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Intracultural variation in blood pressure in Beira, Mozambique

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Intracultural variation in blood pressure in Beira, Mozambique
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Barkey, Nanette Louise
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Anthropology ( jstor )
Blood pressure ( jstor )
Body mass index ( jstor )
Cultural anthropology ( jstor )
Diseases ( jstor )
Hypertension ( jstor )
Lifestyle ( jstor )
Psychological stress ( jstor )
Psychosociology ( jstor )
Women ( jstor )
Anthropology thesis, Ph.D ( lcsh )
Dissertations, Academic -- Anthropology -- UF ( lcsh )
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Thesis (Ph.D.)--University of Florida, 2002.
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Includes bibliographical references.
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Vita.
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by Nanette Louise Barkey.

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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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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 ARP AC: 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 I
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
The City of Beira 28
PontaGea 38
3 REVIEW OF THE LITERATURE 44
Introduction 44
An Overview of Hypertension in Africa 45
Defining and Measuring Psychosocial Stress 63
Cultural Consensus Modeling to Study Psychosocial Stress and Social Support 74
Summary 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

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 Results 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
CENSUS 209
REFERENCES 210
BIOGRAPHICAL SKETCH 225
v

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.
vi

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.
vii

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.
1

2
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).
Dressier (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 learn 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.

3
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-westem 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

4
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

5
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). Dressier 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 modern 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” (ibid 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

6
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

7
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 intracuitural 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 intracuitural 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, Dressier (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)

9
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.

10
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 Cored, 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

11
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

12
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 1999,1 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 tensáo 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 (Dressier 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

13
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
1999,1 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

14
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.
Pilot research
Teaching
Language Study
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
16

17
million people living in the capital of Maputo (ibid). 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 (ibid).
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 (ibid).
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

18
(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

19
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

20
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

21
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.

22
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

23
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 capita 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

24
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" (ibid 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.

25
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 (ibid).
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 (ibid). Nationwide, 245 of every 1,000 children bom alive die
before age five (ibid). 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 (ibid), 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)

26
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,

27
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
1 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.

28
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

29
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
t
Catholic
Protestant
Other
Christian
Jehovah
Witness
Muslim
Other
None
Don’t
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,

30
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 (1NE 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
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

31
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 Mozambique 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" (ibid) 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 Mozambique 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

32
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 govenment.
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

33
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 infrastrucure 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 Zacarías has popular support and people

34
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

35
as Indian because their families ususally 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.

36
There are government subsidized pharmacies located at the hospital and health
ceners. 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% (ibid).
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.

37
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 Zacarías, 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" (AllAffica.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.

38
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.

39
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.

40
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 Pedagógica (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.

41
• 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

42
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

43
Saturday August 11th, 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/Intemational 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
44

45
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. 1 IS, 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-

46
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-

47
hypertensive men, while hypertensive women were more likely to be daily smokers than
non-hypertensive women (ibid). 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 Lenfanf 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

48
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.

49
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 "[r]elative 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

50
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).

51
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

52
investígate 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” (ibid). 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

53
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 “acculturated” 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

54
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?” (ibid). 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

55
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 "behavioural and
psychological coping pattern" (p. 194). For white students, being bom in an urban area
predicted high blood pressure, while for blacks, being bom 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.

56
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

57
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 Affo-Caribbeans, with Africans

58
(Nigerians and Cameroonians) having the lowest blood pressure readings. Wilson et al.
(1991) state that populations of Affican-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
"[education 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 Affo-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,

59
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

60
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

61
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 (ibid)
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

62
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.

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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”

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(ibid 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.

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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” (ibid. p. 329). A variety of physical and non-physical (psychosocial)

66
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.

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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” (ibid, p.l 12). 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).

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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.

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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

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(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 (ibid. 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).

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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 bom 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

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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” (ibid 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.
Dressier, 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

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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 (Dressier 1987, 1990, Dressier and Badger 1985), Brazil (Dressier, 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. Dressier 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

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strives to evaluate a person's consonance (or dissonance) with his/her own culture’s
expectations/norms/standards.
Recently, Dressier has been working in the city of Riberao Preto (Sao 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).
Dressier 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 (Dressier
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

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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

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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. SI03), 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

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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

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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).

79
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

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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

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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 bom 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

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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

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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

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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, ffeelisting, 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

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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,
86

87
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) tensao alta. If they said yes, we discussed which relative(s) had
the condition and the interviewer wrote down their relationship to the participant. In

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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 Dressier found in rural
Alabama and urban Brazil (1990, 1995, Dressier and dos Santos 2000), this common

89
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.
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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

92
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 Moderna 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." (ibid 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

93
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 2001,1 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 2001,1 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.

94
Language study
I took private language classes with a Portuguese professor at the Catholic
University from October 2000 through February 2001. We used materials for instruction
of Portuguese as a second language, or Portuguese for foreigners. My research funding
included monies for studying both Portuguese and local language. In his discussion of the
skills needed for effective participant observation, Bernard states, "the most important
thing you can do to stop being a freak is to speak the language of the people you are
studying - and speak it well." (2002 p. 339). I already spoke Portuguese, but the
language classes helped me to speak it well. 1 had previously studied Portuguese in
Angola, at the University of Florida, and at Eduardo Mondlane University in Maputo
during my predissertation visit.
In Beira, I also studied Ndau, one of the two most common local languages. The
academic dean of economics at the Catholic University recommended two students who
were Ndau speakers and had experience teaching it. I interviewed them and selected one
as my teacher. He had previously taught Ndau to foreign missionaries and Mozambican
church members who needed to improve their skills to participate in services. We
obtained study materials from a Catholic priest who is a specialist in linguistics. I studied
Ndau in the hope that I would be able to follow interviews if they had to be conducted by
my research assistants in Ndau or Sena. This turned out to not be necessary, since we
conducted just three interviews in a language other than Portuguese: one in Sena, one in
Ndau, and one in Shangane.
Formal Data Collection
I collected systematic data on the local models of a successful lifestyle and social
support using a mix of semistructured interviews, participant observation, and cognitive

95
techniques (freelists, ranking). I also participated in a small research project on blood
pressure by the Catholic university, using participants from the Pedagogical University.
Semistructured interviews
During phase one I did 12 semistructured interviews with seven men and five
women. See Table 5-1 for characteristics of the interviewees. The interviews covered
various aspects of three general topics:
• what constitutes a successful lifestyle
• types of social support and circumstances when social support is needed
• the folk illness tensao alta (causes, symptoms, and treatment).
During the semistructured interviews I collected two freelists of 1) the elements of
a successful lifestyle and 2) categories of people who constitute the informant’s social
support network. In addition, people were asked to talk about how lifestyle and social
support have changed in recent years, give an overall assessment of both topics, and
suggest scenarios in which they would seek out social support. The interviews also
covered the folk illness tensao alta (TA). The findings on TA are discussed at the end of
this chapter.
Table 5-1. Characteristics of the Interviewees.
#
Sex
Age approx.)
Occupation
Interview site
1
Male
Early 30s
Clerk (trained as electrician)
Work
2
Female
Early 50s
Teacher
Home
3
Male
Early 60s
Researcher
Restaurant
4
Male
Late 30s
Mechanic
Restaurant
5
Male
Early 40s
Agriculture Project Manager
Work
6
Female
Late 30s
Store Manager
Work
7
Female
Early 40s
Health Project Manager
Work
8
Male
Late 20s
Radio DJ
Work
9
Male
Late 50s
Pastor
Home
10
Male
Late 20s
Student
School
11
Female
Late 20s
Student
School
12
Female
Late 40s
Dental Assistant
Home

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The interviews were conducted in the person’s home or workplace, or at a
restaurant. The informants were chosen because of their special knowledge about life in
Beira. A convenience sample was drawn from a pool of people whom I, or someone else,
identified as having a special knowledge about life in Beira. They were selected to
represent a cross-section of age groups and socioeconomic levels. All were of African
descent except for interviewee #2 who was of Indian descent.
I took notes during the interviews and typed them up the same day in order to
reduce error in recall (Bernard 2002). I did not tape record these interviews. In my
experience in Mozambique, the majority of the people did not want to be tape-recorded.
During my predissertation visit to Mozambique, I watched other foreign researchers tape
record interviews, and saw that they had little success. I asked my colleagues at Eduardo
Mondlane University for their opinions on taping interviews. The consensus was that tape
recording was not well accepted, and suggested I ask interviewees what would they
prefer. During a previous stay in Maputo (February - June 2000), I interviewed several
people. I asked them whether they preferred that I to take notes or record our interview,
and they all opted for note taking. I asked the first few interviewees in Beira for their
preference, and they too uniformly preferred to not use the tape recorder.
Key informant interviews
I also conducted semistructured interviews with key informants during this phase
of the research. I interviewed one doctor from the Beira Central Hospital. I chose her
after asking several doctors in Beira to tell me which physician treated the majority of
patients suffering from hypertension or heart disease. During my interview with her, we
discussed the characteristics of hypertension patients, their treatment options, and
problems with adherence with treatment. I also spoke at length with the following

97
physicians; The Director of the Provincial Health Department, the Director of the Ponta
Gea Health Center, and the Medical Director of the Ponta Gea Health Center. We
discussed the frequency of hypertension in Beira, its causes, treatment issues, and the
cases of individual patients. After describing my research project to each of them, I
solicited their feedback on the study. With the two doctors from the Ponta Gea Health
Center, I made a plan to refer study participants for follow-up care if they had elevated
blood pressure.
Other key informant interviews included a traditional healer, a pastor, a
sociologist and our landlord, (a well-known and respected man in Ponta Gea). In these
interviews, I asked people to tell me about the problems people encountered in everyday
life, how they dealt with them, stress, social support, and tensao alta (TA). I used the
term tensao alta (in Portuguese), rather than hipertensáo (hypertension), for two reasons.
It is more commonly used and understood, and people clearly identify TA as a stress-
related illness. The interview with the traditional healer focused on her treatment of TA,
while the pastor spoke mostly about changing lifestyles, differences between urban and
rural life, and the role of the church in an urban setting.
Our housekeeper was a great source of information about the themes I was
studying. She and I had daily conversations about happenings in Ponta Gea, her life and
friends, and events related to people we knew in common. I often asked her to explain
things I had observed, or topics mentioned in conversations, that I did not understand. We
went shopping together, discussed religion and healing, marriage, children, food, and
war. She was raised in a family who moved around the country while she was growing

98
up, never went to school, married twice, had four sons, lost two husbands, and spent
years working in a government garment factory,
My Portuguese and Ndau language teachers were also key informants with whom
I discussed my research. From them I learned about lifestyle, stress, social support, and
high blood pressure among their neighbors and friends in Beira, and in their own lives.
My Portuguese teacher suffers from hypertension and takes medication to control it. My
Ndau teacher told me about the Ndau concepts of blood, its circulation in the body, the
heart, and what happens to the blood and heart when people become angry, afraid or
worried. I built up good rapport with these teachers, and they provided different, yet
valuable, perspectives on the connection between stress and blood pressure.
Participant observation
I participated in the routine life of a resident of Ponta Gea, buying bread at the
comer bakery, fruit at various comer stands, and other produce at the neighborhood’s
open-air market. I walked our dog regularly in the neighborhood, stopping often to chat
with children and adults. I traveled on local transportation, (chappas, independent vans
that ran on regular routes), walked, and rode a bicycle in the area. One of the women I
interviewed became my tailor, and another our supplier of nutritional supplements. One
interviewee told me he was a retired electrician, and later did electrical work for us at the
house. I also attended the Beira chapter of the Rotary club, and was a volunteer at the
Beira Central Hospital on behalf of the Beira Women's club.
I took every opportunity to steer casual conversations with friends and
acquaintances toward stress and lifestyle in Beira, and to follow up on every mention of
illness, especially when tensao alta (TA) was mentioned. I often asked people directly
whether they knew someone who had TA, or who could help out when people had

99
problems, in order to start a conversation about stress or the local model of social
support.
I recorded my participant observations in the community in a computer file of
field notes throughout the year in Beira. The majority of the notations are about themes
related to health, stress, healing, lifestyle and social support, although there are also notes
on routine community events and important events. I did not take notes during most
casual conversations because it would have inhibited the rapport and flow of ideas.
Everyone I spoke with knew that I was doing research on lifestyle, stress, and high blood
pressure, and that their conversations with me were helping me to understand how people
lived and were sick in Beira. I typed up these conversations within a day or two to remind
myself of their topic and content.
Pilot study at the Universidade Pedagógica
Soon after arriving in Beira I met with the Dean of Medical Education at UCM.
Dr. Elias told me that the first year medical students had recently done a practical
exercise using the students and staff at UCM, which included measuring blood pressure.
He said they were planning to organize a similar exercise on their next break between
classes. I suggested they contact the UP and ask the students and staff there to participate.
On November 13, 2000, the medical students from UCM measured the blood pressure,
height, and weight, and collected other information on 311 people affiliated with the UP.
In November and December I helped to enter, clean, and analyze this data, and wrote a
short report on the findings. Fifty people (16%) in this sample had blood pressure values
greater than 140mmHg systolic or 90mmHg diastolic, the cut-points for high blood
pressure (WHO/ISH 1999).

