew the Portuguese Prime Minister Antonio Salazar. In July 1975, power was
handed over to FRELIMO, a party that was unknown to most Mozambicans (except in
the "liberated areas" named above), and that was "relatively unfamiliar with much of the
country it was to rule" (Newitt 1995 p. 541). The first president of an independent
Mozambique was Samora Machel, who replaced Eduardo Mondlane after the latter's
assassination by letter bomb in Tanzania in 1966. Samora Machel served as the leader of
an independent Mozambique from 1975 until 1986, when he was killed in a plane crash
(often blamed on the South African government), and was replaced by Joaquim Chissano,
who is the current president.
In the late 1970s and early 1980s, Machel and FRELIMO espoused a domestic
policy of scientific socialism, coupled with a foreign policy of regional activism. The
former included a collectivization of agriculture, government control of all trade, and the
active discouragement of all that was not deemed scientific (e.g., religion and traditional
medicine). The latter policy meant that Mozambique actively supported efforts to
overthrow white minority regimes in Rhodesia (later Zimbabwe) and South Africa. The
FRELIMO government was Marxist-Leninist, and thus was identified as a threat to the
stability of southern Africa in the Cold War.
The Rhodesian government of Ian Smith financed a group of Mozambican
dissidents under the name RENAMO (National Resistance of Mozambique) to destabilize
the FRELIMO government. When Rhodesia changed to majority (black) rule in 1980, the
sponsorship of RENAMO was transferred to the South African Defense Force, which
provided RENAMO with increased training and weaponry, and supplied bases inside
Mozambique. A deadly civil war raged through Mozambique for most of the 1980s,
causing four million citizens to flee their homes (Newitt 1995), and killing nearly a
million people. FRELIMO renounced socialism in the late 1980's, and international aid
agencies accelerated their efforts inside Mozambique to ease the suffering of the war-
The end of the Cold War and preliminary steps to majority rule in South Africa
both contributed to the success of peace negotiations to end the Mozambican conflict. A
peace accord was brokered by Saint Edigio, an Italian Catholic order, from 1988-92 and
was signed in Rome in 1992. When the accord was implemented in 1993, tens of
thousands of soldiers were demobilized, U.N. Peacekeepers arrived, and refugees and
internally displaced people returned to their homes. National elections for president were
held in 1994, and the leader of FRELIMO, Joaquim Chissano, won. Presidential elections
were held again in December of 1999, with the same result, and Chissano is currently
serving his final term as president.
The leader of RENAMO, Afonso Dhlakama, disputed the results of both the 1994
and 1999 elections, and insisted that he be allowed to name RENAMO governors in the
provinces where RENAMO won a majority of the votes. Because the Mozambican
constitution states that the ruling party names the governors, Dhlakama's request was not
allowed. Following the 1999 elections, Dhlakama did not acknowledge Chissano as the
winner, and threatened to establish a parallel government in Beira in early 2000. With
intense international attention focused on the flooding in the south of Mozambique in
February and March of 2000, Dhlakama did not carry out this threat. In the absence of
political victory, he continues to threaten resumption of an armed conflict, relying on his
power base in the center of Mozambique.
Although Mozambique's liberation movement began in the northern provinces,
FRELIMO's core leadership, Mondlane, Machel and Chissano, come from the southern
provinces of Mozambique. Many Mozambicans openly express their opinion that
FRELIMO is biased toward the needs of the south of the country. FRELIMO chose its
candidate for the 2004 presidential election on June 8, 2002. They selected Armando
Guebuza, another southerner, who has been active in FRELIMO since 1968, and was
involved in negotiations of the Rome peace accord (AIM June 8, 2002).
Since the civil war ended, the economic growth rate in Mozambique has averaged
an impressive 10% per year, even in the year 2000 when the country suffered from
devastating flooding in the south. The majority (70%) of the citizens are subsistence
farmers, and most people are extremely poor, with the average per capital annual income
at $267 (INE 1999). The economy is growing in a few key areas. Commercial agriculture
produces cashews, sugar cane, cotton, tea, and copra. An aluminum plant in Maputo (a
joint-venture with South Africa) was the largest contributor to Mozambique's exports in
2001. Investments are being made to increase tourism, and the country earns money
selling petroleum and natural gas, as well as by providing shipping and port services. The
economy is also helped by remittances sent by Mozambicans working outside the
country, and the sale of hydroelectric power from the Cahora Bassa dam to South Africa.
The Mozambican currency is the metical (plural meticais). The floods of 2000
triggered a sharp period of inflation, and the value declined from approximately $1 =
12,000 meticais in June 1999, to $1 = 16,000 meticais in June 2000. Inflation throughout
2000 and 2001 continued the slide in the value of the metical against the dollar. During
the research period it dropped from $1 = 18,000 in November 2000, to nearly $1 =
21,000 in November 2001. The metical remained been relatively stable in 2002, ending
the year at around 24,000 per dollar. The World Bank required the Mozambican
government to privatize state-owned assets in order to qualify for assistance. A structural
adjustment program began in 1987, the Economic Recovery Program, became the Social
and Economic Recovery Program in 1990 in order to place more emphasis on the social
aspects of economic change. By 1998, as Alden reports "over 850 state concerns had
been sold off to Mozambicans or to Mozambican companies, while foreign equity
interests in these purchases have stood at roughly 50 per cent" (2001 p. 85).
While privatization is designed to stimulate a free market economy, in
Mozambique it has also had a role in "the deepening of the patronage networks as
providing fresh sources of capital and unleashing Mozambicans' inherent entrepreneurial
spirit" ibidd p. 117). Western nongovernmental organizations (NGOs) poured into
Mozambique in the late 1980s and early 1990s. Some NGOs work within the government
ministry structure, while others work autonomously and create parallel programs.
Mozambique is one of the most aid-dependent countries in the world, with an ever-
increasing foreign debt and little autonomy to determine its expenditures (Hanlon 1996).
Despite structural adjustment restrictions, the Mozambican government tries to
provide access to biomedical services to its population. The staff at most hospitals and
clinics is poorly trained and paid, not well motivated, and thus provide low quality
services. In Maputo, there are numerous private clinics for those who can afford them,
but the majority of the country relies on government health facilities. The government
subsidizes health care by providing most consultations free of charge, and medications at
a greatly reduced price in hospital and clinic pharmacies. Unfortunately, staff members
often charge patients a fee for their services (although this is illegal) and hospital
pharmacies claim to have few drugs available. Outside the health facilities there is a
system of state-run pharmacies selling subsidized medications, plus private pharmacies,
which are the best stocked but whose prices are too high for most Mozambicans.
There is a sharp contrast in basic health indicators between the urban and the rural
areas. At birth, the life expectancy in the rural areas is 40.2 years, compared to 48.8 in the
city (INE 1999). A similar disparity is seen for life expectancy at age ten, with rural men
and women living to an average age of 46.3, while city dwellers live until age 49.5 ibidd).
The crude mortality rate (all deaths per 1,000) is 14.3 for urban Mozambicans, but is 24.0
for those in the rural areas ibidd). Nationwide, 245 of every 1,000 children bom alive die
before age five ibidd). AIDS is a growing health threat in Mozambique, with an
estimated 16% of the adult population now infected with HIV (Ministry of Health 2001).
AIDS infection rates are the highest in the three central provinces of Manica, Sofala and
Tete ibidd), possibly the result of the increased mobility of the population, particularly
related to the movement of refugees and soldiers during the civil war.
The Portuguese colonial government attacked the practice of traditional medicine.
Later the socialist FRELIMO government also persecuted it for being non-scientific. In
sharp contrast, it is today officially embraced by FRELIMO under the rubric of
AMETRAMO (The Mozambique Traditional Doctors Association), a government-
sponsored group. Traditional medical practices in Mozambique encompass a range of
diagnostic and treatment techniques. Practitioners use a variety of different treatments,
including plant-based treatments, consultation with spirits, home births, divination
through the throwing of bones or stones, and prayer with patients. Missionaries provided
most of the early descriptions of traditional medical practices in Mozambique. Henri
Junod (1912) first described the practice of traditional medicine among the Thonga in
southern Mozambique as he observed it in the late 19th century. Dorothea Earthy (1933)
worked with Valenge women from 1917 through 1930, and describes their medical
practices in a chapter her book on Religion, Magic and Sorcery.
In recent years, there has been an increase in research on traditional medicine
across Mozambique. Two Mozambican anthropologists, Josefa Marrato and Alcinda
Honwana have studied the ways in which traditional medicine was used to help the
country recover from the civil war (Honwana 1997, Marrato 1996). Elisa Muianga
(1996), a Mozambican historian, also researched the role of traditional medicine in
healing war trauma, specifically among women who had been kidnapped by RENAMO.
Robert Marlin (2001) studied traditional medicine, infertility, and AIDS in response to
wartime experiences in Tete province. James Pfeiffer (2002) is engaged in an ongoing
study of healing within emerging independent protestant churches. Harry West (1997)
looked at sorcery and power in the northeast, and Christy Schuetze (n.d.) examined the
reemergence of women traditional healers (curandeiras) in Sofala province. Carolyn
Nordstrom (1997) documented the war between FRELIMO and RENAMO in what she
terms "ethnography of a war zone", which includes documentation of the persecution and
successes of biomedical and traditional healers.
Contact and Exchanges
Mozambique has had prolonged contact with other countries, particularly its
neighbors in Southern Africa. Beginning with male labor migrants to South Africa and
Zimbabwe, during colonial times, Mozambicans were exposed to Western lifestyles and
the consumer goods they brought back. Nationalist leaders learned about different
political and economic ideologies while in exile in Tanzania, Kenya, or other sympathetic
African and European countries. Many Mozambicans studied abroad in countries as a
result of scholarships provided in socialist solidarity between 1960-90. More recently,
students are beginning to study in the rest of Europe, Brazil, South Africa, and North
America. In addition to these contacts, Mozambique was greatly influenced by the
presence of European colonial powers, like Britain and Portugal. At independence in
1975, Portugal offered citizenship to Mozambicans with any Portuguese ancestry. As a
result, many urban Mozambicans have relatives working or studying in Portugal, which is
seen now as a gateway to the rest of the E.U. One indication of the strong links between
Mozambique and Portugal is reflected in the routes of Mozambique's national airline
(LAM). Non-stop flights to Portugal on LAM are offered several times per week, and it
costs the same to fly to Lisbon from Maputo or from Maputo to the north of the
Mozambique (approximately $400).
I spent three months in Mozambique on a pre-dissertation visit in the summer of
1999. My original plan was to study the long-term health effects of war trauma and how
traumatic wartime memories affected stress level and health. I traveled across the
country, visiting eight of the ten provinces, interviewing and observing. I interviewed
university professors, NGO employees, government workers, housemaids, truck drivers,
and health care workers. I was told repeatedly that most people had put the war behind
them, and that the most common stressor was change in the economic situation, owing to
Mozambique's shift to a free market economy and the dictates of the World Bank. As the
government privatized its holdings, previously secure government jobs were no longer
secure. Non-productive factories were closed and the workers were laid off. This
downsizing also affected the rural people, particularly those who participated in the cash
economy growing cotton or cashews, as the government withdrew its support for those
These economic changes are due to both internal and external forces, but
determining the causes and assigning blame is not a high priority for most Mozambicans.
What is most important is that they no longer have a job, cannot sell their crops for the
same price, or fear that their livelihood may be the next victim of reforms. Under the
colonial administration, job possibilities for black Mozambicans were extremely limited,
and the government underpaid cash crop producers. In the first years of independence,
anyone who had any formal education was pressed into service because of the needs of
the country, the government payroll swelled, and agricultural subsidies were high. The
latest turn on this roller coaster is the paring down of the government workforce, growth
in the private sector, and minimal government investment in the agricultural sector. Job
seekers must have appropriate credentials, compete for positions, and be productive in
order to keep a job.
The potential for great wealth exists for some black Mozambicans, and consumer
goods are pouring into the country. FRELIMO no longer restricts the type, quantity, and
price of goods that can be sold, but few can afford the luxury items like CD players,
cellular phones, and washing machines. To summarize what I was told in 1999, many
Mozambicans feel like the rules of economic survival keep changing, and they are
stressed by having to keep up with these changes, by having to play by rules that are
different from the ones they learned growing up.
The City of Beira
Beira is the capital city of Sofala province, located on the coast of the Indian
Ocean at the mouth of the Pungue river. The province had a population of 1,289,390 in
the latest (1997) census, and the city is home to 397,368 inhabitants (INE 1999). Beira is
the second largest Mozambican port, providing access to the Indian Ocean for central
Mozambique, and the landlocked countries of Zimbabwe, Zambia, and Malawi.
Proximity to the ocean make it prime for fresh seafood of all varieties, and for hot, humid
weather during the summer months (October through March).
The city of Beira is divided into 26 bairros, eight in the "cement city", and 18 in
the "reed city". Cement city is the term used for the areas where houses are of a solid
construction (usually concrete block), while reed city describes neighborhoods where the
houses are made of locally available materials such as grass, mud, stones, and thatch.
As Beira is at the crossroads of Mozambique, it is home to many religions. The
Catholic Church has the strongest presence given its affiliation with, and assistance from,
the Portuguese colonial government. The Fransiscan arm of the Catholic Church
established itself in Beira in 1898 (Newitt 1995 p. 435). Beira is also home to numerous
protestant churches, Muslim mosques, and other places of worship.
