Intracultural variation in blood pressure in Beira, Mozambique

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Intracultural variation in blood pressure in Beira, Mozambique
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INTRACULTURAL VARIATION IN BLOOD PRESSURE IN BEIRA,
MOZAMBIQUE













By

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

2002















ACKNOWLEDGMENTS

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
page

ACKNOWLEDGMENTS........................ ..................................................................... ii

ABSTRACT .................................................................................................................... vi

CHAPTER

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


iv








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

APPENDIX

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,
MOZAMBIQUE


By

Nanette Louise Barkey

December 2002


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.













CHAPTER 1
INTRODUCTION


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

Defining Culture

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
added)

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.

Culture Change

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

community.

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.

446).

Intragroup Variation

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

members.

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

An Overview

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

them.

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

described below.

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

countries.

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

social support.

Lifestyle

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

they live.

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.

Psychosocial Stress

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

wealthier citizens.

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
Teaching
Language Study DH -
Key Informant Interviews
Participant Observation
Freelisting
Ranking
Questionnaire Development
Survey
Quantitative Data Management
Figure 1-1. Calendar of Activities.

Research Setting

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






15


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

backgrounds.













CHAPTER 2
SETTING

Mozambique

Geography

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.

Demography

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

1999).

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.

Religious Affiliations

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).

History

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,

and radios.

Political Divisions

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-

affected population.








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).

Economic Situation

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).

Medical Systems

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).

Post-War Changes

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

industries.









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

Geography

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.

Religion

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

History

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

provinces expired.

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.

Political Divisions

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).

Race Relations

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

12% ibidd).

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.








Ponta Gea

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.

Housing

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

government employees.

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.













CHAPTER 3
REVIEW OF THE LITERATURE

Introduction

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.

Age

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.

Diet: Salt

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

African populations.

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

blood pressure.

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.

Overweight

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).

Physical Activity

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).

Sex

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

Schooling

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).








Socio-economic status

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

pressure.

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.

Rural-Urban Comparisons

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

obesity.

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

difference.

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.

Intrarural variation

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

rubber plantation.

Intraurban Variation

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

activity.

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.

Discussion

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

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

informants.

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).








Social Support

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)

Active Coping

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

expectations/norms/standards.

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

consonance.

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

years.

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

1986).

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.

2).

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.

Summary

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

populations.

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






85


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.













CHAPTER 4
HYPOTHESES

Introduction

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

hypertension there.

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

diaspora populations.

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
pressure.

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,













CHAPTER 5
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

across time.








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

Preliminary Steps

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.

Site selection

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

reed city.

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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