100
Four months later, I visited the UP, along with a professor from the medical
faculty at UCM, to remeasure the blood pressure of these 50 people. Twenty-five of the
50 people who were invited to come the second time came to be remeasured, all men.
Seventeen of the 25 repeat participants had high measurements during the second visit.
During the same visit, I measured the blood pressure of 40 other students and faculty who
came because they heard that we were there and were interested in knowing their blood
pressure.
This pilot project revealed a few patterns of high blood pressure in this
population, but more importantly, it showed me that people in this community are very
interested in having their blood pressure measured. I used the follow-up visit to the UP to
pretest a Portuguese translation of the John Henry scale (James 1996), and to look for an
association between scores on that scale with blood pressure. Fifty-five people completed
the John Henry 12-point scale in addition to having their blood pressure measured. The
John Henryism results are discussed in the last section of this chapter, on finalizing the
questionnaire.
Freelisting
I collected two types of freelists in phase one; the elements of ideal lifestyle, and
categories of people who make up social support networks. As described above, the 12
people who participated in the semistructured interviews each provided the two freelists.
Ten additional freelists on lifestyle and social support were collected from a
convenience sample of five men and five women these were different people than the
previous interviewees), to make sure that 1 had the most complete list of lifestyle and
social support items possible. The majority of the ten people who provided the ten
additional freelists were students at the Catholic University who come from middle and

101
upper class families in Beira. I could have stopped after the original 12 freelists done as
part of the interviews, because they provided me with all of the final list of items that
were included in the model used in phase two. A total of 44 freelists were collected, 22
on lifestyle and 22 on social support, from 22 different people.
The questions used to elicit the freelists were the same for people who provided a
list in the course of an interview, and for the additional ten people who only provided the
freelist but were not interviewed. To elicit a list of lifestyle items, participants were asked
"What are the elements of the lifestyle of a successful person?" As a prompt, I asked,
"How do these people live, what do they do, what do they have?”.
To elicit categories of people involved in social support, I asked "Who can you
turn to when you need help?". In response, many of the informants asked for
clarification, "What kind of help?". I used this opportunity to ask them to first list
scenarios of when they (or people they knew) needed to seek assistance for a problem.
After they had done this, I asked them to list people who can help out during these
scenarios.
Ranking
After compiling and analyzing the freelist data, I had 12 people (different people
from the people who had freelisted), rank 41 lifestyle items in order of importance. They
were given a set of 3 x 5 inch file cards with the name of each item written in Portuguese.
The cards were shuffled after each person completed the ranking exercise. Three other
file cards had three category names written on them; not important, important, and very
important. People were asked to sort the 41 cards with the lifestyle items into the three
categories first. Once they had done this, I asked them to rank the cards in order of

102
importance within each category. I asked people to use two steps in order to make the
task easier for them, and to collect both rating and ranking data.
Freelist and Rankings Findings
Lifestyle
The 22 freelists for lifestyle items yielded more than 100 individual items.
Individual lists ranged from eight to 21 items. After like items were consolidated, there
were 98 items, of which 48 were listed more than once. The full list of items is in
Appendix B.
From all of the items that were freelisted, I selected 41 items (in Table 5-2) for the
ranking exercise. I excluded the 50 items that were mentioned just once, and, after
discussions with key informants and several of the listing participants, eight items that
were mentioned more than once.
I did not include "have a mistress" because this is only expected of men, not of
women. I took out "have enough food" because this would be a subjective assessment
and could be biased by the mood the person is in at the moment of the interview. I did
not include "not lack" in the ranking exercise because it was too vague a concept and
could not be adequately measured in the survey phase. I also did not include bicycle
because riding a bicycle is clearly not something that a successful person does, and it was
unclear whether the people freelisting had intended to mean that the successful person
buys a bicycle for his or her children.
The other four other items mentioned more than once were items that were
collapsed into broader categories. For example, participants mentioned "sponsor a soccer
team", or "build a school", or "help out people who don't have as much." I included these

103
items under the label “philanthropy,” which was also mentioned several times but not
included in the ranking.
I included “have a spouse,” even though it was mentioned once because during
the interviews most people discussed the successful lifestyle assuming that the person
was married. I knew from participant observation and conversations that having a spouse
was an important part of life in Ponta Gea and should be included in the ranking exercise.
Table 5-2: Average Score for the Items that were Ranked.
Lifestyle item in ranking exercise
Score
1
Own a home *
3.73
2
Spouse (be married) *
7.73
3
Acess to private health care *
8.12
4
Good job
11.51
5
Electricity *
11.84
6
Running water *
12.13
7
Have enough money
13.66
8
Car*
14.71
9
Speak Portuguese at home *
15.83
10
Have housekeeper *
16.13
11
Driver's license *
17.84
12
Water tank *
18.07
13
Home telephone *
18.19
14
Speak a some English *
18.25
15
Have maximum three children
18.34
16
Air conditioning *
18.50
17
Refrigerator *
19.37
18
Send children to private schools *
20.44
19
Freezer *
20.45
20
Eat out in restaurants *
21.82
21
Television *
21.83
22
Stereo (with cassette tape player) *
22.33
23
Stove (w/oven, not a hotplate) *
22.52
24
Satellite TV *
22.78
25
School material for children
23.14
26
Cellular telephone *
24.14
27
Spend holidays outside Beira *
24.36
28
Video player *
24.58
29
Have a stable life
24.85
30
New clothes for your children
25.08

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Table 5-2 continued
Lifestyle item in ranking exercise
Score
31
Furniture set
25.10
32
Computer / Internet
25.49
33
Water pump
25.58
34
Have multiple sources of income
25.84
35
Generator
26.14
36
Not have any worries
27.52
37
Washing machine
27.93
38
Invite your friends over
27.97
39
Carpet on the floor
34.67
40
Serve high quality drinks
35.75
41
Shop in luxury stores
36.75
The score in the right column was generated by Anthropac (Borgatti 1992), using
the ranking data in the consensus function. This program names this output as the correct
answer. It is the average rank given to the item by the 12 people. The items marked by an
asterisk were included in the phase two survey.
Analysis of the ranking data from 12 respondents showed high agreement
(respondent reliability =0.858) using the consensus function. Table 5-3 shows that the
ratio of the first eigenvalue to the second is greater than three, an indication of consensus.
Though 12 respondents is a small number, there were no negative loadings on the first
factor and the mean knowledge score was 0.58 (range .29-80), standard deviation was
0.15.
Table 5-3 Eigen values
Factor
Value
Percent
Cum %
Ratio
1
4.288
69.4
69.4
3.603
2
1.190
19.3
88.6
1.692
3
0.703
11.4
100.0
6.182
100.0
Based on the results of the rankings, 24 items were included in the questionnaire
to measure lifestyle. I included items that scored higher than 25 in the consensus analysis,
with the exception of five items. I excluded “have three children or less” because many

105
people in the study are still having children. Likewise, I excluded “buy school materials
for the children” because it would only apply to people with children of school age, plus I
thought that I would find little variation among people who do have school-aged children.
A family that has children attending school will do everything necessary to insure that the
child has a backpack, pencils and copybooks, all of which are readily available and
considered essential. The copybooks are all the same, but the real variation occurs in the
cost and quality of the backpacks, which would be very difficult to assess.
I also excluded three items that would have been too subjective and could have
easily been influenced by the person’s mood and events on the day of the interview. I
could not define “have enough money”, “have a stable life” and “have a good job” in a
standardized way. Nor could I expect people to share the same definition of what each
concept means as I could expect them to share the definition of having a spouse or not, or
speaking Portuguese at home or not.
Table 5-4 Lifestyle Elements Included in the Phase Two Questionnaire.
Thing people Do:
1. Send children to private schools
2. Access to private medical care
3. Speak Portuguese at home
4. Speak some English
5. Obtain a driver’s license
6. Spend holidays outside Beira
7. Have a housekeeper
8. Eat out at restaurants
9. Have a partner/spouse
Things People Have:
10. Car
11. Home
12. TV
13. VCR
14. Running water
15. Water Tank
16. Electricity
17. Telephone
18. Cell phone
19. Satellite TV

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Table 5-4 continued.
Things People Have:
20. Sound system
21. Stove
22. Fridge
23. Freezer
24. Air Conditioning
Social Support
The 22 freelists of social support included substantially fewer items than the
lifestyle lists. Respondents mentioned 22 categories of people who provide social
support. Of these, 14 categories were listed by more than one person. Table 5-5 shows the
complete list of items.
Table 5-5. People Who Can Provide Social Support.
(From 22 freelists)
ft of
listings
Resp.
Percent
Average
Rank
Smith's
Score
Friends
17
77
3.118
0.45
Padrinhos (godparents)
11
50
3.273
0.281
Family
9
86
1.789
0.719
Church/Mosque member
9
41
3.333
0.243
Neighbor
7
32
4
0.126
Employer/boss
6
27
3.5
0.133
Spouse
6
27
2.5
0.204
Court
5
23
4
0.106
Priest/Pastor
4
18
4.75
0.069
Coworker
4
18
5
0.061
Conterráneos ("same land")
2
9
2
0.073
Government
2
9
3.5
0.055
Schoolmate
2
9
4
0.052
Police
2
9
2
0.078
Regulo (traditional leader)
1
5
5
0.019
Doctor
1
5
3
0.015
Curandeiro (trad. Doctor)
1
5
6
0.013
Teacher
1
5
4
0.026
My spiritual guide
1
5
1
0.045
Psychologist
1
5
3
0.023
Foreign businessmen friends
1
5
5
0.009
Mulheide (woman's group)
1
£
1
0.045