The 1997 Census data are not available at the level of the city or the bairro, but it
is divided into urban and rural areas of the province. In the province of Sofala there are
two urban areas, Beira and Dondo (pop. 71,644) ten miles away while the rest of the
province is classified as rural. The distribution by religious affiliation in rural and urban
Sofala province is shown in Table 2-1.
Table 2-1. Percent religious affiliation, in urban and rural Sofala province (INE 1999).
Zionis Catholic Protestant Other Jehovah Muslim Other None Don't
t Christian Witness Know
Urban 11.8 26.3 13.6 1.1 0.5 4.3 2.3 36.5 3.6
Rural 22.0 9.2 6.1 0.1 0.3 0.3 3.8 53.0 5.0
This table shows two important patterns in religious affiliation in the rural and
urban areas. First, urban dwellers that claim a religion are mostly Catholic or Protestant,
with the category Zionist in third place. The same three religions are the most frequently
mentioned in the rural areas, but the Zionist churches replace the Catholic Church as
having the most members. The small number of Muslims anywhere in Sofala reflects the
low number of Muslims in the center of the country, and a concentration of Muslims in
the urban areas. Second, Western religions appear to play a more important role in the
urban context, compared to rural areas, where 53% of the people report no religious
affiliation. FRELIMO's policy of discouraging religion, both traditional and Western, was
renounced in late 1980s. After that, churches have been growing steadily in membership,
faster in the cities, and with the Zionist churches having more success in the rural zones.
Ethnicities in Beira
Referring again to the census data (INE 1999) for the urban areas of Beira and
Dondo, racial or ethnic data on urban Sofala is presented in Table 2-2. The census uses
the term "Somatic Type/Origin" for this classification. The breakdown of black and non-
black citizens for Sofala province parallels the national statistics -- overwhelmingly of
African ancestry but with some mixed and non-black residents, primarily in urban areas.
Table 2-2: Race and ethnicity in the cities of Beira and Dondo (INE 1999).
Black I Mixed White Indian Other Unknown
Number 514,143 10,962 989 1,578 476 3,643
Percentage 96.7 2.1 0.2 0.3 0.1 0.7
Historically, the center of Mozambique, and Beira specifically, had a great deal of
contact with neighboring countries, principally Southern Rhodesia (today Zimbabwe),
Malawi, and South Africa, and with people from various European countries. Newitt
(1995) states that in the late 1800's, there was little Portuguese presence in the colony,
even in the two largest cities (Beira and Laurenco Marques). "There were numerous
foreigners British, Boers, Germans and others crowding the port towns of Beira and
Laurenco Marques [today Maputo], but they were seen by the struggling colonial
administration as a threat rather than as a help." (p. 364). The Portuguese could not
manage the entire colony so they contracted out most of the territory to private companies
that took responsibility for the administration (including taxation) and pacification of the
people living there.
The Companhia de Mogambique was given control over the two central provinces
of Sofala and Manica from 1891 to 1941. "The Governor of the territory and a majority
of the board members had to be Portuguese" (Newitt 1995 p. 369), but the majority of the
money was British or French, and the company came to be under the control of a
Belgian, Albert Ochs. Primary projects in the territory during this period were the
building of a railroad between Rhodesia and Beira, and the development of the port of
Beira. These contributed to a mini-boom in the population of Beira, which in 1898 had
4,223 inhabitants (1,172 of them European). By 1910 there were 6,665 people living in
the city (Newitt 1995). Newitt reports that Beira had a "distinctive British flavour" (p.
396), with sports clubs and bars catering to the British and the issuance of a "sterling
currency" ibidd) by the Banco de Beira. By 1928 the city of Beira had 23,694 residents, of
whom 2,153 were European (Newitt 1995 p. 442). The Companhia de Mogambique sold
the railroad to the Portuguese colonial government in 1949, after their lease on the two
Beira was a popular vacation spot for white Rhodesians beginning during the
period of the Companhia de Mocambique and continuing until 1975. After World War
Two, the white population in Rhodesia expanded, and "Beira beckoned to them as a
seaside resort offering water sport and an element of Latin culture" (Newitt 1995 p. 469.)
Their enjoyment of the beach, seafood and nightlife in Beira, primarily during the Easter
holiday and the month of July (the coolest winter month), continued through to
Mozambican independence (Alexander 1971).
During the civil war in Mozambique (1978-1992) the strategic Beira corridor was
kept open by stationing Rhodesian, (later Zimbabwean), troops along the 250 kms from
the coast to the border with Rhodesia (Zimbabwe). In December of 1990, an agreement
between FRELIMO and RENAMO was signed that included a provision whereby
"RENAMO agreed not to attack the rail corridors from Zimbabwe to the sea in return for
the withdrawal of Zimbabwean troops to those corridors." (Newitt p. 573). During the
civil war the city of Beira remained under government control, but RENAMO had, and
still has, very strong support in the city, and across the province of Sofala. As noted
above, Dhlakama moved to Beira following his loss in the 1999 presidential elections,
did not recognize the election results and threatened to set up a parallel government.
As mentioned earlier, the government has privatized or closed down many of its
holdings in the past fifteen years. In Beira, this included the shutting of several
govenrment-run factories and laying off their employees. At the same time, foreign
companies are now permitted to operate inside the country. A Scandinavian
telecommunications company won a bid to install cellular phone service in Beira
beginning in 2000. A large South African company sells satellite television dishes and
service which allow the wealthy to watch more than thirty channels, primarily from South
Africa. Mozambican television was only introduced to Beira ten years ago, and carries a
variety of news programs, Portuguese game shows, and Brazilian soap operas. Beira has
one movie theater where the cost of a ticket ranges from $1.50 to $2.25 and the films
featured tend toward either action-adventure or romantic comedy genres.
The majority of people in Sofala province back the RENAMO political party, and
there is a strong feeling of neglect from the FRELIMO government in Maputo.
RENAMO has requested that they be allowed to name governors in the provinces where
they won a majority of the votes. Seventy-four percent of voters in Sofala voted for
RENAMO's Dhlakama for president in 1994, and 79.9% voted for him in 1999.
RENAMO has a visible presence in Beira and across the province. On the 9th of
November 2000, RENAMO sponsored demonstrations across Mozambique against the
government. One of the larger rallies was held in downtown Beira. The RENAMO office
for Sofala province is on the main street of Beira, in the posh residential neighborhood of
Macuti. There is strong resentment in Beira that the FRELIMO government neglects the
center and north of the country. Popular belief is that it only provides infrastructure and
other development to the southern provinces, home to most of its supporters.
One often-cited example of this neglect is the state of the roads in Beira compared
to Maputo. The roads are in terrible shape, with huge holes and crevasses filling up with
mud and/or water during the rainy season. The paved roads are poorly built and
maintained, and the unpaved roads (primarily in the reed city) turn to mud and many are
impassable for several months. The national government awarded a contract to a South
African road repair company that started work in August 2001 and was continuing to
repair roads throughout the city when I left in November 2001.
A new FRELIMO governor was transferred to Sofala province from neighboring
Manica province as the research began. Felicio Zacarias has popular support and people
have high expectations that he will be a positive force in bringing development to the
province. He has denounced corruption and incompetence in the provincial government,
and in a populist gesture, opened the road in front of his residence to traffic. It was
previously closed from 7pm to 6am. The governor has fired medical staff members who
provide poor service to or demand bribes from citizens, and he is rumored to drive around
in Beira incognito to entrap policemen seeking bribes (AllAfrica.com 2002).
During Portuguese colonial rule, blacks were not permitted to walk on the
sidewalks in Beira, or to even be in certain neighborhoods after dark. Most of the cement
city was reserved for white and a few Indian or assimilado residents. Black residents
worked in these neighborhoods, but if they were there after dark they had to show a pass
from their employer. The Portuguese built a hospital in the neighborhood of Ponta Gea
for Europeans (Hospital dos Europeus), and another hospital for the "indigenous
population" (Hospital dos Indigenes) in another part of town.
Today, people are generally free to live and walk anywhere in town. However,
there are two gated (with barbed wire) communities in the neighborhood of Macuti, one
for employees of the pipeline being installed between Beira and Zimbabwe. The second,
often termed the "Apartheid complex", is for anyone with enough foreign currency to
afford the rent. Guards monitor the entrance, stopping unknown blacks from entering,
and allowing all whites (residents or not) to come and go. Many of the nicer homes in
Macuti, Palmeiras and Ponta Gea have guards, who open and close the gate, and provide
a degree of security.
The most difficult relations between ethnic groups are between blacks and
Indians. Of the latter, those who come originally from South Asia are simply referred to
as Indian because their families usually immigrated before the creation of Bangladesh or
Pakistan. The Indian residents we contacted for the survey were welcoming and usually
agreed to participate. Still, my research assistants were surprised and commented on how
hospitible the Indian participants were, noting that they had not previously been invited
into Indian homes, They quickly added that they would not have recieved the same warm
reception had I not been there, and probably would not have been invited in.
Health Care in Beira
Beira has one hospital (The Beira Central Hospital -HCB formerly the
Indigenous Hospital), a private clinic, and several government clinics. The European
Hospital in Ponta Gea has been converted into a large health center, with various out-
patient specialty clinics. A large number of the doctors at the HCB are expatriates,
including German, Cuban, and Vietnamese doctors. The government clinics are designed
to serve as referral points to the HCB and in many cases they fulfill this function. Rural
residents usually consult a health clinic first for an illness, and obtain a referral form to
the hospital if they require more attention. However, most residents of Beira go directly
to the HCB outpatient department for their health complaints.
The private health care clinic opened in 2000 in the heart of the downtown, and is
open 24-hours a day. Doctors from the HCB moonlight there after their shifts at the
hospital. Interestingly, many doctors use the private clinic as a way to make contact with
wealthy patients, who then continue their care at the HCB. The doctors are paid a flat
salary for their hours at the private clinic, and are not allowed to charge the extra fees
routinely found at the HCB. If a wealthy patient from the private clinic continues his or
her care at the HCB, the doctor can charge a fee to give that patient priority access and
avoid a long wait.
There are government subsidized pharmacies located at the hospital and health
centers. As mentioned above, these often have very few drugs available. Beira also has
subsidized pharmacies away from these health facilities. Medications can be purchased at
private pharmacies and the open-air markets. These same markets also sell traditional
medicines, although usually in a separate section of the market.
A nurse training school operates at the Beira Central Hospital, and a medical
school at The Catholic University which opened in 2000. The two main problems
contributing to poor medical services in Beira is a lack of medical personnel, and lack of
adequate pay for those in the system. In addition, there is a general lack of modem
equipment and poor maintainence of existing technology.
The AIDS infection rate in Sofala province is estimated to be 17.8% of people
over the age of 15 (Ministry of Health 2001). The nationwide incidence rate is around
Traditional medicine exists throughout Beira, but it has a low profile in the
cement city. A traditional doctor in Ponta Gea advertised in the local newspaper, but
when I went to his house, the neighbors told me he had moved to Maputo because he was
sick. A synopsis of Beira written by the Catholic University states "Traditional and
modem medicine must collaborate with each other, each one knowing its own
limitations" (Magondone n.d. p.29). This echos the Mozambican national policy of
collaboration between biomedicine and alternative or traditional medicines. However, I
was never able to detect any evidence of collaboration with traditional healers during my
many discussions and visits in Beira to the medical school, hospital, health centers, or
provincial Ministry of Health.
Economic and Academic Setting
The two most important economic engines in Beira are the port and the railroad.
These two work together to generate the bulk of the profits made in the province for the
government. They link the landlocked countries of Zambia, Zimbabwe, and Malawi to
the sea. Unrest and economic turmoil in Zimbabwe is threatening its ability to pay
shipping costs, which could severely affect Beira's economy. The governor of Sofala
province, Felicio Zacarias, recently commented on the potential impact of Zimbabwe's
problems on the province. "The old products that used to be exported from Zimbabwe,..
are now being imported to Zimbabwe. .. .this will have an impact on the economy,
especially in the central region of Mozambique" (AllAfrica.com 2002).
Beira is home to the Catholic University of Mozambique (UCM), and a branch of
the national Pedagogical University (UP). The UP is based in Ponta Gea and trains
teachers in a variety of disciplines. The majority of the UP's students have been teachers
at the primary or secondary level who were selected to continue their formal training. The
UP is a national university with a diverse student body, including students of all ages,
socioeconomic backgrounds, representing several provinces. There is a dormitory for
single students, while married students rent off campus or live with relatives.
The main campus of the Catholic University is in Palmeiras, where the university
administration and faculty of Medicine are located. The Economics faculty is located in
Ponta Gea, and offers day and night classes. Approximately 500 students study
economics at UCM and their Ponta Gea campus is expanding. UCM does not have an
entrance exam like the national universities (Eduardo Mondane U. and the UP).
Admission is based on an ability to pay between $500 and $700 (U.S.) per semester in
tuition, resulting in a primarily wealthy student body.