107
Categories of people who provide social support selected for the questionnaire:
1. Family members
2. Padrinhos (godparents)
3. People at your church or mosque
4. Close friend
5. Neighbors
6. Boss
7. Colleagues (coworkers /schoolmates)
8. People from your home region (conterráneos)
I combined spouse into the category of family; priest, pastor or church member
into "people at your church or mosque;” and coworker and schoolmates into colleagues
because the same word in Portuguese (colega) is used to refer to both.
During the phase two survey, participants told us they would turn to people or
institutions not included in these eight categories. So, during the coding of the social
support data, we added the category of bank and government agency to the list above.
The latter category included courts, the Mozambique Women's Organization
(government), and neighborhood leaders.
The following scenarios [when social support is needed] were collected during the
interviews and freelisting exercises.
1. When you are sick.
2. When a family member is sick.
3. If your child is taking drugs.
4. If your son gets his girlfriend pregnant.
5. Conflict within a couple.
6. If you need to borrow money.
7. When someone dies.
8. During the floods.
9. If your child drops out of school.
10. If your children are acting badly.
11. When there is conflict at work.
Defining a shared model of social support. Based on the interviews, as well as
discussions with my research assistants and university colleagues, I chose five scenarios

108
where a person needs to seek out social support to include in the survey questionnaire.
The scenarios had to be generic enough to apply to all the interviewees' lives. We found
out later that many people did not have jobs with coworkers or attend school, so they did
not give an answer to scenario four.
Once the scenarios had been selected, I discussed with ten informants who would
be the best category of social support for each one. They were read the scenario and then
asked to say who would be the best person to turn to for help in that situation. They were
then asked, "If that person is not available to help, who is the second best choice to turn
to for help in this situation?", and so on, until they said that we had exhausted the
categories of people appropriate for the given scenario.
Scenarios adopted for the questionnaire:
1. When you need to borrow money.
2. If a family member is sick.
3. In case of conflict with your partner (within the family).
4. To solve problems at work or at school.
5. The death of a family member.
For scenario 1, (borrowing money), the most common response was boss/work.
Many employers will give a salary advance to an employee who has a family crisis. A
few of the informants mentioned that if an individual does not have family members
living in Beira, or if their family was poor, then getting money from an employer was the
best option. Second choice was to borrow money from a family member, one who has the
means to give a loan. Usually, this means someone who works and has a steady income.
Close friends can also be approached for a loan, as can padrinhos, if the couple is
particularly close to them. If a person has no kin or close friends living in town, then a
conterráneo can be asked to give financial support. Neighbor is not an appropriate

109
category of person to ask for a loan, and no one mentioned colleagues or fellow
church/mosque members.
When a family member is sick (scenario 2), the first option given was to ask other
family members for assistance, taking the person to the hospital, or caring for them at
home or in the hospital. If transportation is needed for medical care and the family has no
car, then a neighbor with a car is usually approached. In addition to providing transport,
neighbors will also come to visit the sick person. Friends can also be counted on for
emotional support, visits, and food, as can colleagues or padrinhos. Church or mosque
members will often come visit a sick person at home or in the hospital. Many churches
have organized groups of people (usually women) who have the job of visiting the sick
members.
When a couple has problems (scenario 3), the first resort is to the padrinhos,
especially if they live in town. When couples do not live geographically close to their
padrinhos, or do not feel emotionally close to them, they may turn to a close friend or
family member who they feel close to. If a problem escalates, then a family conference
may be called. In Beira, most people come from a patrilineal background, in which case
the husband's family would be called first. If the situation worsens, then both sides of the
family are called together to discuss a solution. Church members or pastors/priests are
also seen as good people to give advice to couples who are having problems.
To resolve a problem with a coworker or schoolmate (colega), most informants
felt that the most appropriate place to seek advice was from a family member, close
friend or family member, in that order. The most frequently mentioned family member

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was spouse. Less frequently mentioned options were church member or padrinho, and
only one (of ten) people mentioned boss.
In case of a death in the family (scenario 5), all eight categories of people who
give social support were mentioned, and most respondents noted that help comes from all
sides during this time. Family members are the first line of support, and they provide
financial, moral and logistical assistance. Employers often provide transportation to the
burial, as well as financial help. Churches and mosques also provide transportation, along
with moral support. Neighbors and friends come over to sit with the family, as do
coworkers/schoolmates, and conterráneos. Food is usually provided by family, neighbors
and friends. Colegas contribute financially as well as giving moral (emotional) support.
Discussion of the Findings
The research in phase one yielded a rich description of life in Ponta Gea, and
provided insights into what type of lifestyle is valued, how a successful life is lived,
recent changes in social support norms, and what kinds of social support are valued for
different situations. Because of the nature of the topics covered in the interviews, the
transcripts also provide a window into the concept of stress, and how people deal with
stressors in their lives. The semistructured interviews also covered the folk illness of
tensao alta, which is discussed below.
Lifestyle
The shared model of lifestyle in Ponta Gea was developed during phase one. Data
came from 12 semistructured interviews, ten people who just did free lists, 12 different
people who ranked the lifestyle items in order of importance, key informant interviews,
and participant observation in the neighborhood.

Ill
The ideal lifestyle involves assimilation to the culture of the colonial rulers,
including fluent use of Portuguese. It also involves having the financial resources to deal
with uncertainty and change and conspicuous consumption. There are clear gender
differences, as well. I discuss these in turn.
Connections to the colonial period
During the semistructured interviews, several of the respondents compared the
successful lifestyle to the assimilado lifestyle as defined by the Portuguese during the
colonial period. One older man said, "The life of an assimilado is what is sought out
today. Use a fork and knife, and don’t eat with your hands. Be Catholic, live in a cement
house, speak Portuguese and adopt Portuguese culture." (interview 3). During colonial
times, assimilados were allowed to life in the areas of town reserved for whites only, and
were closely associated with the Portuguese colonial authorities (Newitt 1995). Other
informants mentioned the importance of living in the cement city, speaking Portuguese,
formal education, and having a "western" style of life. The assimilado lifestyle is clearly
the foundation of the shared model of lifestyle in Ponta Gea.
Contract laborers from central Mozambique were recruited to work in Rhodesia
(Zimbabwe) and South Africa during colonial times. These men were expected to acquire
certain material possessions before returning home. A worker who completed his term
and returned to Mozambique without a suit, watch, gramophone, and bicycle was looked
down upon because he had obviously squandered his wages on alcohol or women. If he
did bring these items back, (and even signed another contract to earn more and buy
more), he was accorded prestige for being a hard worker and frugal with his earnings.
The specific possessions a person has to own to be accorded that prestige had changed by
2001, e.g., a car instead of a bicycle, or stereo instead of gramophone. What has not

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changed is the expectation that a person who has worked hard, saved money, and traveled
outside the country, will own high prestige items. One of the principal markers of being
assimilado is fluency in Portuguese and, today this increasingly extends to knowledge of
English.
Language use is related to status in Beira and across Mozambique. School
children often refuse to respond to relatives who address them in the local language in
public settings so as not to be embarrassed in front of their friends. The ability to speak
Portuguese well indicates formal schooling, and also opens up a connection to the rest of
the world. While talking about high status people, one older woman remarked, "They
speak Portuguese in their home because they are more evolved and don’t want to speak
the local language. Their kids don’t even speak their own language. The problem is one
of colonization. You used to have to speak Portuguese to study in the state sponsored
schools." (interview 7). Fluent use of the Portuguese language was one of the
requirements to gaming assimilado status.
The relationship between language use and status is reported to be different in the
center of Mozambique than in the south. In the center there is not one dominant local
language-both Sena and Ndau are widely spoken. In addition, people from across the
country have moved there for economic opportunities or to flee the civil war, bringing
with them their own languages. Portuguese serves as a lingua franca. Several
interviewees told me that local languages are more widely spoken in the southern part of
the country. "The people in the south speak more Shangane, but here in the center we
speak more Portuguese." (interview 3). Interviewee #4 stated," In the center and north of
the country people speak more Portuguese. In the south they use the local languages

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more." Other informants stressed the importance of knowing one's local language as a
way to preserve cultural ties and enable good communication with older relatives.
English is rapidly becoming the language of choice in Mozambique, a country
bordered by five English-speaking countries. "The TV has made English popular, but
mostly for the younger population. They all want to learn [it]. The older people don’t
really thinks about learning English, it was never emphasized for them. Now it’s too
late!" (interview 1). An informant who can speak English well, and uses it at work, said,
"People use English to make a good impression. You can go anywhere with it. A lot of
people use it just to show that they have a higher level than other people." (interview 4).
Gender differences
There are sharp differences in expectations of behavior between successful men
and women. Men are expected to go out to bars and chase young girls, referred to as
catorzinhas (literally "little fourteen year olds"). Having a steady, (younger) beautiful
girlfriend is a visible sign that a man has plenty of money. Interviewee #5 made a
connection between the practice of polygyny in traditional rural life and the taking of
lovers outside marriage in an urban setting, " Now they cannot have more than one
official wife, but they still have others (women), and the first wife has to accept it."
Having a mistress was mentioned four times in the 22 freelists but was not included in the
model.
A successful man is expected to spend a lot on buying his mistress nice clothes
and jewelry, thus keeping her happy. "You have to have a girlfriend to show off to
everyone. It’s stylish and necessary to have one." (interview 4). This behavior is
recognized to have a negative effect on the man's wife and family. "But then they don’t
leave any money at home. They take all the money and don’t leave any for the family."

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(interview 4). "A lot of men arrange a girlfriend, and pay nice things for her, and then
there is less money for the family." (interview 11). If a man leaves too little money for
the basic expenses, his wife is then supposed to make ends meet and somehow provide
food for the family and other household members for the day or weekend.
In the interviews, when I asked "tell me how does a successful person live?”
almost all the respondents replied with a description of how a successful man lived. The
word in Portuguese for person (pessoa) is feminine, but in most of the responses, the
masculine form was used, which is the default gender in Portuguese. Sometimes I asked,
as a follow-up question, "And, what about successful women, is it the same for them?".
One person said, "The women like to buy nice clothes with good labels and dress very
nicely with nice jewelry" (interview 1).
Several interviewees described women as having a different constitution than
men, and having a more isolated life in general. Women are seen as weak and controlled
by their emotions, always complaining, and with no way to release their frustration or
anger. Interviewee #5 said that women " they have less recreation, and they have a
heavier carga (burden). They have more responsibilities at home, and some also have
jobs". Another person noted, "Women don’t have enough things to do, enough ways to
relax and enjoy themselves." (interview 11). According to interviewee #12, women don't
have as good of a social support network, "Men can talk more easily with their friends
and share their thoughts. They can just go out, find a friend of theirs, go and sit and drink
somewhere and laugh and talk. When a woman is upset she doesn’t go out, she usually
stays home and doesn’t talk to her friends or to anyone.". Another woman expressed it

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this way, "Men use drugs or alcohol to forget their problems but women keep their
problems with them." (interview 6).
Status and conspicuous consumption
In addition to buying nice things for your girlfriend, there are multiple ways to
show off your status, to impress people. Several informants felt that by sending a child to
private school, and buying him or her nice clothes and school supplies, parents were
making a public statement about how much money they had. The same sentiment was
expressed about having a nice car. Neighbors remarked that a certain neighbor had
bought a new car and was driving around and parking it in such a way to draw attention
to the car. The latest craze in Beira was cellular telephones, which were introduced
during the first month I was in Beira (November 2000). Several of the interviewees said
that having a cell phone was necessary for some people, but felt that the majority of
people bought them to show off their wealth. "Cell phones are popular now and I think
that only businessmen need them. But the students carry them too. But they don’t really
need them. The students who already get picked up and dropped off by their family at
school, they are the ones carrying the phones." (interview 1).
Informants also mentioned shopping in nice stores, eating differently, and
spending more money than needed, as behaviors to show off wealth. Interviewee three
linked clothes, shopping and food consumption patterns of successful people "They get
all dressed up to go shopping. They buy things that are expensive and go to expensive
stores. They don’t eat local foods like nshima". (Nshima is one name for the local staple
food of com meal porridge.) "Wealthy people don’t come from families that teach them
to eat right. What they leam is that if you’re rich you eat meat, grease, oil, and try to get
fat." (interview 5). Having a freezer full of meat, (usually in the living room) is one way

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to show your wealth to friends and family. One informant stated that he does not think
the meat in a neighbor's freezer was for their consumption, but more to show off to
people who came in the house, (interview 4). Conspicuous consumption often takes
place in public places. "They buy expensive things, not because they are good quality, but
just to show other people they have money. For example, at the Hotel Tivoli a Coke costs
35,000mts (nearly $2.00), and at the Oceana a beer costs 25,000mts (about $1.40). They
buy these things there to show everyone how much money they have." (interview 1).
Elsewhere, a Coke sold for 25 cents, and a beer for 60 cents.
Counterbalancing uncertainty
Interviewees repeatedly told me that a main stressor for them was to not know
what would happen next, if you would lose your job or your home. An ability to predict
or count on the future was lacking in most people's lives. The theme of uncertainty was
mentioned directly or indirectly in the interviews, and also in informal conversations and
observations.
"Stability is what is important. If you are not sure whether you will have a job or
your house tomorrow then you will worry a lot" (interview 12). One way to hedge your
bets in an uncertain economic situation was to diversify your portfolio, to have income
from rental property or a small side business, as well as a regular job. The ideal
household model was to have one primary wage earner, one or more members who sold
food or other good from the house or the market, and one person who was self-employed.
Some of the wealthiest people I interviewed told me that their spouse sold something
from their house or ran another type of small business on the side.

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Connections to the outside world
The Mozambican government began broadcasting its television channel, TVM, to
Beira in 1992. Of the survey sample in Ponta Gea, 85% reported that their household
owned a television set. Of these TV owners, 85% reported having access only to TVM,
while 15% had a satellite dish that allowed them to pick up many other channels. The
majority of the satellite channels are in English, coming from South Africa, England
(BBC), or the U.S. (CNN).
In addition to Mozambican news and events, TVM regularly broadcast shows
from Portugal (RTPA) and Brazil. Brazilian soap operas are extremely popular in
Mozambique, and one is shown immediately following the evening news every evening
on TVM. We asked people who owned a TV to tell us their favorite program. Sixty
percent named the news as their favorite program, while 18% said that the soap operas
were their favorite. The rest preferred sports, debates, or other types of programs such as
animated programs or game shows.
Access to the Internet, and to computers in general, was difficult and expensive in
Beira throughout the study period. One Internet service provider was available in the city,
but service was slow, often unavailable, and monthly rates averaged around $10 per
month. An Internet café was opened during the research, but was frequented primarily by
foreigners. The computer lab at the Catholic University campus did not have Internet
access, and was used mostly for teaching purposes, rather than open access. At the
Pedagogic University, a limited number of computers were available to students for 30-
minute intervals in the Portuguese cultural center located there. Phone contact with other
countries was also difficult and expensive. Direct dial international calling was available
to customers who paid their phone bill in U.S. dollars, otherwise an operator placed the

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call. International and long-distance domestic calls were beyond the reach of most
Mozambicans. Regular mail service was limited to people who rented a Post Office box,
in addition to being slow and unreliable.
Changes
Many informants compared today with the past, "The rules have changed and I
don't know anymore how I am supposed to live. It was not like this when I was growing
up." Or, "During Samora's time we did not have all the things we have today, but we
knew where we stood, things were better then." Many specifically mentioned a period in
the early 1980s when the government rationed all food and consumer items, and all stores
were under government control. Even though supplies were limited during that time,
respondents felt that the distribution of goods was fair and people were not competing to
outshine their neighbors in conspicuous consumption.
Social support
In general, people interviewed noted a disintegration of social ties and social
support in recent years. One woman was describing a recent lunch she had organized for
the workers at a public school. "There is less solidarity, people have no time or concern
about other people. ... There was one guy there with a bottle opener and we asked him to
borrow it to open the sodas. He asked to be paid for the use of the bottle
opener! "(interview 2). She was shocked that he would ask for payment and noted that this
is an indication of the value placed on the success of the individual rather than of the
group.
As in the discussion of lifestyle, people mentioned that social support was better
in the time of Samora (1975-1986). Compared to that time, respondents reported that
today there is more crime, a worse health care system, and generally less respect for other

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people. One respondent, (who was nine when Samora died), said " During the time of
Samora there was a lot less sickness because there was a better medical system. They
gave out drugs to prevent malaria and other illness, and they reduced the rate of these
diseases" (interview 10).
Padrinhos, or godparents, are the ideal first resort when a couple is facing marital
problems. The godparents (also translated as sponsors) should ideally be a couple who is
older than the couple they sponsor, and thus have more experience with negotiating the
perils of married life. The padrinhos "have to give your problem their full attention, take
care of it if possible, listen to you and try to figure out what’s wrong, talk to different
people, get the whole story, then call the couple and advise them" (interview 4).
After the socialist opposition to organized religion was dropped in the late 1980s,
churches of all kinds and Muslim communities have taken on an increased role in
providing aid to families or individuals facing problems. Many of the large churches have
smaller groups of people called "communities" within them, usually organized around
neighborhoods. People living near to each other are formed into a community, meeting
weekly to hear and resolve issues facing their local members. In addition to home visits
from priest or pastors, there are groups within the church who are designated to visit the
sick or bereaved families and to help with funeral preparations.
Rural-urban ties
Split over whether the rural life is more sheltered and idyllic or equal in exposure
to stress and worries. Children are more tempted by bad things in an urban setting, and
many parents chose to send their children to rural areas for schooling. Gorongosa high
school, two hours from Beira, was popular among parents because of its reputation and
also its setting, far from urban temptations. " In the campo (rural area) the situation is

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different, and people are more unified" (interview 11). " This is a very individualistic
place, not like in the country." (interview 6).
Family meetings
Respondents often discussed calling a family meeting as a way to resolve serious
problems. In the scenario regarding marital problems (#3), most of the people I
interviewed that a problem should first be taken care of by the couple, then by the
padrinhos, and, if necessary, by calling a partial or full family meeting. Beira is just south
of the dividing line between the matrilineal (northern) portion of the country and the
patrilineal (southern) portion of the country. In the case of a mixed marriage, there is less
guidance as to which side of the family should resolve the dispute. One respondent was
pragmatic, "There are some things that you have to talk over with your own family, not
just your spouse’s family. If the wife is at fault in a problem, then you have to go to her
family." (interview 8). In several interviews, people simply said that a family meeting
can be called, and, the side of the family called depended on whose family lives closer. If
the situation becomes serious and divorce or legal action is imminent, then both sides of
the family would be consulted.
Neighbors
There was a lot of heartfelt discussion over whether neighbors make good people
to talk to, or not. Several informants stated that a person should not tell his/her problems
to a neighbor because s/he cannot be trusted and will tell others about the problem.
"Neighbors are not your good friends. They start to learn what’s going on in your house
and then tell others." (interview 4). One reason is transience, "You might not live with
your same neighbors forever but the family is always there." (interview 7). Choosing a

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neighbor to confide in requires choosing well, "You can not talk to just any neighbor, but
only the ones you are close to, that you can trust." (interview 12).
Stress and Tensao Alta
In the semistructured interviews I asked people to tell me about tensao alta.
Almost all the interviewees told me that it is caused by stress, and that more women
suffer from it than men. Tensao alta is a folk illness that is very common among
Mozambican adults, and is characterized by a number of symptoms, including fatigue,
dizziness, rapid heartbeat, and pressure on the heart. Most of the cases are self-diagnosed,
without having the blood pressure measured, and the condition flare up in times of social
stress.
My interest was primarily in the connection that people make between social
stressors and tensao alta (TA), in order to understand how stress might be associated with
the biomedical illness of hypertension. In short, TA is viewed as a condition that occurs
when a person (usually a woman) has too many stressful situations going on in her life,
leading to an overload and breakdown. The overload may occur after a sudden shock
(e.g., the death of a close family member), or may simply be the accumulation of many
problems in her life, problems she cannot cope with. The most commonly cited cause of
TA is preocupacoes (worrying), or focusing too much on one's life and problems. Once a
person has developed TA it becomes a chronic condition, as s/he is more susceptible to
having more episodes of TA during stressful times.
I asked the interviewees to tell me why more women suffer from TA than men. I
was told that women are more responsible for the family and when things are not going
well (e.g., a pregnant unwed daughter or a son on drugs) she is more affected by them.
One man said "Men are better prepared to cope with stress, they are taught not to cry in

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any situation, they just learn to accept things that a woman will not. Even if someone dies
I cannot cry! But, keeping emotions in can also cause stress. Men have to have “a forca
de autodominar" (self-control)." (interview 5). This sentiment was echoed by other
informants, pointing out the heavy burdens that women carry, and their tendency to be
more emotionally affected by situations. A young woman I interviewed explained that
many women do not have anyone to talk over their problems with. "Men can talk more
easily with their friends and share their thoughts. They can just go out, find a friend of
theirs, go and sit and drink somewhere and laugh and talk. When a woman is upset she
doesn’t go out, she usually stays home and doesn’t talk to her friends or to anyone"
(interview 12).
Throughout the time I spent in Mozambique, in Beira and elsewhere, I was told
that thinking too much is not good for a person's health. It is common to hear that a
person who is mentally unstable or even psychotic is in that state due to too much
thinking. "You can get sick by studying too much and end up crazy. One of our
colleagues went with us to a course in South Africa. He wanted to leam English in three
months so he studied all the time. He ended up losing it and they had to send him home.
Now, after resting a long time he is ok again." (interview 9).
Preparing the Questionnaire for Phase Two
I used the data from the interviews, participant observation, freelists and rankings
to create local models of lifestyle and social support for testing in phase two of the study.
In addition, I included three other scales in the questionnaire: the John Henry scale
(James 1994, and James and Thomas 2000), the Cohen (1983) self-assessment of stress
scale, and the life events (social readjustment) scale (Holmes and Rahe 1967, Miller and
Rahe 1997). I pretested the John Henry scale during the March visit to the UP (described

123
above). The other two scales (life events and self-perception of stress) were tested in a
pretest and are described below and in Chapter 6.
John Henryism Scale
In Mozambique, I translated the John Henry scale into Portuguese and sent it to
Dr. Sherman James, the researcher who developed the scale. He and I finalized the
Portuguese version of the scale for use in Beira. This Portuguese version of the scale was
pretested at the Pedagogical University (UP) during a follow-up visit in March 2001,
(described above). We took note of the participants’ age, sex and weight (measured on a
bathroom scale), and I measured each person's blood pressure three times. If an
individual's blood pressure fluctuated significantly or was on the borderline of high, I
measured a fourth time. Blood pressure measurements were made with a mercury
sphygmomanometer, listening for the first and fifth Kortykoff sounds.
Of the 63 people who participated in the March measurements at the UP, 55
completed a self-administered 12-item John Henryism questionnaire. Of the 55 forms
completed, two did not have the person's name, and one person left too many of the
questions (seven) blank, so these three were excluded from the analysis. Of the remaining
52 forms, seven had 1-3 items left blank. Following Dr. James's instructions, I averaged
the scores of the items the person had completed, and assigned this averaged score to the
missing items. As a result, I have 52 forms of the 12-item scale that can be analyzed.
The majority of the participants are students at the UP, the rest are professors and
staff at the UP, and students from other post-secondary schools. The majority of the
students at the UP worked as teachers, usually at the secondary schools level, and are
returning to complete their college education. The sample of people who completed the
John Henryism scale included eight women and 44 men. The number of women is too