Geography and Demography
According to the most recent census (INE 1999), the neighborhood of Ponta Gea
is home to 23,879 people, of whom 10,994 are female, and 12,879 are male. Slightly
more than half the people living in Ponta Gea are over the age of 16 (14,321 or 60%),
making its population older than the rest of the country as a whole. In my survey, I
interviewed people in Ponta Gea who were over the age of 30. The recent census data
(INE 1999) show that there are 6,050 over age 30 living in the bairro (or 25.3% of the
people). Skewing of the population towards the younger age groups, a common pattern in
developing countries, is seen across Mozambique.
Ponta Gea is one of the classiest neighborhoods in Beira, made up of
predominantly large houses and enclosed yards, with seaside restaurants and a large
(former) luxury hotel. A South African writer described Ponta Gea, and one of its
landmarks, in a book about vacation spots in Mozambique (Alexander 1971). "Beira's
most impressive hotel, the Grande on Rua Dr. Sousa Pinto in the fashionable Ponta Gea
suburb, has long since closed its doors." (p. 126). The Grande Hotel was built during a
short-lived Central African Federation in the 1950's, but was closed in the early 1960s
due to lack of clientele able to afford its high rates. Today, the Grande Hotel is an urban
planner's nightmare, a nice oceanfront location, yet inhabited by more than 1,000
squatters living without electricity, sanitation or running water. The Mozambican
government is rumored to be planning to relocate these people because the hotel's
foundation is sinking.
Ethnic and Political Divisions
Because it is an upscale neighborhood, the percentage of non-Mozambicans and
non-black Mozambicans living in Ponta Gea is higher than the percentages given in
Table 2-2 above. Although reliable statistics on the presence of non-black Mozambicans
and foreigners in the neighborhood are not available for Ponta Gea, the research team
found people with the following nationalities living there: Chinese, Brazilian, Indian,
Spanish, Italian, Zimbabwean, French, British, Russian, Cuban, Portuguese, Canadian,
Dutch, Norwegian, Greek.
While non-Mozambicans could not be included in the study, non-black
Mozambican citizens were included, mostly of Portuguese and Indian descent. A total of
39 non-blacks participated in the survey portion of the research (15% of the total sample
of 261), 16 of European descent, and 23 of Indian descent.
As mentioned earlier, the cement city, including Ponta Gea, was restricted to
whites and a few assimilado blacks during colonial times. Prior to 1975, black citizens
were allowed to work in homes and businesses in Ponta Gea, but had to leave by dark.
When Mozambique became independent, the majority of Portuguese citizens fled the
country, fearing for their safety.
At this time, the FRELIMO government nationalized ownership of all houses in
Mozambique and allotted them to individuals and families. Many of the large houses in
Ponta Gea were subdivided by their occupants into apartments and, along with garages
and dependencias (outbuildings on the lot), were rented out to generate income. At the
same time, there was an influx of residents moving, legal and illegally, into Ponta Gea,
swelling the population of the bairro.
In the last decade, the Mozambican government began the process of giving
occupants individual ownership of their residences. Each apartment or house's value was
assessed and the people living in the house were allowed to make monthly installments to
a government agency, hoping one day own their home. Homeowners (or owners-to-be)
can rent out their apartment or house to individuals or businesses, banking the money as
they live elsewhere. It is not unusual to see an NGO (non-governmental organization)
office in one half of a duplex or a small government office on the first floor of an
apartment building. The result is a bustling mix of individual homes, multiple-dwelling
residences, commercial and government activity, plus educational and religious
institutions co-existing in the neighborhood. Taking into account the changes that have
taken place in the population of Ponta Gea in the 27 years since independence, it is not
surprising that it is home to people representing a variety of socioeconomic, educational
and religious backgrounds, coming from across Mozambique and beyond. A map of the
bairro of Ponta Gea is found in Appendix A.
These non-residential installations are located in Ponta Gea:
* Universidade Pedagogica (one of three campuses in the country)
* The Economics faculty (classrooms, library, offices) of the Catholic University
* The City's main Catholic Cathedral, including its radio station, Radio Pax
* A variety of Protestant Churches
* The Governor's residence
* The National Institute for the Visually Impaired (school and residences)
* The Zimbabwean Consulate
* Six restaurants, including one that doubles as a nightclub.
* Three Bakery/Cafes.
* Police Station
* State-run Pharmacy
* Military / Police Out-patient Clinic
* Government Out-patient Clinic and Maternal Child Health Center
* Grande Hotel (now inhabited by several hundred squatters)
* Red Cross of Mozambique delegation offices.
* German Cooperation (GTZ) offices.
* Action Contre la Faim (a European Development agency).
* ACDI-Voca, an American NGO.
* Special School for Deficient (Handicapped) Children.
* The Mozambican Secret Police office.
* An open-air market the Bazaar of Ponta Gea.
* The city golf course.
* The cotton advisory board office.
* The sports center, basketball pavilion, and a soccer stadium.
* The Education Office for the City of Beira.
* The Marriage Palace (a non-religious wedding site)
* Two small hotels
* The World Food Program (U.N.) offices.
* Provincial Library.
* Provincial Meteorology Station.
* Offices of the Catholic Diocese.
* Provincial Agriculture and Rural Development offices.
Health Care in Ponta Gea
Biomedical services in Ponta Gea are available at the large health care center
(formerly the European Hospital) or a clinic run by the Mozambican police. The latter
was originally organized to provide health care to members of the force and their
families. In the past few years, this clinic has expanded to include other clients willing to
pay a nominal fee. Most of the people I interviewed in Ponta Gea refer to the Police
Clinic as "private" because it is less crowded than the other health care center, clients
who are not police pay a small fee, and it is run more efficiently. However, this clinic is
technically not private because it is subsidized by the state and the staff are all
The health care center located in the former European Hospital offers a range of
services, including several special clinics. The campus of the European Hospital was
large and included more than a dozen buildings, but the present-day Ponta Gea health
center operates in only part of these installations. Pre-school (well-child) clinics are
offered daily and are attended by fifty to eighty women and their children. The health
center also has an evening outpatient clinic for those unable to attend during the day and
a weekly clinic for the treatment of sexually transmitted diseases. Participants in our
study who were found to have high blood pressure were offered a referral to the Ponta
Gea health center for follow-up care.
Ponta Gea has three pharmacies, at the public and police health centers, plus one
that is state-subsidized but freestanding. Just beyond the edge of Ponta Gea, inside the
limits of the downtown area, is a well-stocked private pharmacy.
The Universal Church of the Kingdom of God (IURD) in Ponta Gea provides
healing services for anyone who wants them. They hold services seven days a week, three
times per day on weekdays. The Tuesday services revolve around healing mental and
physical ailments. This church is one of the fastest-growing churches in Mozambique and
healing is an important aspect of its appeal (Pfeiffer 2002).
Events of Note during Fieldwork in Beira
During the year I lived in Ponta Gea several important events happened there and
across the country. On November 9, 2000, RENAMO organized demonstrations in
several provinces. Forty people were killed and one hundred injured in the ensuing
violence. In the northern town of Montpuez, seventy-five people who had been detained
during the demonstrations suffocated in a jail on November 21st.
The next day, November 22, 2000, a well-known journalist Carlos Cardoso was
assassinated outside his office in Maputo. At the time of his murder, he was investigating
a case of bank fraud that was rumored to reach into the highest levels of the government.
Dr. Antonio Siba Siba Macuacua, was appointed in April of 2001 by the government-run
Bank of Mozambique to clean up and re-organize the failing Banco Austral. He died on
Saturday August 11 h, 2001 after falling fourteen floors from the bank building, while
preparing his final report, due that Monday.
Closer to home, we experienced other national events in Beira. The Mozambique
national school sports festival was held in June of 2001. The primary venues were in
Ponta Gea, where teams and individuals competed in basketball, track, soccer, and
volleyball. The leader of RENAMO, Afonso Dhlakama, took up residence across the
street from our home in Ponta Gea during July and August of 2001. He used the rented
home as a base to visit and mobilize communities in the central provinces.
The FRELIMO national party congress was held in Ponta Gea for three days in
mid-September 2001. President Chissano led the party as they re-dedicated themselves to
reducing poverty, fighting crime and corruption, encouraging investments and rural
development, and ending regional imbalances (AIM 2001). Around the same time, a
retrospective on the life and work of Samora Machel, was on display at the Ponta Gea
sports center. Despite the popularity of RENAMO in this area, the Machel retrospective
was well attended, and many people I spoke with in Ponta Gea recall him, and the years
he ruled Mozambique, very fondly.
REVIEW OF THE LITERATURE
This chapter begins with a review of the literature on risk factors for high blood
pressure in Africa. From this overview, it becomes clear that the risk factor of
psychosocial stress for hypertension is important but has not been sufficiently explored.
Next, I review the topic of psychosocial stress: its causes, definitions, techniques that
have been used to measure it, and how social support can mediate it. One source of
psychosocial stress is dissonance with cultural norms. The final section of this chapter
reviews the literature on cultural consensus modeling (CCM), and discusses how CCM
can be used to create cultural models that are then used to measure an individual's
consonance or dissonance with core cultural models.
Definitions of Terms Used
I use the terms hypertension and high blood pressure interchangeably in this
chapter. When blood pressure is used alone, it refers to the measure of a physiological
indicator. The type of hypertension discussed in this paper is essential hypertension, as
distinct from pregnancy- or chemically-induced hypertension. The term Africa refers to
the continent south of the Sahara.
The World Health Organization defines hypertension as arterial blood pressure
above 140/90 mmHg (World Health Organization/International Society of Hypertension--
WHO/ISH 1999), while many European and African countries define it as above 160/90
mmHg (Cruikshank et al. 2001, Steyn et al. 2001). Most published studies of
hypertension use one or both of these cut points to define hypertension. Normally, study
participants who report taking antihypertensive medications are placed into a category of
hypertensive. Their blood pressure measurements are usually excluded from the data
analysis, since these may be affected by the medication.
Comparing epidemiological research on hypertension is difficult. Researchers
often do not use standardized sampling, definitions of hypertension, or methods of
collecting key data like age, blood pressure, and obesity. Most studies of hypertension in
Africa are cross-sectional and use non-random samples, usually relying on hospital or
clinic patients for subjects. Still, comparison is important, and we can find patterns
despite this lack of standardization in measurement or sampling.
An Overview of Hypertension in Africa
Risk Factors for High Blood Pressure
Hypertension is attributable to multiple risk factors, although its specific etiology
is unknown. It is not possible to identify one risk factor for the development of
hypertension in a group or individual. A noted expert on hypertension in Africa, Dr.
Walijom Muna (1996) explains: "...there is not one unique environmental or hereditary
explanation for these geographic and ethnic differences [in blood pressure]. They are the
result of a complex interaction between various genetic and environmental factors. We
have to consider the psychosocial and cultural factors, even though they are difficult to
measure qualitatively or quantitatively, because they could be very important
determinants in the rates of hypertension" (p. 11 S, my translation).
Despite the fact that hypertension is a multi-factorial condition, we can measure
its established risk factors, evaluate their relative contributions to high blood pressure in
Africa, while at the same time continuing to explore the contribution of other, less well-
documented risk factors. Lore (1993) hypothesizes that the main contributing risk factors
for hypertension in Africa are "consumption of sodium salt and alcohol, psychological
stress, obesity, physical inactivity, and other dietary factors" (p. 357). I begin with a brief
overview of the more frequently studied risk factors (age, alcohol and tobacco use, diet,
obesity, physical activity and sex), and then discuss the available evidence for social and
psychological factors, including rural and urban residence.
Early studies of blood pressure in Africa found little or no increase in prevalence
rates with age (cf., Donnison 1929, Williams 1941, Shaper 1967). In the past 30 years
however, most studies have noted an increase in risk with age. Urban residents of Dakar
(Astagneau et al. 1992) had astonishingly high prevalence rates for the age groups of 55 -
64, and 65 and older. Women had rates of 66.7% and 81.8% respectively, while men had
rates of 60.8% and 68% for the same age groups. In a Liberian study, women had a much
steeper increase in risk with age than men (Giles et al. 1994). Lore notes that "virtually
all the studies from West Africa show a rise in....blood pressure with age" (1993 p. 358).
In a comparison of two populations in South Africa, Mollentze (1995) observed that
hypertension rates increased with age in both the rural and the urban sites.
Alcohol and Tobacco Use
Available data on the effects of smoking and alcohol use on hypertension in
Africa are currently inconclusive. A research team in Tanzania (Edwards et al. 2000)
divided their respondents into daily smokers or non-smokers, and heavy drinkers vs. non-
heavy drinkers of alcohol. The effects of these two variables had mixed results in their
study of 1,698 people in an urban district and a wealthy rural area. In the urban area,
hypertensive men were significantly more likely to be heavy drinkers than non-
hypertensive men, while hypertensive women were more likely to be daily smokers than
non-hypertensive women ibidd). Yet, in the rural area, neither factor was significantly
different between the groups. Mbaya (1998) observes that "most hypertensive presenting
at [Kenyatta National Hospital] do not imbibe alcoholic beverages, do not smoke,
consume very meagre rations of meats and their by-products" (p. 301). Despite Lenfant's
(2001) generalization that "the risk factors for cardiovascular disease are the same in
different populations" (p. 980), there is not consistent evidence that smoking or alcohol
use are predictors of hypertension in African populations.
There is an ongoing debate about salt intake and salt sensitivity and blood
pressure in African and African American populations (c.f Wilson 1986, Wilson and
Grim 1991, Curtain 1992, Dimsdale 2000, Kaufman 2001). This debate centers on two
issues related to salt; 1) low availability and use of salt in many parts of Africa prior to
European contact, and 2) a selective pressure for an ability to store salt in these low-salt
During the Pleistocene ... [m]an's sodium intake was most likely comparable to
what the Bushmen obtain today from their natural diet. Perhaps this was adequate
for early man most of the time. However, it is reasonable to postulate a small but
constant selection pressure from sodium depletion heat exhaustion against those
individuals who lost more sodium during a hunt. (Gleiberman 2001)
One explanation for the low blood pressure readings found among pastoralists in
East Africa is that they have a very low salt intake. Mugambi and Little (1983), note that
low salt intake, along with "absence of stress of civilization and low dietary fiber" (p.
869) contributes to low blood pressure among the Turkana of Kenya. Lore (1993)
explains that ash was previously used in Kenya to flavor food, but that ash was replaced
by salt as the preferred flavor enhancer. Hunter et al. (2000) studied blood pressure in
three groups of rural Zimbabwean women (n=515). Sodium-potassium ratios were
predictive of high systolic and diastolic pressure for all age groups. (This study is
described further below, in the section on intra-rural variation.)
Damasceno (1999, 2000) studied sensitivity to salt intake among hypertensive
patients in Maputo, Mozambique. The author notes that salt sensitive hypertension is
generally found at higher rates among black hypertensives when compared to whites, is
correlated with age and obesity, and that salt-sensitive patients tend to experience a
higher climb in blood pressure over time (1999 p.28). A recent pilot study with 20
participants in Ghana (Cappuccio et al. 2000) found that reductions in urinary sodium
(encouraged by nutrition education) were accompanied by a fall in systolic and diastolic
Diet: Fat and Fiber
A study of Seventh Day Adventist seminarians in Nigeria showed no relationship
between blood lipid levels and blood pressure (Famodu et al. 1998). Three groups were
compared: strict vegans, semi-vegetarians, and non-vegetarians from nearby
communities. Vegans were the thinnest of the three groups and had the lowest serum
cholesterol. The difference in blood pressure was not significant between the groups, nor
was it related to blood lipid levels. The authors conclude "Negroid Africans are
constitutionally not predisposed to cardiovascular disease because of their dietary habits,
though this may change by the advent of urbanization and subsequent adoption of
hypertension-related dietary habits..." (p. 548). Mbaya (1998) reports that nomadic
groups in East Africa, like the Samburu and the Maasai, do not experience the incidence
of hypercholesterolemia or atherosclerosis that would be predicted when they begin to
consume a high cholesterol and high fat diet.
Dietary fiber intake was low in a group of South Africans over age 65 who were
studied by Charleton et al. (1997a), just 17g/day. A food frequency questionnaire was
used to collect the dietary data. At the same time, hypertension was high in this group,
71.7%. Unfortunately, the authors do not present an analysis of whether there is an
association between fiber intake and blood pressure.
Obesity, usually measured by body mass in index (BMI), is consistently
positively associated with blood pressure across the globe. In Africa this is also true
(Astageneau 1992, Kruger et al. 2001), although the magnitude of the effect varies by
study and site. Being overweight, as measured by waist-to-hip ratio and body fat (skin
fold) measurements, is also positively associated with blood pressure in Africa (cf., Luke
et al. 1998).
Kadiri and Salako (1997) is the only study I found from Africa which did not find
an association between obesity and blood pressure in either men or women, (urban
Nigeria). However, Seedat (1998) observes "obesity makes an important contribution to
hypertension, especially in urban black females of sub-Saharan Africa" (p. 395).
Forrester et al. (1998) note that relativeie weight, usually characterized as body mass
index (BMI) is the most reliable correlate of hypertension, ... the average BMI bears a
close relationship to hypertension prevalence" at the population level (p. 466-7).
Charleton et al. (1997b) examined the connection between physical activity and
blood pressure in a group of 142 South Africans over age 65. Although reported physical
activity was low and blood pressure measurements were high, no association was found
between these two variables, for systolic or for diastolic blood pressure. Lack of physical
activity is an important factor in becoming overweight, and thus deserves more study in
the African context. At the same time, it is extremely difficult to measure actual physical
activity. Most researchers rely on respondent self-reports that are known to be unreliable,
and the act of studying a person's physical activity usually serves to increase it, rather
than reflecting actual activity rates (Kimberly et al. 2000, Forrest 2001).
It is unclear from the available evidence as to whether there is a sex difference in
hypertension in Africa. Often, observed sex differences disappear when well-established
risk factors such as age or BMI are held constant. A study of health status in urban
Zimbabwe showed that women over age 45 had higher blood pressure readings than men
of the same age (Watts and Siziya 1997). Their sample included 49 men and 71 women
in this age group. The authors note high rates of obesity in the women they studied, and
that "this obesity seems benign" (p. 264). Because this study was on general health status,
the authors did not explore the relationship between obesity and blood pressure in their
data. Edwards (2000) studied urban and rural men and women in Tanzania. The results
showed an urban-rural difference, but no significant difference between men and women
in either setting. Blood pressure was higher for women than men in both the urban and
the rural sites in South Africa studied by Mollentze and colleagues (1995).
Social, Economic, and Cultural Factors
Among African-Americans, higher education level is associated with lower blood
pressure, and it is hypothesized that more education helps people cope better in a
capitalistic society. In Nigeria however, educational level was positively associated with
blood pressure (Ogunlesi et al. 1991).
Studies of socio-cultural factors that affect blood pressure in Africa usually
include socio-economic status (SES) (including education, occupation and income) and
urban residence. The next section examines the question of urban-rural difference in
blood pressure. Urban residence in Africa may imply higher education and income, along
with higher prestige occupations, although this is not always the case. Increasing SES
level is correlated with increasing BMI in the African context (cf., Cooper et al. 1997),
but researchers do not always separate the effects of SES from those of BMI on blood
Rural-Urban Patterns in Blood Pressure
Researchers have observed that urban Africans suffer more from hypertension
than their rural counterparts. Although researchers do not know the mechanisms by
which urban life contributes to increased blood pressure, much speculation revolves
around obesity (from increased food consumption and decreased physical activity),
increased sodium intake, and psychosocial stress. We can study the role of urban life in
hypertension by examining more closely intra-urban variation, and the risk factors that
lead to high blood pressure. This is what I have done in my research in Mozambique. At
the same time, it is important to examine intra-rural variation, and to compare similar
people in rural and urban settings.
The Luo migration study in Kenya, compared rural and urban migrants from one
ethnic group to explore the rise in blood pressure in urban areas. Researchers found that
blood pressure was correlated with duration of urban residence (Poulter et al. 1984), and
began to rise as early as two months after migrating to the city (Poulter et al. 1985). To
investigate selection bias, they compared rural Luo who intended to migrate with those
who had no intention to migrate and found no differences in blood pressure (Poulter et al.
1988). Because blood pressure is associated with obesity, close attention was paid to
dietary changes associated with migration, but it was found that the urban Luo actually
consumed fewer calories. The authors concluded that weight gain in the urban (migrant)
Luo must be related to "fluid retention, via an increase in renal efferent sympathetic
nerve activity, as a consequence of an environmental stress" ibidd). I think that a decrease
in physical activity might have also contributed to the urban Luo being overweight,
despite lower calorie consumption.
Edwards et al. (2000) studied 1700 adults in a middle-income rural district of Dar
es Salaam with a prosperous rural area, as part of an on-going study of adult morbidity
and mortality. The rates of hypertension found by this research team do not differ
significantly by area of residence. Mbanya (1998) studied 1058 adults in Yaounde,
Cameroon, and 746 adults in three rural areas, 60 km away. Age-standardized prevalence
for hypertension was higher in the urban area for both men and women. However, after
adjusting for BMI, the differences in blood pressure disappeared because the urban
sample was more obese than the rural sample. In Malawi (Simmons et al. 1986), an
observed urban rural difference in blood pressure also disappeared after adjusting for
As part of a larger study on hypertension in the African Diaspora, Cooper's team
(Cooper et al. 1997, Kaufman 1996, Kaufman et al. 1999), compared two communities in
southern Nigeria. They found age-adjusted prevalence hypertension rates of 7.3% in the
rural site, compared to 25.6% in the urban site. Obesity, sodium/potassium levels, and
social integration (as measured by social status incongruity) all explain part of this
Consistent urban-rural contrasts in high blood pressure have been found in South
Africa. Norman Scotch compared 1,000 urban and rural Zulu people in South Africa
(1963a). The urban group had significantly higher blood pressure, related to age, obesity,
and, for women marital status, number of children, and church membership. Twenty
years later, Seedat (1982) found hypertension prevalence rates of 25% among urban Zulu,
compared with 9% among rural Zulu (160/95mmHg), and noted that the Zulu were
affected by the stresses of an urban lifestyle. According to Packard (1989), this argument
was made often by the South African medical community during apartheid to justify the
policy of keeping Africans in bantustans, because city life was bad for their health. More
recently, Mollentze and colleagues (1995) found no difference in blood pressure between
urban and rural South Africans after adjusting for age and sex. Recent longitudinal
studies of urbanization suggest that rural South Africans experience an increase in blood
pressure when they move to the cities (cf.,van Rooyen et al. 2002 and Vorster 2002).
Two early studies in Botswana (Kaminer and Lutz 1960, Truswell et al. 1972)
found extremely low blood pressure measures, with no cases of hypertension. Although
the authors noted that acculturatedd" populations had higher blood pressure than did the
rural Bushmen and women, they did not attempt to measure acculturation.
John Hunter and colleagues (2000) looked at variation in blood pressure in
women in three rural communities in Zimbabwe, to test the hypothesis that the economic
environment plays an important role. The research team identified women who
participated in one of "three levels of economic development: 1) the traditional economy
on communal lands, 2) the wage economy in areas of large-scale commercial agriculture,
and 3) the wage economy in mining areas" (p. 773). They analyzed data on 515 non-
pregnant women to answer the question "Does increasing modernization in rural areas
produce rising hypertension?" ibidd). Women involved in the latter two economic
systems had higher blood pressure than women engaged in subsistence farming. The
authors concede that because of a small sample "statistical validation weakens" (p. 782),
and conclusions drawn about age can only be considered preliminary.
Giles and colleagues (1994) studied people from eight ethnic groups living on a
rural rubber plantation in Liberia. They noted that "all groups were living under similar
conditions" (p. 273), yet one group, the Mano, had significantly higher blood pressure
readings than three of the other groups, after adjusting for age and sex. (Height and
weight were not measured.). The authors note that although study participants lived in a
rural area they did not live in a "remoteness from western culture" rather, they had "a
moderate amount of contact with" it (Giles et al. p. 274) by virtue of living on a large
Astagneau (1992) randomly sampled 2300 people in an urban section of Dakar.
He found that 10.4% of the people were hypertensive using the stricter definition
(160/95mmHg), and 23.6% using the less strict one (140/90mmHg). No significant
differences were found between women and men for either cutpoint. Age and obesity
(BMI) were positively associated with blood pressure. This study is important because of
the large sample size and the thoroughness of the research design.
In recent review articles, Seedat (1998, 2000) states that urban black South
Africans are more likely to have hypertension compared to their white or Asian
counterparts, and that blacks develop the condition at an earlier age. In a study of blacks
in an urban community in the Cape Peninsula of South Africa (Steyn et al. 1996), the age
group 55-64 had the highest rates of hypertension, (40.5% for men and 47.2% for
women). The most important predictors of hypertension were age, obesity, and degree of
urban exposure (percent of life spent living in an urban area). Urbanization was measured
as the percentage of an individual's life was lived in the city. They found "the increase in
blood pressure with age among people who had spent less than 40% of their lives in the
city was less than those who had spent more than 40% of their lives in the city" (p. 761).
Somova et al. studied students at the University of Zimbabwe (1995), over a four-
year period. In addition to "traditional risk factors for hypertension: age, family history of
hypertension, alcohol consumption and smoking habits", the team also evaluated
birthplace (rural or urban), family stability and two measures of behaviorall and
psychological coping pattern" (p. 194). For white students, being bom in an urban area
predicted high blood pressure, while for blacks, being born in a rural area was predictive.
In a poor urban area in Zimbabwe, Watts and Siziya (1997) found that blood pressure
increased with age, and a higher percentage of women over age 45 had hypertension than
did men in the same age group.
Regional Patterns in Hypertension Prevalence
A 1993 review article (Kaufman and Barkey) summarized what had been
published about the prevalence of and risk factors for hypertension in African
populations. That article divided the continent into four regions: west, southern, central
and east. This regional approach reveals broad patterns of the prevalence of hypertension,
despite differences in sampling and defining high blood pressure.
East Africa is often singled out as the region with the lowest blood pressure
readings. High blood pressure is rare among nomadic pastoral groups, like the Turkana
(Mugambi and Little 1983). In recent years, East Africa has also begun to show
increasing rates of hypertension (cf., Edwards 2000). Mbaya (1998) reports, that "over
the past 40 years there has been a progressive rise in the incidence of high blood pressure
in East Africa" (p. 300).