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low to use sex as a variable in the equations below. Table 5-6 describes the sample from
the UP who completed the John Henryism scale.
Table 5-6. Age, Weight and John Henryism score. (n=52)
Minimum
Maximum
Mean
S.D.
Age
20
46
29.15
7.29
Weight
50
76
62.23
5.72
John Henry
31
58
47.54
5.53
The results of regression equations to predict blood pressure by age, weight and
John Henryism scores are shown in Table 5-7. Age is a significant predictor of systolic
and diastolic blood pressure, as is weight. Scores on the John Henryism scale do not
significantly predict either measure of blood pressure in a regression equation.
Table 5-7. Prediction of Diastolic and Systolic Blood Pressure by Age, Weight and JH.
(°=52).
Diastolic
Slope
Significance
Systolic
Slope
Significance
Age
.217
.109
Age
.300
.027
Weight
.347
.012
Weight
.312
.021
JH scale
.124
.337
JH scale
.057
.653
The Self-Perceived Stress Scale
The Cohen self-perceived stress scale (1983) was translated into Portuguese at the
end of phase one, in preparation for its use in the survey questionnaire in phase two. The
original Cohen scale has ten items, and respondents are asked to give a score using a five
point Likert scale. The research team pretested the Portuguese translation of the ten-item,
5-point Likert scale on 15 people in Ponta Gea. Following the pretest, we decided to
narrow the scale down to four questions and use a three-point scale. Respondents were
having a very difficult time distinguishing between the ten questions, and an equally
difficult time using the five-point scale. A few respondents in the pretest said, "you just
asked me that" during the Cohen scale questions.

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The Life Events Scale
The life events scale (Holmes and Rahe 1967, Miller and Rahe 1997) asks people
about stressful events that may or may not have happened in their lives in the previous
year. This scale was also translated into Portuguese and pretested. The pretest showed
that people had no difficulty in replying to the yes/no questions about things like whether
they had moved, gotten married, or had a family member die in the previous year
The final version of the questionnaire is presented in the next chapter, which
describes the survey done in phase two of the research project.

CHAPTER 6
PHASE TWO:MODEL TESTING
Phase Two: Survey Methods
Research Assistants
In May and June 2001,1 selected three research assistants for phase two, trained
them, and together we finalized and pretested the survey instrument. I solicited
candidates for research assistants from the two universities in Beira, the UCM and the
UP. At UCM, I asked the Dean of medical education to recommend students who met
my criteria. I requested that he find serious and reliable students who are interested in
research, need to earn some money (since many of the UCM students are very wealthy),
and preferably be from Beira - both for linguistic competence and to insure that they
would be in town for the June/July school holidays. The Dean suggested two students
who were completing their first year (this was the end of the first year of the medical
faculty’s existence). I met with them and decided to hire them both because I thought
they would complement each other and the project. Ms. Aguida was young (20), was
very bright and personable, good with computers, but a little bit shy at the beginning. Mr.
Fransisco had worked as a medical technician in a rural health center, and still worked for
the Ministry of Health but they had given him six years leave to complete his medical
studies.
At the UP, I asked an anthropologist who teaches in the geography section to
recommend two students. He suggested two third-year geography students, I interviewed
them, and chose one. The student I did not choose was from another province and was
126

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extremely shy. Mr. Bizeque was a fourth-year student, who had been a teacher for 15
years before going to university, was from Beira, married with children and had
previously lived in Ponta Gea. He had also worked on a number of research projects and
was familiar with recruiting people to be in studies and with interviewing techniques.
The initial training of the research assistants took place over a ten-day period. I
began by explaining the objectives and methods of the study, and how I envisioned the
survey to would be done. We developed a contract outlining their participation in the
study and payment.
I paid them an hourly rate based on the pay scale used for research projects at the
Catholic University (approx. $1 per hour), plus travel time and costs. I told them that
they would receive a bonus at the end of the project if they worked well, and they all
were given a $50 bonus in August at the end of the survey.
We translated the questionnaire from English to Portuguese, discussing each
question and what information it was supposed to elicit. At various stages in the
translation we practiced the newly translated section on people. Their training continued
during the pretest and the survey.
During the survey I continued to train the research assistants. I gave them
feedback both during group meetings and privately. 1 talked with them about the
presentation of the study to potential participants, the transition to the interview, their
interviewing techniques, and how they handled questions from interviewees. In the final
weeks of data collection I trained the research assistants to code the data, and we spent
time at the beginning or end of the day coding the interview forms. After the data had

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been entered, I showed them how the data looked in Excel, and we did some of the
analyses together in SPSS (2000).
Translation of the Questionnaire
As part of their training, the research assistants and I translated the questionnaire
from English to Portuguese. I wanted the translation to be in the Portuguese that is
spoken in Beira, and not necessarily textbook Portuguese. Mr. Bizeque (from the UP)
was the best at translating the questionnaire, even though his English was the most
limited. He had previous research experience, a solid training in the Portuguese
language, plus a gut feeling for the level of understanding we would encounter in Ponta
Gea. These qualities contributed to his invaluable input during the translation and
throughout the survey.
Pretest of the Questionnaire
Once the questionnaire had been translated and each section tested on a few
people, we pretested it on ten people living in Ponta Gea. The pretest was a close
approximation of the actual study conditions. We went to people’s houses, asked if they
met the study criteria, and explained the purpose and structure of the questionnaire. After
each pretest interview, we returned to my house to discuss how the interview had gone
and what changes we needed to make, either to the instrument or in our interviewing
techniques.
Sampling
Although the survey sample was nonrandom, I designed it so the sample would a
cross-section of the neighborhood of Ponta Gea. The research team and I divided the
neighborhood into five zones. We used landmarks and main streets to divide the area
into smaller neighborhoods, and discussion with three key informants. For example, one

129
zone is the area around the Governor’s house, another around the Catholic cathedral, and
a third the zone where the bairro meets the main city’s commercial center. We
interviewed approximately 50 people from each zone, for a total sample of 265 people.
Slightly more than 50 people were interviewed in the larger zones, and fewer in the
smallest zone (A). The zones are marked on the map in Appendix A.
Table 6-1. People Interviewed by Zone.
Zone
Women
Men
Total
A
25
22
47
B
29
29
58
C
27
27
54
D
27
25
52
E
27
27
54
Total
135
130
265
Four people were interviewed who were later excluded from the final analysis,
two were the spouses of other respondents, and two had questionnaires that were
incomplete. Thus, the total sample of eligible participants is 261.
A total sample size of 250 was estimated for the survey before I went to Beira. I
wanted to have enough people in the survey so that I could break the sample down by sex
and by age group and still have enough people in each cell for the analysis. I also
projected that this number of interviews was feasible given the time available. I initially
planned to have two teams of researchers, one led by me, and another by an anthropology
student from UEM in Maputo, who was originally from Beira. Once I started doing the
interviews in phase one, I decided that I wanted to be present at every interview, whether
or not I was the one conducting the interview. I knew this could reduce the number of
interviews (possibly to 120-130), but would also increase their quality and my
understanding of the results. Even though only one team was interviewing, we were able
to complete the 265 interviews in just seven weeks.

130
I decided not to interview people living in an abandoned hotel on the edge of
Ponta Gea. These people are squatters and there is no water, electricity or sanitation in
the building. I felt it was primarily a safety consideration to not interview there.
Likewise, I chose not to interview at the UP dormitory in Ponta Gea. The students there
were not living in a normal family environment but were living in rooms with nonrelated
people.
Research Permission
Before starting the survey, I met with the provincial director of health (DPS), and
he enthusiastically endorsed the project, asking that I give a small seminar for his staff
with the results. He confirmed that there are almost no studies on adult health in
Mozambique, and few health studies using qualitative and quantitative methods. The
director gave me invaluable feedback on the project, and brought up the issue of paying
the interviewees. His opinion was that it is better not to pay people for their participation
because it will ruin the chances of future researchers who do not have the ability to pay.
The Provincial Director of Health brought up the ethical question of what to do
when we found people with high blood pressure. He suggested I speak to the medical
director of the Beira Central Hospital (previously the Indigenous Hospital). I also met
with the director of the Ponta Gea Health Center (previously the European Hospital). She
and I set up a system to refer interviewees who had high blood pressure to go there for
follow up. We printed up referral forms to give the participants with the date of the
interview, their name, and the values of the three blood pressure measurements taken at
the end of the interview. It was more convenient for the study participants to go to the
Ponta Gea Health Center because they could walk there, than to the Beira Central
Hospital.

131
I also obtained permission from the Secretario de Bairro of Ponta Gea. He is a
member of the ruling party who is appointed to coordinate government services at the
bairro level, and to solve local disputes. I visited him with the members of the research
team, introduced them and explained our project. He recommended that we make ID
cards with each of our pictures, which he then signed. The research assistants wore their
ID badges for the first week or so, and thereafter carried them in their pocket. When we
went to tell the Secretario de Bairro we had finished the study, we found he was no
longer there but had been replaced.
Layout of the Questionnaire
Language
The questionnaire was administered orally and answers recorded on the
questionnaire form. The instrument was written in Portuguese. Three interviewees, all
women, were interviewed in local languages at their request, two by Bizeque and one by
Fransisco who translated the questions into the local language but filled in the answers in
Portuguese. The rest of the interviewees felt comfortable speaking Portuguese so we used
Portuguese for their interviews. The words and style of the language in the questionnaire
were carefully chosen to be accessible to everyone, even people who had never had
formal schooling.
Prompt card
We prepared a 3 x 5 file card with the categories of people who provide social
support. This card was designed to prompt people’s responses for five scenarios that were
read in the section on social support. If a person had told us that s/he had not gone to
school, or we had other indications that the respondent could not read, we did not give
them the prompt card. In other cases where we suspected the person could not read, we

132
asked them if they would like to look at the card with the categories on written on it.
About five percent of the people (n=12) we offered the card to declined to take and use it,
saying they could not see it because of vision problems.
The sections
The questionnaire had seven sections:
1. Demographic
2. Lifestyle
3. Cohen Stress scale
4. Social support
5. Life events
6. Family and person health history
7. Anthropometric and BP measurements
The English and Portuguese versions of the questionnaire are in Appendices C
and D.
Modifications during the survey
The questionnaire initially included a 12-item section on John Henryism. We
eliminated these questions from the final version of the survey because the respondents
had difficulties with understanding and answering them. Specifically, respondents had
trouble specifying an answer along the five-point Likert scale. More importantly, there
was a problem with social desirability, as has been noted by James (2000). These
difficulties are detailed in Kennedy and Barkey (n.d.).
The questions on the Cohen self-perceived stress scale also had to be modified
during the survey, although we kept the scale in the questionnaire. The original Cohen
scale consisted of ten questions, but this was decreased to four in our questionnaire,
because of complaints by respondents about the repetition of the same theme. We
modified the wording of the questions according to feedback from the participants and
the research team. As with the John Henry scale, participants could not answer using the

133
five point Likert scale, but had an easier time after we reduced the number of choices to
three.
Data Collection
We began formal data collection in phase two on June 15, 2001.1 attended all the
interviews, along with one or two of the research assistants at any one time. This
schedule gave the three research assistants time off to attend to personal matters since we
were working seven days a week. We interviewed all day, usually until 7 or 8 pm.
Interviews were done in the evenings and on weekend in order to reach working people,
particularly men. We had a modified work schedule on the weekends, usually stopping
by 2 or 3 pm, so as to minimize our encounters with people who were drinking alcohol.
After dark and on weekends one of the male research assistants was always present
because it would have been improper and unsafe for Aguida and me to work alone. Our
time schedule was constrained by the fact that the research assistants were all students
and had to return to classes during the first week of August. We averaged eight
interviews on a full workday, occasionally doing 10 or 11 per day, over the period of
seven weeks.
We would begin at the edge of a zone within Ponta Gea and walked house-to-
house, introducing ourselves, giving a brief summary of the project, and asking if there
were people in the house who could talk to us. For apartment buildings we began at the
bottom of the building and worked our way up. We prepared a one-page flyer about the
study and left it when no eligible adult found was home, so they could look it over before
we returned. We kept a notebook of appointments and houses to go back to later.
Evenings were a very popular time for scheduling appointments. Weekend days were
good times to find people who worked away from home during the week (Bernard 1995).

134
Once a person agreed to participate, we were usually invited into the living room
or chairs were brought to the yard. If the person's house was too small or they felt
embarrassed by it's simplicity then we conducted the interview outdoors. The
Institutional Review Board at the University of Florida determined that we could obtain
oral, rather than written, informed consent. (See Appendix E.) Our oral consent
procedure consisted of the following information. We explained who we were and our
affiliations, and that this study was voluntary and anonymous. We told the interviewee
that she or he was free to not answer any question, or to stop the interview at any point.
When we began the interview the person usually started by telling us their name, even
though we had said we did not need to know names. Each questionnaire was assigned a
unique ID number. More than half the participants asked if I lived in Ponta Gea. I replied
that I did, told them the house we were renting, and most of them knew our landlord and
the house.
The four members on the research team took turns conducting the interviews.
Often my research assistants suggested whose turn it was to conduct the interview, or
who should do it. They usually requested that I interview the wealthiest people we
encountered. When one of my research assistants was doing the interview I took notes in
a notebook of interesting comments and sometimes ask follow-up questions during the
interview or afterwards. I also unobtrusively took note of the items on display in the
public areas of the homes where we interviewed because I was struck by the use of public
space to demonstrate prestige or status.
The interviews lasted between 30 and 120 minutes. Many of the interviewees
wanted to talk about the questions or the issues introduced by the questions. The Cohen

135
self-assessment of stress prompted many of the respondents to tell us about stressors in
their lives. In the same vein, the life events questions also generated many stories about
the respondent's life in the past year or several years. We took notes on these open-ended
discussions in separate notebooks and compared them after the interview. The research
team member(s) not conducting the interview took notes on these stories and insights in
order to free the interviewer up to focus on the questionnaire and the person being
interviewed.
Measurements
Because blood pressure is highly responsive to various stressors, how it is
measured is extremely important. In a best-case scenario, multiple measures are taken
and the mean of those measures, or the mean of the final measures taken, is used as the
person’s blood pressure. The person should be seated comfortably, and (ideally) not have
consumed alcohol or caffeine during the past hour. Blood pressure can be measured using
a mercury sphygmomanometer and stethoscope, or one of a variety of electronic
machines. These machines are difficult to move and require an external power source,
and thus, have not been widely used in blood pressure research in field settings in Africa
(Mufunda et al. 1996).
I took all the blood pressure measurements, measuring each person at least three
times. The three measurements were recorded onto the interview form. I was the only
person to measure blood pressure to reduce interobserver variation. We wrote the blood
pressure measurements on another paper and gave it to the participants, unless they said
they were not interested. If a person’s BP was slightly high, or they reported not knowing
they had hypertension, or if I felt that stress related to our presence or the interview was
making the BP go up, we would make arrangements to come back a day or two later to

136
remeasure. The next day we were usually still in the area near to the person's house and
we would schedule a return visit.
The members of the research team helped each other measuring the heights and
weights. The participant was asked to stand against the wall and a flat board was placed
level on their head and a line drawn on the wall. The height from this line to the floor was
then measured using a tape measure. Weights were measured with a portable (bathroom)
scale and rounded to the half kilo. The scale was set to zero before each weighing and
was recalibrated with another scale weekly.
At the conclusion of the interview, the person conducting it would check to make
sure the form was complete and ask if the respondent had any questions. We thanked the
person for taking the time to talk with us and reminded him or her that we would be in
the area for a while and to not hesitate to contact us if necessary.
Inclusion criteria
To be in the study, a person had to be over age 30, a resident of Ponta Gea, and be
a Mozambican citizen. We only interviewed one person per household. We did not
include women who were pregnant in the survey. I did include one person who was 29
years old but the following month she was turning 30.
I wasn’t sure whether we should include Mozambicans who were not primarily of
African descent. After soliciting advice from various sources, I decided to include them
and to indicate their race on their interview form, to be able to separate them out of
analyses if I chose to. During the survey we found adults representing 15 other
nationalities living in Ponta Gea (who were not interviewed). The most common
nationalities encountered, besides Mozambican, were Portuguese and Indian.

137
First impressions
The most common reaction to our arrival at someone's door or yard was to
assume that we were missionaries. We had to explain repeatedly we were not from a
church group, but that we were doing a health project. Still, there was a lot of suspicion,
particularly among Muslim families. In response to our question asking whether she
would like to participate in our study, one Muslim woman stated, "I am not from your
church". We explained we were part of a health study with no ties to a church, and she
agreed to participate. Word got around the neighborhood pretty quickly that we were a
health study and not a missionary group.
Measuring non-participants
People who did not meet the study requirements were told that they could still
have their weight and blood pressure measured. Other family members, friends or
neighbors were often present and asked if they could participate. If they met the inclusion
criteria we made an appointment to interview them at their home, but otherwise we
explained that we could just tell them their weight and blood pressure. (People were less
interested in knowing their height, because it is printed on their identity card.) We
measured the weights and heights of children. These extra-study measurements were
written on slips of paper and given to each person, or, in the case of children, given to the
oldest child or a parent. The measurement of people who were not in the study helped to
reinforce our reputation in the community as a health team, and dispel the myth that we
were missionaries.
If a family member or friend was present, the research team member not directly
involved in the interview would engage that person in quiet conversation, or ask if she or
he would like to have his/her weight or blood pressure measured. We distracted the other

138
people or person in the room to allow the interviewee to speak as freely as possible. After
the demographic (first) section of the interview, other people in the room usually became
bored and drifted away.
Receptivity to the study
On the whole, people in Ponta Gea were very receptive to the survey. The
majority of the participants were very helpful, and welcoming. Many gave us coffee or
sodas, along with bread or cake or cookies. We refused several invitations for lunch or
dinner so as not to cause a burden for the participants and their families. Many
participants and nonparticipants were curious about the study, asked us about blood
pressure, told us of their own experience with blood pressure, and asked about what we
were finding.
In only a few cases we found people to be less than completely cooperative. One
woman was combative (asking the interviewer to ask her a "better" question or saying "I
do not want to talk about that with you"). A second woman cried because she was having
serious personal problems, and one man was indifferent, watching TV and not paying
much attention to the interview. These three people completed the questionnaire after the
interviewer asked if they would like to stop or continue, and became more cooperative as
the interview progressed.
Most of the respondents wanted to talk, especially during the questionnaire
sections on social support and perceived stress. Other people asked about what blood
pressure was actually measuring, the dangers of high blood pressure, what was low blood
pressure, or about general health issues. We discussed these topics and spent a lot of time
listening to people tell us about their personal and health issues. Listening

139
sympathetically seemed to be a help to many of the interviewees and they often thanked
us after the interview for coming to see them.
Referral to the Ponta Gea hospital
If participants had blood pressure measurements greater than 140 mmHg
(diastolic) or greater than 90 mmHg (systolic), I asked if they would like to be referred to
the Ponta Gea hospital. I explained we had arranged with that hospital for follow-up care
with people from the study at no charge. A few of the respondents were already under the
care of the main Beira hospital or a private doctor (usually a family friend) and refused
the referral. The majority of those found to have an elevated BP accepted the referral
form. In a few cases I referred nonparticipants to the Ponta Gea hospital after measuring
their blood pressure and finding it was high. The research team made several visits to the
PG hospital to see who was coming with the referral slips and to see what the technician
there was finding and prescribing.
Coding the Questionnaire
The code sheet for the questionnaire is found in Appendix F. The code for each
question was written in the left hand margin of the interview form and later entered into
the computer.
The coding for level of schooling followed the system used in the national census
(INE 1999). The structure of the school system in Mozambique has changed several
times and the census put together a chart/table showing the equivalent educational levels
for the different times. In the questionnaire we asked people what year they completed
their formal education so we could correctly assess and code their level to be comparable
to the other participants. The Mozambican census code sheet for educational level is in
Appendix G.

140
The variable maternal language was coded in a two-step process. After we had
listed all the languages participants reported speaking (n=23), we coded them from 1-23.
These were then collapsed into four groups, (l=Portuguese, 2=Indian languages,
3=Sena/Ndau, and 4=other Bantu languages), and each person was given a second code.
A code for "place of birth" was also created in a two-step process. Initial
responses were coded as follows:
l=Beira
2=Sofala (the province where Beira is found)
3-11= the other provinces of Mozambique
12=outside Mozambique.
Later, numbers 3-11 were collapsed into three categories; north, central and
southern provinces.
One question asked about where children in the household went to school (if
children in the household went to school). The respondent gave the name of the school
and we made a list of all the schools named. One of the research assistants, Bizeque, had
been a teacher in the area for many years, and he grouped the school names into four
categories: private, public, church-related, and university/boarding schools.
In the final section of the questionnaire the respondent is asked to give symptoms
she or he had experienced if she or he reported having hypertension. These were put in a
list, with like symptoms combined under one heading. Likewise, respondents also gave
symptoms of hypertension experienced by their immediate family members. These were
also put in a list with like symptoms combined.

141
Data Entry
The data were entered into an excel worksheet and later imported into SPSS
(2000). Hilton Vasconcelos assisted with the data entry process. The statistician at the
Geographic Information Systems office of the Catholic University helped manipulate the
data in excel and convert it to SPSS (2000). Some of the text data were initially organized
in MS Word. We made lists in Word of the hypertension symptoms respondents reported,
or symptoms they reported for their family members. We also listed the schools people
sent their children to, maternal languages, and the medications taken for hypertension.
Data Checking and Verification
After the data were entered, the values on the interview forms were checked
against the values in the database. The minimum and maximum values for each
continuous variable were checked to make sure that only reasonable values were entered
(e.g., no ages below 29 and no heights above 2 meters). For categorical data, frequencies
were run to make sure that only the allowed values were found. Missing or irregular data
were completed or checked by returning to the participant's house and verifying the
information with him or her.
Creating New Variables
Age was collapsed into four groups; 29-39,40-49, 50-59, and 60 and over.
BMI was calculated with the following formula: weight/height2.
Monthly income in the Mozambican currency meticais was converted into dollars,
Income in dollars was collapsed into terciles.
The average of the three systolic and three diastolic blood pressure measurements
was calculated. The mean of the three is used as an individual's diastolic or systolic blood
pressure.