In southern Africa, and particularly South Africa, high blood pressure is an
important cause of morbidity and mortality. A review of all admissions to the main
medical ward in Bulawayo, Zimbabwe showed that hypertension was the fourth most
common cause of admission between 1987 and 1994 (Mudiayi et al. 1997). In Malawi
(Maher and Hoffman 1995) hypertension is the ninth most common cause of admission
to the main hospital in the capital. A sentinel reporting system of family practitioners in
South Africa revealed that hypertension was the second most commonly reported illness
for adults (de Villiers and Geffen 1998).
Wilson, Hollifield, and Grim (1991) divided the continent into the same four
regions and compared mean systolic blood pressure data on 40-49 year olds collected by
other researchers by region, as part of a meta-analysis. They chose this age group
"because that is when essential hypertension usually manifests itself and secondary
causes including pregnancy are less likely" (p. 1-88). The meta-analysis did not control
"for obesity, stress, diet or any other risk factors" (p. 1-87). Despite the flaws of this
analysis, the authors conclude that within Africa "[S]ystolic blood pressure was
significantly lower for both men and women in East Africa than in the other three
regions. Women in Southern Africa had significantly higher blood pressure than those in
West Africa, but the same was not true for men." (p. 189).
Comparing Africans and Africa Diaspora Populations
Hypertension in Africa needs to be considered within the context of the very high
incidence of hypertension among members of the African Diaspora. High rates of
hypertension in populations of African-origin in the New World is linked to higher
morbidity and mortality in these same populations, when compared to other groups.
Although the incidence of hypertension is not currently as high in Africa, research among
African populations can shed light on the problem in diaspora groups.
Early work by Dawber and colleagues (1967) compared blacks and whites in the
US with those in the Caribbean, and concluded, "Negro populations have higher blood
pressures than whites living in the same areas and studied by the same investigators,
particularly among females and in the older age groups" (p. 256). Until the last few
decades, researchers have found low blood pressure readings in Africa (cf., Donnison
1929, Williams 1941, Hiemaux and Schweich 1979). In fact, some of the lowest blood
pressure measurements have been recorded for lean, nomadic groups like the Turkana,
(Mugambi and Little 1983), the Samburu (Shaper et al. 1969), and the hunter-gatherer
Kung (Kaminer and Lutz 1960).
When we examine the patterns of high blood pressure in people of African origin,
we find a consistent gradient of increasing prevalence. Hypertension prevalence rates are
lowest in Africa, increase in Caribbean and Brazilian populations, and are the highest
among blacks in the U.S. and England. Cooper et al. (1997) confirmed this trend when
they compared seven population of West African origin. As expected, African Americans
had the highest blood pressure rates, followed by Afro-Caribbeans, with Africans
(Nigerians and Cameroonians) having the lowest blood pressure readings. Wilson et al.
(1991) state that populations of African-origin "have the greatest variation in blood
pressure of any ethnic group" (p. 1-87), ranging from very low in parts of Africa to
extremely high in the U.S.
There is an opposite rural urban gradient within Africa compared to the African
diaspora groups. As discussed earlier, blood pressure increases with urbanization in
Africa. In the U.S., the opposite is found. Wilson's team (1991) presents several
explanations for the different effect of urban life and blood pressure in the U.S. compared
to Africa. They suggest that, rural American black populations suffer as a result of low
educationin and socioeconomic status .... a substantial impact of racist psychosocial
stress in rural areas not felt in urban areas", and "genetic factors cannot be ruled out
because rural black populations may have a lower degree of admixture with Caucasians
than urban blacks" (p. 1-90).
Walker and Sareli (1997) note the similarities in how coronary heart disease
(CHD) appeared in white and black American populations, with the current situation in
South Africa. They state that "the current low CHD mortality rate of urban Africans
clearly resembles the situation which prevailed in the US and UK in the 1920's" (p. 24).
The same authors note that certain risk factors for CHD, high fat and energy intake,
hypertension, diabetes, and serum cholesterol are becoming more common in Africa, and
thus "we can expect urban Africans to attain the high mortality rate for CHD now
experienced by Afro-Americans."(p. 23). In order to avert an epidemic of CHD in a few
years time, they recommend a "prudent lifestyle" including eating less fat and more fiber,
not smoking, reducing hypertension, and maintaining present high levels of physical
Increasing Rates of Hypertension in Africa
An overview of the prevalence rates in various sites in Africa reveals three things.
1) There is an increase in blood pressure over the last 40 years. 2) There is an increase in
blood pressure with urbanization. 3) Lack of standardized methods for sampling, blood
pressure measurement, and defining hypertension makes it difficult to compare studies or
establish continent-wide patterns.
An increase in hypertension in Africa mirrors an increase in chronic disease on
the continent. Feacham (1992) points to three factors to explain the rise of chronic
disease in adults in developing countries; demographic changes, including lower fertility
and mortality rates, lead to a higher absolute number of adults, people are more exposed
to risk factors like smoking, diet, alcohol, and reduced physical activity, and, success in
treating infectious diseases has decreased case fatality rates, making chronic disease and
injury relatively more important causes of death.
W. Lore, the editor of the East African Medical Journal, describes the trend of
increasing blood pressure in Africa, with particular attention to Kenya (1993). He notes
that beginning in the mid-twentieth century there was a rise in blood pressure,
accompanied by a correlation between age and blood pressure that had previously been
absent. High blood pressure is usually one of the first manifestations of chronic disease in
adult Africa populations. Salako (1993) observes that the international community
believes that infectious diseases deserve all of their attention in Africa. But he states that
"the truth is that hypertension, ...is a major cause of morbidity and mortality in these
countries, and by afflicting people at the most productive times of their lives, constitutes
a major impediment to economic development" (1993 p. 998). Razum (1996) points out
that in Africa, cardiovascular disease is most commonly found to "be hypertension and its
sequelae, not ischaemic heart disease like in industrialized countries" (p. 120).
Given the costs of treating high blood pressure and its sequelae, primary
prevention of hypertension is the only feasible option open to most African countries.
Yonga (1998) stresses that heart disease is "not an unavoidable concomitant phenomenon
of socio-economic development", but argues that if Africans look to lessons learned in
the West and make the lifestyle changes adopted there in recent years, "we may by-pass
this expensive accompaniment to ... industrialization" (p. 494). Lenfant (2001), the
director of the U.S. National Heart, Lung and Blood Institute, echoes this sentiment. "It
would be a shame if the low- and middle-income countries went through the same rise in
cardiovascular disease experienced by the wealthier ones although steps can be taken to
reduce it" (p. 981).
Psychosocial Stress and Blood Pressure in Africa
While the established risk factors for hypertension discussed above are important
areas of research, less work has been done on the role of psychosocial stress. Mbaya
(1998) notes that psychosocial stress is a risk factor for hypertension in East Africa,
because "superimposed on the individual personality and physiology are socioeconomic
and cultural environments which produce their own effects (p. 301).
Nearly 40 years ago, Norman Scotch (1963a) assessed the contribution of socio-
cultural factors to hypertension in a rural and an urban Zulu community. Having noted a
striking difference in blood pressure between the two communities, Scotch asked, "can
we now determine those factors, if any, that discriminate between hypertensives and
normotensives in a community?" (p. 1206). He found that the number of children a
woman has is positively associated with hypertension for urban women, but not for rural
women. Likewise, being post-menopausal in the rural area was associated with
hypertension, but not for the urban women. Scotch explains these findings in the context
of the different roles of women in the urban and the rural sites. The social status of rural
Zulu women is closely tied to their ability to produce children, and menopause marks the
end of this high status period, and is a stressful event. In the city, a woman is expected to
earn a salary as well as produce children; therefore having too many children is stressful,
while menopause is not.
A recent small study in South Africa (Edwards 1995), however, found no
relationship between psychosocial stress and blood pressure. Edwards used three
different measures of stress: the Township Life Events scale, and occupational stress
scale, and an emotional reactivity scale. Blood pressure increased with obesity, but not
with age or any of the three stress measures in the 30 men interviewed. Edwards ibidd)
writes that a small sample size (n=30), and/or the absence of data on coping style or
social support might explain the lack of a predicted association between these measures
of stress and blood pressure.
Somova and colleagues (1995) compared psychosocial risk factors for
hypertension in black and white students at the University of Zimbabwe, in a cross-
sectional study and a four-year follow-up. They found that no psychosocial factors,
(anger, anxiety, expression, active coping, family instability), predicted hypertension in
white students. Among blacks, traditional risk factors family history of hypertension,
BMI, smoking and alcohol intake predicted hypertension. In addition, for black
students, family instability, the John Henryism Active Coping Scale (James 1994), and
suppressed anger were also predictive of hypertension, even after controlling for the
factors noted above.
A sample of 54 patients admitted to the hospital in Niamey, Niger for
complications from hypertension, were studied by Toure and colleagues (1992). The
most frequent risk factors found were: Type A personality (76%), stress (48%), obesity
(37%) and tobacco use (35%). Stress was measured in this study using an adapted
Holmes and Rahe (1967) Social Readjustment Scale.
It is clear that we have a lot to learn about the contribution of psychosocial factors
to the development of hypertension in Africa. Research in this area will make three
contributions. First, it will help us understand better the role of the many risk factors for
hypertension in Africa, including the role of psychosocial stress, and this knowledge can
be applied to prevention programs. Hopefully, it will also reveal the specific stressors of
urban life on the continent. Second, knowledge gained by studying the role of
psychosocial factors in Africa can be compared to patterns found in African Diaspora
populations. With this, we can begin to unravel the mystery of why the latter have such
high rates of hypertension, and why the rural-urban pattern is inverted in the west. Third,
this research will advance our ability to measure psychosocial stress in a variety of
cultural contexts. The scales and screening questionnaires currently in use in
psychosocial research are inadequate to measure this phenomenon in different cultures,
and more work is urgently needed to improve our tools in this area. The next section
reviews the literature on the measurement of psychosocial stress and its relationship to
specific health outcomes.
Defining and Measuring Psychosocial Stress
This section defines stress, specifically psychosocial stress (PSS), and discusses
how PSS has been measured. Throughout the section, I give examples of how PSS is
associated with different health outcomes, especially with cardiovascular disease. Stress
has been linked to a variety of health outcomes, but the present discussion is limited to
physical health outcomes. Ironically, the notion that mental processes (psychosocial
stress) affect the physical body (increased blood pressure) runs counter to Cartesian
dualism, even as I use its divisions between mental and physical health outcomes.
The term stress is used to describe a state of being of an organism, while the term
stressor is used to denote an "environmental noxious stimulus" (Cassel 1976 p. 109). A
useful definition of stress is "a psycho-physiological response to a change in the person-
environment relationship in which the resource demands exceed the current level of
resources available" (Oths 1991 p. 16). Many authors use stress to describe the stimuli
that provokes a response, but for that I prefer the term stressor. A stress response is an
organism's reaction to a specific stressor, its attempt to counteract the stressor and regain
homeostasis. This discussion is confined to the study of psychosocial stressors. The term
psychosocial refers to a cluster of stressors that are produced by the social environment,
and mediated by an individual's psyche.
Models of Stress
Howard and Scott (1965) reviewed eight conceptual models of stress, and
concluded that most of these models are of limited use to researchers, because they were
developed within one discipline and are thus designed to address discipline-specific
questions. In addition, the authors note that these models of stress were incomplete,
because none of them "take into account all of the relevant variables that produce stress"
ibidd p. 267). The stress models that are still in use have been expanded to apply to a
wider variety of situations and attempt to take into account a wider variety of stressors. I
consider Mechanic's (1962, 1978) and Selye's (1956) models to be the most useful in
understanding the complexity of a stress response.
Mechanic (1962) developed a social-psychological model of stress caused by
social situations. His model evaluated how people respond to stress, which he defined as
"the discomforting responses of persons in particular situations" (1962 p. 7). Mechanic's
model is helpful because it encompasses the entire stress response, including coping
strategies, the social resources available to people, how people think about the stressful
situation, and what they do about it. Later, Mechanic applied his model to health-seeking
behavior (1978), and concluded that perceived stress (he used the term distress) is a
powerful predictor of whether an individual seeks help for a health problem.
Selye's General Adaptation Syndrome (GAS) is a biochemical model of stress
(cf., 1956). According to the GAS, the stress response in humans is characterized by a
series of hormonal releases, which can ultimately lead to a breakdown in the body's
immune response. The first stage of the stress response is an alarm and mobilization. This
is followed by a stage of resistance, a set of internal responses to stimulate tissue
response. "If the stressor continues to affect the organism despite these responses, the
third stage, that of exhaustion, is eventually reached" (Howard and Scott 1965 p. 155).
According to Selye, chronic stress leads to a permanent state of biochemical imbalance,
which can then cause a decrease in the ability of the immune system's to function
optimally, opening the door to a number of diseases.
Bieliauskas (1982) reports that Mason (1971) challenged Selye's
conceptualization of stress as a purely biological response. Mason conducted experiments
where the stressor was held constant (e.g., workload, undernutrition but how those
stressors occurs varied (e.g., speed of onset of the stressor), and found that, some people
did not develop a physiological stress response. He argued that stress should "not be
regarded primarily as a physiological concept, but rather as a behavioral one" (Mason
1971 p. 331). As Bieliauskas explains, "Any response an organism makes to stressors is
likely mediated first at the behavioral level and then may have a secondary physiological
impact" (1982 p. 5).
The context in which a stressor occurs may be as important as the stressor, and
people's psychological characteristics play a large role in determining the stress response.
My own model of stress draws on both Mechanic's and Selye's models because I believe
that they complement each other. Mechanic's model describes the social context in which
stress occurs and the potential for individual mediating factors, while Selye's explains the
physiological response and potential long-term biological effects.
James and Brown (1997) reviewed anthropological research on the biological
responses to stress, specifically the release of catacholamines and increases in blood
pressure, and linked this work to Selye's GAS. Selye originally conceptualized the GAS
in response to environmental stressors, but James and Brown point out that
"psychological perceptions of events and relationships may be as important in eliciting
the syndrome (GAS), as noxious environmental stimuli" (p. 315). For these authors,
environmental stressors include "many things people do, think, or experience as a part of
their lifestyle" ibidd. p. 329). A variety of physical and non-physical (psychosocial)
stressors can trigger the biochemical stress response (GAS), while, at the same time,
individual behavior, personality, and social resources mediate their impact.
Psychosocial stress (PSS) is often poorly defined and operationalized. It
encompasses a broad category of stressors, and many biomedical researchers use it as a
catchall term for any concepts they do not know how to measure. Psychosocial stress is
produced by social situations, making it less tangible than temperature or altitude or
malnutrition, and highly subjective. It is mediated by an individual's psyche, as well as
by the person's previous experiences and culture.
Psychosocial stress is often defined by what it is not. For example, all stressors
that are not produced by the natural environment (e.g., climate, altitude, etc.), or are not
nutritional in origin, are lumped together into this category. Definition by elimination
leaves a varied lot of stressors in one category. Although we try to separate out
psychosocial stressors from physical or nutritional ones, the social and the physical
environments are inextricably linked. Most often, a research project will select one or
more types of psychosocial stress, (for which a scale exists), and study PSS along with
other (physical) stressors.
A quarter century ago, John Cassel (1976) summed up the current state of
research on psychosocial stress and health, and set an agenda for the future. He credits
Rene Dubos with broadening the scope of epidemiology from "acute or semi-acute
infections caused by virulent microbial organisms" (p. 108), to a field that also takes into
consideration that "environmental factors that are capable of changing human resistance"
(ibid.). Cassel emphasized the importance of the social environment, and broadened the
concept of stress, which had been defined primarily as a physical phenomenon.
Cassel (1976) builds on Selye's model of stress and envisions the connection
between stressors, stress, and disease as leading to an imbalance in the endocrine system,
which makes a person more susceptible to ill health. The stress state of an individual
interacts with her genetic makeup and previous exposure to the stressor, and to an illness.
Cassel pointed to two questions he felt that stress researchers needed to tackle; 1) whether
specific stressors can be linked etiologically to specific diseases, and 2) whether stressors
affect different people qualitatively or quantitatively in the same way. Most importantly,
he proposes that researchers not look at "psychosocial processes as unidimensional, [as
either] stressors or non-stressors, but rather as two dimensional, ..stressors, .. [which are]
protective or beneficial" ibidd. p.112). Cassel's conceptualization of psychosocial
processes as potentially harmful and/or beneficial opened the door for research on social
support as a factor in the stressor stress response equation.
Culture Change as a Stressor
Cassel (1960) suggested that culture change might be stressful to people for
reasons other than changes in diet, exercise, or other health habits. He explained that
culture change was confusing for people who were socialized in one culture were now
confronted with a different set of social meanings. Dressier and dos Santos (2000) have
based their work in Brazil on Cassel's notion of cultural incongruity, where individuals
find that their culture is no longer helpful to them in the negotiation a new social world.
Likewise, the cultural consonance model (described below) is based on the idea that
"individuals can be low in cultural consonance... because they are, for whatever reason,
unable to act upon the widely shared ideas about how to live life appropriately. In either
respect, individuals .. are prevented from effective participation in their own society."
(Dressier and dos Santos 2000 p. 312).
Anthropologists Scudder and Colson (1982) studied Zambian communities that
were forced to relocate and identified three types of stressors; physiological,
psychological, and socio-cultural. They note that socio-cultural stress is composed of
many factors. It includes economic shocks, a leadership vacuum, and a reduction in what
they term "a society's cultural inventory... a temporary or permanent loss of behavioral
patterns, economic practices, institutions and symbols" (p. 271). The authors highlight
various strategies used by communities to cope with forced relocation, ranging from
conservative to high risk-taking. Individual- and group-level innovations are found in
these communities, and a wide variety of coping strategies are employed. Scudder and
Colson advocated more in-depth study of these innovations and strategies, as well the
role of community and household dynamics in coping.
Measuring Psychosocial Stress
The most common measures of PSS are life events scales (cf., Holmes and Rahe
1967, Miller and Rahe 1997) and perceived stress scales (cf., Cohen 1983, Cohen and
Manuck 1995). Unfortunately, these scales are often inadequate for the measurement of
psychosocial stress in the populations for which they are designed, and even less effective
when transported to other populations.
In the 1930's, Adolf Meyers began to measure life events and their effects on
health. He noted that what patients tell physicians about their lives may be related to the
illness they are suffering from. Hawkins, Davies, and Holmes (1957) formalized Meyers'
idea into the Schedule of Recent Events (SRE), "which was used .. over the next decade
to document associations between stressful life events and" a number of diseases (Cohen
and Manuck 1995). The Holmes and Rahe (1967) Social Readjustment Rating Scale built
on the SRE.
The Holmes and Rahe scale (1967, 1997) measures stressful life events in terms
of "life change units" (LCU). It is based on the thesis that all life changes are stressful,
whether they are considered positive (e.g., marriage, the birth of a child, a new home), or
negative (e.g., a death in the family, loss of a job). In this scale, each event has a LCU
value assigned to it, and an individual's score is the total of these LCUs for the events
that an individual reports, within the time frame specified. The Holmes and Rahe life
events scale (1967) was recalibrated in 1997 by Miller and Rahe to reflect changes in the
intervening years, and the influence of demographic characteristics on stress scores was
compared. The most recent Life Changes Questionnaire (Miller and Rahe 1997) asks
about 74 potential life change events.
The impact of life events is just one important measure of stress in a person's life,
but an individual's perception of those events also needs to be considered. If a person
does not perceive a life event to be stressful, then s/he may not experience a stress
response. The Cohen perceived stress scale (1983) measures an individual's perception of
stress, and has been used to predict a number of health problems. This more subjective
measure of stress gives increased weight to an individual's personality and psyche, and
begins to include the role of social support as a mediating factor.
Standardized scales may not measure the same thing among people who are from
different populations than the ones the scales were developed for. To get the best measure
of an individual's experience of psychosocial stress, scales should be developed for, or at
least adapted to, specific settings. A thorough ethnography is necessary to understand the
stressors being studied and how people experience, react to, and cope with them. Even
knowing how people talk about stress is crucial. For example, a pilot study helped Oths
(1991) learn that changing a few key words or phrases (from "cope with" to "handle",
and from "support" to "help") made the interview much more understandable to her
Limitations in the Study of Psychosocial Stress and Health
Many studies of health status and PSS are cross-sectional or retrospective. This
can be a problem, especially when respondents are told they have a health problem, and
are then asked about their stress state. Asking a person who has recently been diagnosed
with coronary heart disease about stress is sensitive, and raises questions of causality.
Some authors compared people who had been diagnosed with an illness to a control
group of individuals who had not been diagnosed, to test whether PSS played a role in the
development of that illness.
Yen and Syme (1999) reviewed recent work at the intersection of sociology and
epidemiology. They note that sociologists are engaged in the study of how variables like
SES, Social Structures (racial segregation, income inequality, violence) affect health.
They note that while epidemiology has done a good job of "identifying factors in the
physical environment that are hazardous to health, similar work on the social
environment is just beginning" (Yen and Syme 1999 p. 302). The authors suggest that
now is the time for sociology to bring its work into the field of psychosocial stress. They
acknowledge the importance of the work of Cassel and others in the 1970s, but conclude
that research on social stress "has never really attracted strong and continued interest by
epidemiologists ibidd. p. 303). In my opinion, stress research has also been overlooked by
medical anthropologists, with the exception of biological anthropologists, and recently a
handful of cultural anthropologists (cf., James and Brown 1997, Lewis 1990, Schell
1997, Ulijaszek and Huss-Ashmore 1997, Dressier 1991, 1995, Oths 1991).
We cannot ignore the fact that individual people respond to PSS in very different
ways. The social resources that a person can mobilize when confronted with a stressor is
usually measured in terms of social support. Social support is conceptualized as "the
emotional, instrumental or financial aid that is obtained from one's social network"
(Berkman 1983 p. 53). It is a concept that is difficult to operationalize. No matter how it
is defined and measured, social support is consistently found to mediate between
stressors and the stress response, as measured by health outcomes.
A Swedish study (Rosengren et al. 1993) followed 752 men born in 1933. At the
beginning of the study the men were asked about stressful life events, their social
networks, and basic demographic factors. Men who experienced more life change events
were at increased risk of death in the seven-year follow up, although those with good
emotional support were protected, and had a reduced mortality rate. A case-control study
was done with chronic headache (migraine and tension-type) sufferers and two groups of
controls (Martin and Theunissen 1993). No differences were found between the two
groups in terms of stressful life events, but the headache sufferers scored lower on social
support. A prospective study in Norway (Dalgard and Haheim 1998) found that social
participation and locus of control were as important as social support in predicting
mortality. The authors conclude that lifestyle and individual psychological resources are
important psychosocial factors in overall mortality.
Another prospective study in the U.S. found that socially isolated men had higher
risk of death from CVD, accidents and suicide (Kawachi et al. 1996). McLean et al.
(1993) studied the effects of stress on pregnancy outcomes, and they explain that
psychosocial stressors cannot be studied in a vacuum, "... since a woman's ability to
manage stressors may depend on her personal disposition, her psychological state, the
composition and adequacy of her social network to provide support, failure to consider
the interaction between these factors in an analysis of stress and adverse pregnancy
outcomes may have led investigators to miss key causal relationships" (p. 52)
Sherman James developed the concept of John Henryism (JH) during research
among black Americans, for whom John Henry, a legendary "steel-driving man," was a
salient figure. James defines John Henryism as "a strong behavioral predisposition to
cope actively with psychosocial environmental pressures" (James 1994 p. 163). "The
John Henryism hypothesis assumes that lower socioeconomic status individuals in
general, and African Americans in particular, are routinely exposed to psychosocial
stressors that require them to use considerable energy each day to manage the
psychological stress generated by these conditions" ibidd p. 167). James recognizes that
not everyone responds with the high effort coping his scale is measuring, only those who
have this personality type. The John Henryism scale consists of 12 questions that ask
respondents to reply using a 5-point Likert scale. The scale has been used in many
communities in the U.S., as well as in Holland and Nigeria.
Dresser, Bindon, and Neggers (1998) used the JH scale in a small city in
Alabama, and modified the five point Likert scale to a three-point scale (not at all true,
somewhat true, and very true). They found that John Henryism was associated with
increasing systolic blood pressure for men, but decreasing blood pressure for women.
These findings correspond with other work by Dressier in the same community (1985)
where active coping had opposite effects on blood pressure in men and women. The
effects of John Henryism vary by gender in this setting because of gender differences in
work and family role, obstacles to success, racism, and demography.
Dressler's Research on Psychosocial Stress
Dressier has spent nearly 20 years studying psychosocial stress and health
outcomes, primarily blood pressure. In the 1980s, he researched stress and coping (1985,
1986, 1987, 1990) in the black community of a small city in Alabama. Around the same
time, he began a parallel research program in Brazil (Dressier, dos Santos and Viteri
1986, Dressier, dos Santos, Gallagher and Viteri 1987), again focused on stress, but its
interaction with modernization. Dressier has continued to study stress and social support
in Alabama (Dressler 1987, 1990, Dressier and Badger 1985), Brazil (Dressler, Balieiro
and dos Santos 1997), Jamaica (Dressier, Grell, et al. 1988, 1995), and Mexico (Dressier,
Mata, Chavez et al. 1986, 1987), and their effects on blood pressure, depression, and
other health outcomes.
Dressier originally developed the concept of Social Status Incongruity (SSI) as a
measure of PSS that contributes to blood pressure and depression. SSI hypothesized that
a gap between a person's social status and the way the person lived his/her life, ("living
beyond one's means"), would be stressful. Dresser used the SSI model in Brazil,
Alabama, Mexico, and Samoa. These instruments were adapted and used in a
comparative study of blood pressure in West Africa, the Caribbean, and a black
community in Chicago (Cooper et al. 1997, Kaufman et al. 1996).
Beginning in 1995, Dressier modified his conception of PSS from social status
incongruity to the study of cultural consonance. As described above, cultural consonance
is closely tied to Cassel's proposal that being out of sync with one's own society is
stressful. Rather than measuring a person's incongruity with his/her social status, Dressier
strives to evaluate a person's consonance (or dissonance) with his/her own culture's
Recently, Dressler has been working in the city of RiberAo Preto (Sdo Paulo state)
in southern Brazil. There, he is comparing people from four different neighborhoods,
each representing different socioeconomic strata. This research on cultural consonance
and blood pressure is at the intersection of the modernization paradigm and the stress
model (Dressier 2000a, 2000b, Dressier and dos Santos 2000).