142
Two dichotomous variables were created for the two definitions of high blood
pressure (>=140 and >=90, >=140 or >=90).
Several other new variables were created during the course of the data coding and
analysis. I describe them in the section where I introduce and use the variable in the
analyses below.
Presentation of Preliminary Results
Preliminary Analyses
Preliminary analyses of the survey data were done in the field. Time constraints
prohibited doing all the analyses in the field. The rest were completed after I left
Mozambique, using SPSS (2000) and Anthropac (Borgatti 1992).
Presentation of Study Results
On October 17, 2001, Ms. Aguida, Mr. Fransisco and I gave a presentation about
the research to the medical students at the Catholic University. Mr. Fransisco and I went
to the provincial health department several times to arrange a seminar there. The
provincial director was on annual leave for one month and no one else was able to host
the seminar.
Meetings in Maputo
In August, September, and October of 2001 I traveled to Maputo to work with my
students at Eduardo Mondlane University, and to participate in their defenses of their
theses. I also met with Dr. Damascaeno, the cardiologist, and shared the preliminary
results with him. I talked to several colleagues at UEM about what I was finding in the
study and sought out their input on the results and questions that I had about the data.

143
Follow-Up Interviews
After formal data collection in phase two was completed and I did the preliminary
analyses of the data, I was faced with several questions raised by the data. To further
investigate these issues, I conducted formal and informal follow-up interviews with both
key informants from phase one and with phase two interviewees. The topics explored
during these discussions included, but were not limited to; food patterns, eating at home
compared to eating away from home, food preparation, use of traditional and alternative
medicines to treat high blood pressure, and the role of churches in stress management and
healing.
In September and October of 2001,1 went back to several of the phase two
participants' homes to see how people I identified as having extremely high blood
pressure during the study were doing, and whether they had sought out treatment. One
woman had been hospitalized and not at home the first time I went to her house. On a
later visit, she told me that her daughter was paying closer attention to her health
problems and taking her to the hospital for regular checkups, a marked change from her
daughter's behavior previously. Other participants told me during the follow-up visits that
they were doing well and had been able to resolve most of the problems they had been
experiencing.
Two women from phase two spontaneously came up to me on the street at
different times to report on what had happened since I interviewed them. One was out
"power walking" early in the morning, and she told me she was losing a little weight to
lower her blood pressure. She also said that a neighbor I had interviewed had gone to the
hospital where she was diagnosed with a heart defect and sent to Maputo. The second

144
woman thanked me for interviewing her and measuring her blood pressure, and said she
was now thinking more about her health and ways she can prevent high blood pressure.
Archival Research
1 conducted research on the history of Beira and its neighborhoods during phase
one and after the completion of phase two. Most of this research was done with
secondary materials at the Beira branch of the national Heritage and Cultural Archives
(ARPAC). The director, Dr. Chuva, and the head of the library, Mr. Joao Joaquim, were
most helpful in this undertaking. I also interviewed people who were identified as having
special knowledge about the history of Beira throughout the research project. The
information from the archives and these interviews helped me to choose the
neighborhood for the research, and to understand the stories people told and references
they made during both phases of the research.
Survey Results
Describing the Sample
The survey sample is almost evenly split between men and women, with 131
women and and 130 men. Respondents are between the ages of 29 and 79, with a mean
age of 44.5. The sample is skewed towards the low end of the age range, with 38.7% of
the sample between 29 and 39 years old. One third of the sample is between 40 and 49,
and just 28.4% are over age of 50.
Number and Percent of survey participants by 10-year Age Groups:
29-39 years old 101 38.7%
40-49 years old 86 33.0%
50-59 years old 46 17.6%
60 years and up
28
10.7%

145
The weights of the participants are given in kilograms, and range from 37 to 117.5
kilograms. The heights of the participants are measured in meters. See Table 6-2. Body
Mass Index (BMI) was calculated as weight (kg) divided by height (m2) -
(weight/height2).
Table 6-2:Age, Weight, Height, BMI and Income. (n=261)
Minimum
Maximum
Mean
S.D.
Age
29
79
44.52
10.8
Weight (kg)
37
117.5
70.27
15.26
Height (m)
1.41
1.98
164.05
8.55
BMI
15.62
48.28
26.17
5.68
Income* ($)
12.50
1,750.00
234.9
255.9
*n=241
Income
Monthly income was measured in meticais (the Mozambican currency), and later
converted to dollars (20,000 meticais = 1 USD). The national minimum wage in
Mozambique is 500,000 meticais per month, ($25 USD per month). Five people report a
household income below the minimum wage of $25 per month. The range in income is
striking, and exactly what I was expecting. Although Ponta Gea was designed by the
Portuguese to be a middle-class neighborhood, today it is home to people with a wide
variety of socioeconomic levels. The survey sample reflects that diversity in income.
Asking people about their household's monthly income was clearly the most
difficult question on the questionnaire. Twenty people did not give an amount. A few
respondents refused outright to answer the question, while others said they did not know
because their spouse did not tell them his or her salary, or because they did not know
about the income of other household members. Note that the sample size for the variable
income is 241,20 people fewer than the rest of Table 6-2.

146
I wanted to be able to assess income in terms of income per household member.
Because income was reported as total income for the household, and we asked how many
people lived in the household. I created a second income variable; household income
divided by the number of people in the household.
Education
Education was obtained by asking: What's the highest grade in school you have
completed? In Portuguese we used both the words nivel and classe, literally level or class,
for the English word grade. After people told us the highest grade completed, we asked
them what year they completed that grade. The year was necessary to classify them
according to the different educational systems that have existed in Mozambique over the
years. We used a table produced by the Mozambican census (INE 1999) to classify
people's educational levels from the different systems into equivalent categories. This
table appears in Appendix G. Table 6-3 provides the number and percent of the sample
that completed each level.
Table 6-3. Education Level of Survey Participants.
Frequency
Percent
0
None
19
7.3
1
Literacy
1
0.4
2
Primary School
67
25.8
3
Middle School
47
18.1
4
High School, part 1
55
21.1
5
High School, part 2
35
13.0
6
Vocational
0
0
7
Technical training
3
1.1
8
Advanced technical training
16
6.1
9
Teacher training
0
0
10
University
19
7.3
Total
260
100

147
Household composition
Each respondent was asked to report how many adults (over age 18) lived in the
household, and how many children. To get a picture of household sizes, the total number
of people who live in the household was summed (adding the number of children and the
number of adults). More than 57% of the households consisted of four to seven people,
and the mean size of 5.74 individuals per household was higher than the Mozambican
average of 4.2 (INE 1999).
The household composition for the survey sample is shown in Tables 6-4 and 6-5.
Table 6-4: Household composition. (n=261)
Minimum
Maximum
Mean
Standard
Deviation
Adults living in
the home
1
9
3.24
1.61
Children living
in the home
0
9
2.51
1.93
Total household
members
1
16
5.74
2.67
Table 6-5. Number of people per household (adults and children) n=261
Number
Frequency
Percent
1
11
4.2
2
18
6.9
3
21
8.0
4
35
13.4
5
45
17.2
6
36
13.8
7
34
13.0
8
24
9.2
9
17
6.5
10
10
3.8
11
3
1.1
12
2
.8
13
2
.8
14
1
.4
15
1
.4
16
1
.4
Total
261
100

148
Eleven people reported living alone. Most of these were maids or guards who live
in the small houses (dependencia) at the rear of most properties, and consider themselves
as constituting a separate household. One man is a mechanic and lives at the shop where
he works. An older man (age 79) reported living alone, although his maid lives in the
dependencia behind the main house with six of his relatives. The older man's son and
grandchildren lived a few blocks away. A single woman (age 31) lives in an apartment
provided by her employer (the railroad). Her brother lives in the apartment next door with
his wife. Two men reported that their wives had recently left them, to explain why they
are living alone. One 32 year-old male teacher lives alone in housing for professors, and
had recently returned from studying for two years in Portugal.
Smoking
Smoking was reported by 18.5% of the total sample. Older people smoke less
than younger ones. The age group 40-49 had the highest rate of reported smoking, 22%.
Only 13 women reported smoking, compared to 35 men. I would caution against the
over-interpretation of these data. Smoking status was self-reported during an interview
with a team of people who had identified themselves as health researchers and were
asking about the respondent’s health.
Age Group
Total
29-39
40-49
50-59
60 +
Do not
smoke
83
66
41
22
212
Smoke
18
(17.8%)
19
(22%)
5
(9.2%)
6
(4.6%)
48
(18.5%)
Total
MOl
85
46
28
260

149
Race or ethnicity
People were assigned by the research team to one of three racial/ethnic groups:
having primarily Portuguese, Indian or African heritage. These categories are based on
the classification system used in the neighborhood and in the city in general. People of
Indian heritage are referred to in slang as mwenye or mounhe, used to refer to a person
from India. Eighty-five percent (n=222) of the sample is primarily of African heritage,
while six percent (n=16) are of European heritage, and nearly 9% (n=23) of south Asian
descent.
Mobility and belonging
I hypothesized that mobility and being from outside of the community would act
as stressors. Three measures were used to evaluate this hypothesis: years of residence in
Ponta Gea, maternal language, and province of birth.
Residence in Ponta Gea
Prior to independence inl975, Ponta Gea was reserved for people from Portugal, a
few from India, and the occasional Mozambican assimilado. Eight people in the sample
have lived in Ponta Gea for more than 27 years (before 1975). Most of these are of Indian
heritage, with the others coming from assimilado families. Mean number of years living
in Ponta Gea is 13.4. One quarter of the sample reported moving into Ponta Gea between
1975 and 1980, the period that the government was most actively nationalizing property
and distributing the houses.
Maternal language
We used the question about maternal language from the Mozambican census (INE
1999), which asks: "In what language did you learn to speak?" Portuguese is the
maternal language of 30% of the sample. The two primary local languages, Sena and

150
Ndau, were the maternal languages of 10.5% and 21% of the sample respectively. Eight
percent of the people surveyed speak Chuabo from neighboring Zambezia province (to
the north) as their first language. Another 6.5% spoke Xitswa (from the south) as their
first languages. Respondents listed 23 maternal languages, but apart from the five listed
here, none were spoken by more than 5% of the sample.
Province of birth
Place of birth was coded as the province of birth, except for people who were
bom in Sofala province. Beira is the capital of the province of Sofala, and people bom in
the city of Beira were coded as being bom in Beira. If they were bom in Sofala, but
outside of the city of Beira, they were coded as Sofala province. More than 40% of the
sample was bom either in Beira or in Sofala province. Seventeen percent of the people
were bom in Zambezia province to (the north of Sofala), and 14% are from Inhambane
province (to the south). Six people in the study were bom outside of Mozambique. They
were bom to Mozambican parents who were living outside the country at their birth,
usually due to refugee, student, or diplomatic status.
Table 6-7. Place of birth of survey participants: (n=261).
Province
Number
Percent
Beira
41
15.7
Sofala (not Beira)
67
25.7
Manica
8
3.1
Tete
19
7.3
Inhambane
38
14.6
Gaza
4
1.5
Maputo
18
6.9
Nampula
10
3.8
Zambezia
45
17.2
Cabo Delgado
3
1.1
Niassa
2
0.8
Outside of Mozambique
6
2.3