Dressler considers his work as making three contributions to anthropology
"culture theory, the developing bio-cultural synthesis and research methods" (Dressier
2000b p. 15). He uses a two-step approach to measure cultural consonance. He uses
consensus analysis (described below) to create a group model of success, and then
conducts a survey to determine how closely people's lives match this model (Dressler
1996). The greater the distance from the cultural model, the more stress a person is
expected to experience. Other known predictors of blood pressure (e.g., age, obesity and
dietary intake) are measured in order to isolate the variation that is explained by cultural
Cultural Consensus Modeling to Study Psychosocial Stress and Social Support
Cultural consensus modeling offers an alternative to using pre-formulated scales
in the measurement of psychosocial stress. The researchers create cultural models unique
to the group they are studying. The research I did in Beira, Mozambique was similar
methodologically to Dressler's research in Brazil, but the models were created
specifically for Beira. Even though they are unique to one place and time, the models are
systematically constructed to test the general hypotheses that cultural dissonance is
stressful, and that social support can buffer that stress. Therefore, the research done in
Mozambique can be compared to work in Brazil (or elsewhere) testing the same
hypotheses, and even help to refine the theory.
The Roots of Consensus Modeling
Romney, Weller and Batchelder (1986) formalized the consensus model of
culture. Boster (1986) and Weller (1983) had made observations about culture as
consensus, and contributed to the development of the model. Since then, many others
have refined the technique and added new dimensions to the original methodology
(Batchelder and Romney 1988, Caulkins and Hyatt 1999, Caulkins 1998, Garro 1986,
1987, Handwerker 2002, Handwerker 1998, Romney, Batchelder and Weller 1987,
Romney, Boyd, et al. 1996, Weller 1987, 1998, Weller and Romney 1988). CCM was
originally designed for use with dichotomous data, but the model now accommodates
multiple choice and rank-order data as well (Romney et al.1987).
Romney (1989) traces the roots of CCM back to Spearman who, in 1904, wanted
to test whether tests of intelligence were, in fact, measuring intelligence. Spearman
compared the results of these measures to students' and teachers' rankings of other
students. In a similar vein, Romney, Weller and Batchelder (1986) present data on a
general information test, to which the answers were known. D'Andrade (1995) credits
Boster's (1986) work with a variety of manioc plant names as the first to discover the
power of consensus in a study of Jivaro women and varieties of manioc. Boster asked
women to identify different kinds of manioc plants in an experimental garden he planted.
He found that women who answered correctly were also more likely to give the same
answers on a second trip through the garden. Women who gave more modal answers in
the garden with easier types of plants also gave more modal answers in the garden with
the harder to identify plants. Boster knew a priori what the correct answers were, having
planted the garden himself.
Critiques of Cultural Consensus Modeling
Robert Aunger (1999) criticizes cultural consensus modeling as a form of
idealism. Aunger states that his target is idealism, but that CCM is the easiest
representation of idealism to attack. He argues that culture is learned, and transmitted
from one individual to another, yet idealism focuses on the shared nature of culture. CCM
is, by implication of its association with idealism, also interested only in the shared aspect
of culture. Aunger promotes a theory of realism, which emphasizes that culture is
learned. In his reply to Aunger, Romney says that he believes that "culture is both shared
and learned" (1999 p. S103), which I, and probably most anthropologists who use CCM,
agree with. Aunger erroneously states that individuals are not compared to the group
model to look at intra-cultural variation. CCM has been used to study intra-cultural
variation, and several examples are discussed below.
Other critiques of CCM have focused on cultural competence, which describes
how much an individual agrees with, or knows about, the group model of a domain.
Individual competence levels are used to test whether there is consensus and to develop
the group model. People who are know more about a domain, (are more competent), also
agree with each other more about that domain. More weight is given to the responses of
people who agree with each other because people who "agree with each other about some
items of cultural knowledge know more about the domain those items belong to (are
more competent in that domain) than informants who disagree with each other" (Bernard
1995 p. 171). Additionally, indicators of cultural competence can back up a researcher's
intuition that some informants know more than others, and help to identify cultural
experts in current or subsequent research (Johnson 1990).
The word "competence" is loaded and has hindered the acceptance of CCM by
some anthropologists. They may consider it bad form to judge people as less competent
or incompetent in their own culture. Many anthropologists are reluctant to admit that
some informants know more about aspects of their culture than other informants, even
though they rely on key informants. We all know, intuitively, that people who are
specialists, for example herbalists, yoga masters, or biblical scholars know more about
their area of study than other people. Cultural competence, as measured by CCM, does
not imply that some informants are more competent in all aspects of culture, only in the
domain being studied. In his review of the CCM, Bernard (1995) stresses the fact that
informant competence is measured only "within specific cultural domains", it "is not a
test of general competence, only of particular competence" (p. 171).
New terminology is one solution to this problem. I propose "culturally
knowledgeable" or "domain specialist" to replace cultural competence. Others have
suggested alternative terms. Hurwicz suggests the term "expertise" (1995, p. 234).
Caulkins and Hyatt (1999 p. 24) proposed "cultural centrality" where there is agreement
on a domain, or "knowledge" where there is not consensus. However we term it,
anthropologists must acknowledge that some of our informants know more than others
about specific domains, an assumption that has guided our use of key informants over the
Who Has Used CCM and What Have They Found?
Linda Garro studied intra-cultural variation in medical knowledge in Mexican
curers and non-curers (1986) using CCM. She hypothesized that curers and non-curers
would either have 1) two different systems of medical beliefs, or 2) a similar belief
system but with variation on how much they agreed with each other. She found the
second pattern. In the visual representation of the two-dimensional scaling (p. 360) the
curers are much more tightly clustered in the center of the plot of inter-informant
similarities. Garro found consensus among the curers and the non-curers, but higher
consensus among the former.
Garro also studied a group of Ojibway's beliefs about hypertension (1987). She
combined CCM and other methods to construct an explanatory model of high blood
pressure, as well as to look at variation around that model. Garro used two types of
interviews; the explanatory model interview format developed by Kleinman (1980), and a
series of 67 statements to which people were asked to respond true or false. Garro found
a high degree of consensus around the causes and symptoms of hypertension in her
sample of 26. From the interviews and the true-false data, Garro was able to construct an
Ojibway consensus model for hypertension.
In addition, Garro (1987) identified two types of variation around the model.
First, there is "informant disagreement with the "correct" response" (p. 113). These
"informants simply reject some of the specific entailments of the key propositions (of the
model) in order to be consistent with their own experiences" (ibid.). Garro breaks down
the other variation into three sub-types, 1) people who hold an alternative causal model
(e.g., heredity), 2) people who have a different explanation of hypertension but an
explanation that is applicable to other illnesses (a curse, smoking, exposure to the cold),
and 3) variation that is unexplained and considered particular to individual informants,
idiosyncratic (catching hypertension from a blood transfusion, or eyestrain) (p. 114).
Garro's work on blood pressure is important because she used complementary
methods to create a cultural model, and to examine the variation around that model. She
also uses the model as a springboard to ask interesting questions; how this model might
be related to other Ojibway models of disease, how such models develop, and how
comparative work might be done if systematic questions with comparable responses were
used. Garro includes her true-false statements about blood pressure in an appendix for
other researchers to use or adapt.
Weller (1983) used a precursor to cultural consensus analysis to examine the
hot/cold concept among rural and urban Guatemalan women. She expected to find
consensus on which illnesses were hot and which were cold, and which required a hot or
a cold remedy. Instead, she found a high degree of disagreement, within each group, and
between the urban and the rural groups. Her conclusion was that the hot/cold
classification system may exist in these communities, but that there is not a high
consensus about what it means, or about what illnesses fall into one category or another.
Her findings are in sharp contrast to the uniform picture of hot/cold classification painted
by many medical anthropologists who work across Spanish speaking Latin America.
Weller found a high level of consensus among her informants on the domain "contagio"
of illnesses, indicating that the women she interviewed shared a cultural model of
"contagious-ness", and understood what she was asking them. This research used CCM
to show that there was not a shared cultural model of hot/cold illnesses, which had long
been assumed by medical anthropologists working in Latin America. Weller has also
used CCM to compare a folk belief, empacho (Weller et al. 1993), and factors
contributing to breast vs. bottle-feeding in different culture groups (Weller and Dungy
Hurwicz (1995) used consensus analysis to compare the belief systems of
physicians who treat the elderly with the behavior of elderly patients. Specifically, she
wanted to see if the two groups had similar ideas about what symptoms indicated that a
visit to the doctor was necessary, and whether the elderly people's model guided their
health-seeking behavior. She asked a group of 22 gerontologists to group 106 symptoms
or conditions into one of three categories -- when a physician visit 1) not recommended,
2) recommended or 3) mandatory. The ratio of the first factor's eigen value to the second
one was 5.66, which indicates a shared domain. Next, descriptions by 885 Medicare
recipients of 2,493 illness episodes were analyzed to see if the elderly behaved and
thought according to the model held by the physicians. Hurwicz concludes, "in the
aggregate, they (the elderly) followed the same set of rules about the necessity of going to
the doctor as physicians". Their behavior, however, "did not perfectly mirror biomedical
norms." (p. 232).
Garcia and colleagues (1998) applied consensus analysis to the question of
whether people of different age groups in a Mexican barrio of Guadalajara have different
ideas about what causes hypertension. Thirty-five people were asked to freelist the causes
of hypertension and their answers were compared by age groups (15-29, 30-49, and over
50). Thirteen items were selected and these were then ranked by a group of informants on
how important they were in the development of hypertension. The freelist data showed
high consensus for the group, but that intra-age group consensus was even higher. This
intra-group variation continued with the ranking data, where the younger group ranked
obesity as the leading cause of hypertension, while the middle age group cited smoking
and the oldest group cited anger as the most important.
Chavez et al. (1995) define intra-cultural variation as "how knowledge is
systematically patterned within a culture" (p. 41). This group of researchers employed
CCM to look at variation within the general category "Latinas", and asked whether there
is sub-group variation in beliefs about risk factors for breast and cervical cancer. They
looked at three groups of Latinas, 1) Chicanas who were born in the US of Mexican
parents, 2) first generation immigrants from Mexico, and 3) El Salvador. They also
interviewed a group of Anglo women and a group of physicians for comparison. Twenty-
nine risk factors for breast cancer and 24 risk factors for cervical cancer were ranked by
the women and doctors in order of their seriousness.
The research team found high intra-group consensus on the risk factors for breast
cancer, and lower consensus for cervical cancer. Comparing the groups using MDS, the
Anglo women were clustered closest to the physicians, the two immigrant groups also
clustered close together, and the Chicanas were in between these two clusters,
demonstrating their biculturalism. The authors conclude that "women with radically
different views of risk factors for cancer are not necessarily presenting random,
idiosyncratic misconceptions" (Chavez et al. 1995 p. 70), rather they are presenting a
model held by other women like them. The two immigrant groups shared an
understanding of cancer risk factors, it was simply a different one than the Anglos,
physicians, or the Chicanas (Chavez et al. 2001).
Caulkins and Hyatt (1999) found that a re-analysis of previously collected data
using CCM, and insights from thorough ethnographic research, shed new light on their
findings and showed them new patterns in their data. They caution that CCM does not
always find agreement among respondents, but may reveal "non-coherent" domains.
Eight managers of a high technology firm were interviewed to see how closely
they shared a common perspective on what the company needed to do to as it grew.
Caulkins (1998) found low consensus among the managers, and concluded that the weak
agreement was due to turbulence within the company and the larger industry. His careful
ethnography of this company and other high tech companies helped him to understand
the reasons behind the low consensus. Research on another firm also revealed low
consensus among staff members on the role of the firm. Again, ethnography helped
Caulkins to interpret the findings, concluding that this was a contested domain, rather
than a pattern where two or more sub-populations were in disagreement. These three
cases by Caulkins and Hyatt highlight the need for ethnography to accompany CCM,
with the definition of domains, selection of the sample, and interpretation (and re-
interpretation) of the findings.
Kempton, Boster and Hartley (1995) conducted a nation-wide survey of
Americans' environmental values which was developed after semi-structured interviews
with 40 key informants. The research is based on an understanding that "..people
organize their culture's beliefs and values with what we call mental models or cultural
models" (p. 10). Mental models are differentiated as being held by individuals, whereas
cultural models are shared by a group. They continue "..agreement or disagreement about
these cultural models often has a clear social pattern of variation,..." (ibid.). The
researchers expected variation in beliefs and values about the environment by talking to
five groups of people; from EarthFirst, the Sierra Club, "the public", dry cleaners, and
displaced sawmill workers. Instead, they found a strong consensus. When they broke the
respondents down by groups, there was a stronger, more tightly clustered consensus of
the members of EarthFirst and the Sierra Club. People in the other three groups agreed
with these first two, but their answers were more dispersed.
Finally, as mentioned earlier in this chapter, Dressier has refined the concept of
status incongruity into what he terms cultural consonance. Handwerker and Borgatti
(1998) summarize how he uses CCM in studying cultural consonance, "Dressier has used
consensus analysis to construct regionally and historically specific measures of poverty
based not on the conventional and narrow biological conception of need, but on one more
germane to understanding meaning and behavior relative deprivation in lived
experiences. The resulting measure of cultural consonance encompasses the lived
experience of poverty with its multiple dimensions..." (p. 570). Dressler's own definition
of cultural consonance is "..how closely an individual approximates in his or her own
behavior the shared knowledge and understanding of his or her own society.." (2000b p.
Dressier uses CCM to create local models of success and of social support. Even
though the research includes four neighborhoods with sharply contrasting socioeconomic
levels, a high degree of consensus for both models is consistently found. After creating
these models, individuals are interviewed to find out how closely their lifestyle matches
the ideal lifestyle, and how their use of social support matches the cultural model.
Knowing what the ideal lifestyle is, but living a life that is very different, is considered
stressful. The distance from the ideal lifestyle is conceptualized as a stressor. How well
an individual can access culturally appropriate social support indicates their ability to
buffer themselves from life's stressors.
Dressier plans to use CCM model other aspects of Brazilian culture that might
provoke or buffer against high blood pressure, as well as a model of Brazilian national
identity. He uses three steps to the CCM process. Step one generates items in the
domains, through open-ended key informant interviewing, freelisting, and pile sorting.
Step two consists of structured interviews to rate those items, and the ratings are indulged
in the consensus analysis. Step three is where informants "describe their own behavior"
to see how closely it approximates the prototypical behaviors in the cultural model.
Blood pressure in Africa is known to be caused by several risk factors, including
age, obesity, and diet. Psychosocial stress is one risk factor for hypertension that has
received little attention and its effects should be studied more carefully, in conjunction
with other known risk factors. Learning more about the role of psychosocial stress will
help to explain the increase of hypertension in urban settings in Africa, and may also
make it possible to solve the puzzle of high rates of hypertension in African diaspora
Research on psychosocial stress and health is only beginning to be done seriously,
even though Scotch and Cassel planted the idea with their pioneering work 40 years ago.
The tools we have developed to study PSS in western populations are often inadequate
for research in non-western populations. Scales like the Stressful Life Events (Holmes
and Rahe 1967, Miller and Rahe 1997), self-perceived stress (Cohen et al. 1983, 1995),
and John Henryism (James 1994) scales, have been adapted to African settings with
mixed results. We need to look for better tools to research psychosocial stress. One
alternative to using scales developed for other populations is to use standardized methods
to create models that are specific to the study population. Cultural consensus modeling
can be used to develop models of cultural consonance in lifestyle as one type of
psychosocial stress. Similar methods can be used to develop a local model of social
support and evaluate how it is serves as a buffer against psychosocial stress.
From the review of the published literature presented in the previous chapter, it is
clear that more investigation is needed to understand the relationship between
psychosocial stress and blood pressure. Psychosocial stress is often hypothesized to
contribute to the development of hypertension in Africa, as well as in other parts of the
world. Yet, only a handful of researchers have tried to assess the relative contribution of
psychosocial stress to the development of hypertension in Africa. This study is an attempt
to fill in this gap in our knowledge, using a systematic anthropological approach.
I chose cultural consensus modeling in this research to overcome the problems
encountered when psychosocial stress is measured using standardized scales. Relying on
a relatively small number of informants, I was able to construct models of lifestyle and
social support that are salient to the population of Ponta Gea. I draw heavily on Dressler's
theories and methods because his work addresses the issues of psychosocial stress, social
support and blood pressure. He also uses systematic data collection techniques that yield
culture-specific models. I applied Dressler's model and methods in Mozambique in order
to test the model in an African setting and to contribute to our understanding of
There are however a few important differences between the context of Ponta Gea,
Mozambique and RiberAo Preto, Brazil that are relevant to the hypotheses. The
correlation between socioeconomic status and blood pressure is negative in the Americas,
including the Caribbean, but negative in sub-Saharan Africa. Simply put, poor people in
the Western Hemisphere have higher rates of hypertension, while richer Africans suffer
from it more compared to poor Africans. Psychosocial stress associated with poverty has
been hypothesized to be the reason for the former pattern. Public health researchers have
pointed to lifestyle differences to explain the patterns observed in Africa. I wanted to
know more about lifestyle, specifically what (if any) aspects of psychosocial stress were
playing a role in hypertension in an urban African population.
In this dissertation, I tested a series of hypotheses on psychosocial stress and
variation in blood pressure among urban men and women in Beira, Mozambique. After
describing how I tested the hypotheses and presenting the results (in Chapters 5 and 6), I
discuss how my findings contribute to the bigger picture in Chapter 7. In that chapter, I
also outline the questions and methodological obstacles that remain.
To measure the role of psychosocial stress, I had to do two things. First, I had to
measure other variables known to contribute to high blood pressure, such as obesity, age,
and family history of hypertension. Obesity was measured using the Body Mass Index
(BMI) which is calculated by weight (kg)/height2 (meters). Age was measured by asking
participants their age. Adult Mozambicans carry an identity card with their birth date
printed on it, and in cases where people were unsure of their age, we consulted these
cards. I asked each participant whether they had even been told they have tensao alta, as
hypertension is commonly known in Mozambique. I asked if they knew of any family
member who has (or had) tensdo alta. If they said yes, we discussed which relatives) had
the condition and the interviewer wrote down their relationship to the participant. In
addition to these known risk factors, I also recorded participants' sex, ethnic group,
income, occupation, education, and whether or not they smoked.
Second, I measured psychosocial stress in two very different was to determine if
the consequences for blood pressure were instrument dependent. The two scales were the
Cohen Self-Perceived Stress Scale (Cohen 1983) and the Life Change Scale (Holmes and
Rahe 1967, Miller and Rahe 1997).
Participants adults living in the bairro of Ponta Gea varied widely in terms of
socioeconomic class and the length of time they have lived in the bairro or in the city,
ranging from their entire lives to having just moved from another part of the city or from
a rural area. People in the study are experiencing many of the same social, political, and
economic changes present in Mozambique over the last several years. I expect that there
is variation in the consequences of these events, in the amount of psychosocial stress that
they bring to each person's life. In any situation there will be people who experience
more stress than others. If psychosocial stress has an impact on blood pressure, I expect
that the relationship will be measurable in this population. In the future, I plan to compare
the data from Beira to data on psychosocial stress and blood pressure from African
Phase One Hypotheses
In phase one I tested for consensus on what constitutes a successful lifestyle and
social support. The models of lifestyle and social support are based on data from freelists
of "what one needs in order to have a successful life" and ranking of the items in the list.
I expected to find high consensus on these two models--that people share a common list
of what constitutes an ideal lifestyle or social support network. As Dressler found in rural
Alabama and urban Brazil (1990, 1995, Dressier and dos Santos 2000), this common
model of a successful lifestyle should include ownership of material goods and
behavioral elements as well. Again, relying on results from prior research, I expected that
the social support model in Ponta Gea would include substantial support from nonrelated
people given the urban setting and the semimobile lifestyle of the population.
Phase Two Hypotheses
After developing the models in phase one, I conducted a survey of 261 adults in
Ponta Gea to test whether variation in consonance with the models is associated with
variation in blood pressure, controlling for other risk factors of blood pressure. In this
phase, I was testing the following hypotheses:
1. Perceived stress varies positively with blood pressure.
2. Stressful life events within the past year predict higher blood pressure, and
conversely a lower number of stressful life events in the past year will predict
lower blood pressure.
3. Blood pressure increases with known biological cofactors, such as age, body mass
index, and family history of hypertension.
4. Income, education, and degree of urbanization all vary positively with blood
5. Ceteris paribus, ability to access culturally appropriate social support buffers
people against stressors and thus varies inversely with blood pressure.
6. Ceteris paribus, consonance with the shared lifestyle model varies positively with
blood pressure: high consonance predicts high blood pressure,
PHASE ONE: ETHNOGRAPHY
Consensus Modeling: Reprise
I used consensus modeling, (described in Chapter 3), to discover the shared
cultural models of lifestyle and social support in Ponta Gea. This chapter describes the
techniques I employed to build these models, and how individual variation around them
will be studied in the model-testing phase (two). The building of shared cultural models
is useful in two ways: to describe one aspect of a society, and to create a model as a tool
to study variation around it.
I chose cultural consensus modeling (CCM) to explore intracultural variation in
blood pressure. In phase two, I tested whether an individual's distance from a cultural
model is stressful for that person, and whether that stress is buffered by the person's
access to social support. As discussed above, it may seem contradictory to use a
consensus model to study variation, but it makes sense. I first developed a group-specific
model using CCM, and measured how much individuals' lives vary from that model.
Anthropologists cannot ignore the variation that exists within groups they study,
and CCM is a powerful way to measure this variation systematically. Dressier (2000a)
describes the specific methods he uses to create a group-level model, and how he then
studies patterns of variation from the model. The cultural models are specific to the group
of people being studied at a particular time, but the systematic way of constructing these
models means that we can compare the results to other groups, or in the same group
The rich ethnographic aspect of cultural consensus modeling may be lost in the
formality of the method. CCM involves systematic data collection lists, for example -
but it also involves traditional ethnography -participating in the everyday life of a
community, observing social interactions, engaging in conversations and discussions, and
finding members of the community who have a special capacity to explain comments and
behaviors that are novel or seemingly inconsistent. This experience gives the
ethnographer insight into the context of a model and the forces that have shaped it, and is
invaluable in the interpretation of how people's lives vary from the shared model.
Methods Used in Phase One
Learning the city
The research in Beira began in October 2000. During our search for a house, I
became familiar with the layout of the city; primarily the cement city, where houses are
European style, made of wood, cement, and tile. The rest of Beira is referred to as the
reed city because the housing is constructed from local, mostly degradable, materials.
The cement city consists of the downtown (the baixa), the port and industrial area, and
three residential areas, Palmeiras, Macuti, and Ponta Gea.
The neighborhood of Ponta Gea was selected for the research project for two
reasons. First, the residents represent a broad cross-section of socioeconomic and
educational levels, even though it was one of the most exclusive neighborhoods in Beira
during colonial times. Since the departure of the Portuguese in 1975, the neighborhood
has become home to a wide range of people. Following independence, private property
was nationalized, and "...housing vacated by returning [fleeing] Portuguese was assigned
to homeless families, and rents were collected by the state." (Nelson 1984 p. 204).
Second, of the three residential areas in the cement city, Ponta Gea is the least
purely residential and the most dynamic. In U.S. terms it would be considered a mixed
zoning area. Portuguese planners (in 1939) envisioned the European part of the city
divided into the downtown and two residential sectors (Empresa Modema 1951). The
western residential sector [today Ponta Gea] would have "large houses built together
[along] with a commercial area, establishing a transition between the two zones
[downtown and the Palmeiras/Macuti], with a higher population density, but without
sacrificing standards of cleanliness." ibidd p.138). Ponta Gea borders the downtown and
port areas, the main road connecting the cement city cuts through it, and it is home to
several large and small businesses, two university campuses, government offices,
restaurants and clubs, a dozen churches, and the Mayor's residence. According to many
residents of Beira I spoke to, Ponta Gea is not like the other upscale residential areas of
Palmeriras and Macuti, which are considered sleepy, aloof, and inaccessible. One
interviewee gave his taxonomy of the neighborhoods of Beira, in terms of exclusivity:
first tier--Palmeiras and Macuti, second tier--Ponta Gea and the downtown, third tier--the
Many inhabitants of Ponta Gea live in spacious homes, (some of which have been
subdivided), while others live in garages, apartment buildings (ranging from 4-80 units),
or in dependencias (outbuildings at the back of a property, usually built as servant's
quarters). In early November 2000, my husband and I took up residence in a rented house
in Ponta Gea. Our home was typical of one style common to the neighborhood; in
addition to the main part of the house, it had an attached three-room apartment, and a
detached one-room dependencia along the back wall of the property. The owner had been
given the house by the government in the 1980s, and he preferred to rent it for foreign
currency, while living with his family in a nearby apartment he also owned.
A map of Ponta Gea and legend is found in Appendix A.
University contacts in Beira
I contacted the two universities in Beira, the Catholic University of Mozambique
(UCM) and the Pedagogical University (UP) (these are described in Chapter 2). I had met
the President and the director of research of UCM during my predissertation visit to Beira
in August of 1999. In October 2001, I renewed these contacts, described my research
project, and met the members of the new medical faculty. I found that the people from the
medical faculty and the Center for Investigation and Integrated Development (CIDDI) at
UCM had the most helpful input for the project. At the UP, my contacts were primarily
through the geography faculty, which includes the disciplines of anthropology, sociology,
and social and physical geography. Here, I benefited from the presence of several
Mozambican social scientists who were willing to advise me during and after the study.
In September 2001, I presented the preliminary results of the research project to
the Medical School at the Catholic University. Faculty, staff, and students at the Catholic
University participated in the semistructured interviews, cognitive data collection, and
informal interviews. Toward the end of my stay in Beira, I gave a lecture to an
introductory anthropology class at the UP. Because of the proximity of the UP in Ponta
Gea, I could rely on students, faculty, and staff for assistance in the pretest stage of the
questionnaire. I also turned to these people for additional informal interviews throughout
both phases of the research.
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