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Lifestyle
The lifestyle scale is based on the 24 items elicited from respondents in phase one
through freelists and then ranking (described in Chapter 5). See Table 6-8.
Table 6-8. Number and Percent of Participants Responding Affirmatively to each
Lifestyle Item.
Item/behavior
Number
%
Electricity
240
92.3
Speak Portuguese at home
236
90.8
Own a television
220
84.6
Stereo
210
80.8
Being married
195
74.7
Running water
188
72.3
Refrigerator
166
63.8
Freezer (separate unit)
153
58.8
Have a maid
143
55.0
Stove
132
50.8
Own a video player
129
49.8
Telephone
119
45.8
Speak some English
117
45.0
License
115
44.2
Children in private school
107
41.8
Water tank
IT04
40.0
Cellular phone
96
36.9
Own a car
86
33.1
Vacation away from Beira
86
33.1
Own home
81
31.2
Air Conditioner
74
28.5
Eat Out
43
16.5
Have a satellite dish
39
15.0
Private medical care
18
6.9
The least frequently reported lifestyle items were: having access to private
medical care (6.9%), having satellite TV (15%) and eating out in restaurants (16.5%).
Marital status
We used the Mozambican census (INE 1999) categories for marital status. Many
marriages in Mozambique are not registered with the government, but are legal by virtue

152
of the couple having lived together for more than 5 years. The number and percentage of
people in each marital category is given in Table 6-9.
Marital status appears to be a simple thing to measure, but many people changed
their answer after we asked follow-up questions. For example, one woman initially
replied "single", but then said she had been married and her husband died, and was now
living with someone else for several years. Another man also replied singling initially,
but then said that he was separated. We wanted to evaluate each person's current marital
status, based on the item "have a spouse" in the lifestyle scale.
Table 6-9 Marital Status (n=261)
Marital Status:
number
percent
Single
8
3.1
Married
105
40.2
Common Law
88
33.7
Separated/divorced
34
13.0
Widowed
26
10.0
About three quarters of the sample lives with a partner, not surprising given the
age group we studied. There were eight single (never been married) people in the sample.
These were all marginal individuals. One woman of Portuguese descent, whose entire
family had fled to Portugal in 1975, reported, "men only complicate your life". Even
though she was single, she did not live alone; she shared a house with another couple.
People who actually live alone were even more marginal, and they are discussed above.
Electricity
The vast majority (92.3%) reported having electricity in the home, while 20
families (7.7%) did not. Census data for the urban dwellers in Sofala province shows that
65% of those who live in cement block houses (like those found in Ponta Gea) have
electricity. Because there are cement block houses in the reed city which are not on the

153
electric line, this brings down the average for the urban dwellers across the province. The
entire neighborhood of Ponta Gea is on the power grid however, and the participants who
reported not having houses power were usually dependencias or garages that had been
converted into housing or where the electricity had been shut off.
Home ownership
We used the Mozambican census categories to evaluate the relationship people
have to the home they live in. There are four categories: own the home, rent the home,
have the home given or lent to them (cedida), or live in a home provided by their
employer. Because of the policy change in home ownership in Mozambique in recent
years, many people have bought, or are in the process of buying their home from the
national government.
The largest group, nearly 44% of the survey sample, reported owning their homes.
Of the 31% who said they rented, about half reported renting from the government, which
means they are in the process of buying their house from the government. A small
number reported living in a home given or lent to them. Nearly 23% of the sample lives
in housing provided by their employers, either the railroad or a branch of the government
(e.g., Ministry of Health, Ministry of Finance).
Table 6-10. Home Ownership Status (n=261)
Frequency
Percent
Own
114
43.7
Rent
81
31.0
Given/lent
7
2.7
Employer
59
22.6
Stereo ownership
Two hundred and ten people (80.5%) report that their households own a stereo (a
radio with cassette player), while the remaining 51 respondents (19.5%) said they did not.

154
The most recent Mozambican census (INE 1999) reports that 55% of the people living in
the urban areas of Sofala province report owning a radio.
Three lifestyle scores
Lifestyle measure one. I computed three different measures of lifestyle from the
lifestyle data. For the first measure, I totaled the number of items on the lifestyle scale
that each person reported having or doing, with each item having the same value in the
score. Thus, this measure ranges from 0-24. For the second and third measure of lifestyle,
I weighted the values of the different items, according to the ranking done in phase one
and the results of factor analysis, respectively. I explain the second and thirds measures
in more detail below.
The scores on the first lifestyle variable (a composite of the 24 items in the scale)
ranged from zero to 24. One man had all 24 items on the scale, while another man had
none. I was not surprised that the man who had none of these items was a widower who
has never been to school and lives in a room behind the bakery where he works while
raising four children. On the other hand, the man with all of the 24 items has the highest
income in the sample, is a member of parliament, and has a Master’s degree. The mean
score was 12.
The reliability analysis (SPSS 2000) showed an overall Cronbach's alpha of
.8899. The alpha score did not increase significantly if any item were removed from the
scale.
Lifestyle measure two. The second measure of lifestyle was calculated using the
ranking data from phase one to weight each item. I transformed the scores for each item
given in Table 5-2 in the previous chapter into ratings from 1 to 5. Items that were ranked
as more important by people in phase one were given a score of 5, while those that were

155
ranked as less important were given a score of 1. For example, owning your home had the
lowest consensus score on the ranking (3.73) so home ownership was equal to five in this
rating system. Having a freezer had a much higher consensus score (20.45) and freezer
ownership was equal to two in this weighting system. I divided the items into five groups
using natural breaks in the scores on the ranking exercise.
Each lifestyle item was then multiplied by its rating, to create a new variable.
Finally, I summed the 24 new variables (the lifestyle items multiplied by the rating) to
create the second measure of lifestyle. The minimum score on this second lifestyle
measure is zero and the high score was 52. The mean score is 26.219 (S.D. 11.67).
Cronbach's alpha for the items in this scale is very similar to the previous one, .8445.
Lifestyle measure three. This measure is based on the standardized values of the
24 items. In SPSS (2000), I used the function "Descriptives", entered the 24 variables,
and chose the option "save standardized values as variables”. This created a factor score
for each person, a standardized value for the person for all of the lifestyle items. Because
the factor scores contained negative numbers, I added one plus the largest negative value
(1 + 1.98902 = 2.98902) in order to shift all the values into the positive range. The range
of this third lifestyle variable goes from 1-4.99, with a mean of 2.99 (S.D. 1).
The three measures of lifestyle are highly correlated with each other, as shown in
Table 6-11. The data suggest that all three measures are reporting on the same domain.
Table 6-11. Pearson Correlations and Significance of the Three Lifestyle Measures
(n=255)
Lifestyle 1
Lifestyle 2
Lifestyle 2
.987
(.000)
Lifestyle 3
.995
.979
(.000)
(.000)

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The Cohen Self-Perceived Stress and the Life Events Scales
The Cohen's self-perceived stress scale asked people to rank themselves for four
questions along a 3-point scale:
"In the last month, how often have you felt...
1. .. that you were really realizing your goals?
2. .. that you could solve the problems in your life?
3. .. upset or stressed (worn out, irritated)?
4. .. angry or frustrated because things happened you could not control?"
The three possible answers were: never, sometimes, and, almost every day
Scores on the Cohen Scale
Two hundred and fifteen people answered the four questions that made up the
Cohen scale. This number is less than the total sample size because of problems
discussed above with adjustments that had to be made to the scale (reducing the number
of questions, and the number of answers) because of problems respondents had in
answering the questions. See Table 6-12 for the answers to the four questions that
constitute the Cohen scale.
Table 6-12. Percent of responses to the four questions on the Cohen self-perceived stress
scale. (n=215)
Question
Never
sometimes
almost all the time
total
1. are realizing your goals
26.5%
50.7%
22.8%
100
2. able to solve problems in your
life
22
56.5
21.5
100
3. feel upset or stressed
16.3
57.2
26.5
100
4. frustrated because you could
not control things that happened
25.6
57.2
17.2
100
To create a global score on the Cohen self-perceived stress scale, three new
variables were created. First the scores on the first two questions were inverted to reflect

157
how often a person did not feel that she or he was realizing his or her goals, or did not
feel able to solve the problems in his or her life. This was done to make the scores agree
with the last two questions in terms of directionality. Finally, the scores on all four
questions were summed to give each person an overall score of self-perceived stress.
Scores ranged from 4-12, with 12 equaling the highest level of self-perceived stress. See
Table 6-13.
Table 6-13 Scores on Cohen scale. (n=215)
Score
Frequency
Percent
4
4
1.9
5
6
2.8
6
24
11.2
7
48
22.4
8
56
26.2
9
28
13.1
10
30
14.0
11
15
7.0
12
3
1.4
The Life Events Scale
The life events scale consisted of 18 events. Table 6-14 indicates the number and
percentage of people who reported the event happening in his or her life within the
previous year. The most commonly reported events were the death of a close fiend, a new
baby in the house, family conflict and having been seriously ill in the past year.
Table 6-14. Number and Percentage Reporting a Stressful Life Event.
Event
Number
Percent
Close friend died
92
35.2
New baby (in the house)
56
21.5
Family conflict
46
17.7
Was seriously ill
44
16.9
Moved to a new home
36
13.8
Death of a parent
25
9.4
Death of a sibling
25
9.4
Lost job
21
8.1
Spouse changed job
19
7.3
Have a new job
18
ITÜ

158
Table 6-14 continued.
Event
Number
Percent
Reconciled with partner
14
5.4
Child died
11
4.2
Divorced/separated
8
3.1
Got married
7
2.7
Death of a spouse
7
2.6
Finished school
5
1.9
Spent time in prison
4
1.5
Retired
4
1.5
(n=261)
The total score on the life events scale was calculated using the Life Change Units
(LCU) from Miller and Rahe (1997). Each life event is assigned a different value
according to the "estimates of their magnitude" (ibid-p. 279). Death of a spouse has the
highest value of Life Change Units - 119, and finishing a degree has the lowest - 35. The
LCU values were summed to arrive at the total score on the scale.
The total score on the life events scale ranged from 0-444. Fifty-five people have
a score of zero because they did not report any of the events happening to them in the
previous year. The modal score was 70 (n=27), the LCU value for a close friend dying.
The man with the high score of 444 reported losing his spouse, a child, a sibling, and a
parent, in the previous year.
Social Support
We measured social support in a number of different ways in the survey. We
asked each survey participant about his or her religious affiliation, frequency of
attendance at services, and whether or not she or he belonged to a smaller group (called a
community) within the church or mosque. We asked the participant if she or he has
padrinhos living in Beira, and which of his or her family members live in Beira. We
asked about respondent's relations with neighbors, and if she or he had a close friend with

159
whom they could discuss intimate or personal topics. Finally, we asked each person to
tell us to whom they would turn if faced with one of five situations (see below).
Religiosity
Table 6-15. Number and Percent of People Reporting Religious Affiliation
Religious affiliation
Number
Percent
Catholic
140
53.6
Protestant
64
24.5
Muslim
46
17.6
None
11
4.2
(n=261)
People who reported being Christian were asked how frequently they went to
church. Of the 204 self-reported Christians in the sample, one quarter (25.5%) said that
they do not attend church on a regular basis. Slightly more than half (52.4%) reported
going to church on a weekly basis, with the balance saying that they attend more than
once per week.
Muslims were asked whether they attended Friday prayers on a regular basis or
not. Seventy-eight percent (n=36) said they go regularly to Friday prayers, and 22%
(n=10) said they do not.
All respondents who reported being either Christian or Muslim were asked
whether they belong to a smaller community of people within their church or mosque.
Interviews and participant observation revealed that these communities were usually
organized by neighborhood to allow members to have a small group of neighbors with
whom to worship or turn to in a time of need. Of the 250 people who belong to an
organized religion, 94 (37.6%) belong to a community (small group) within their church
or mosque. Membership in a community was slightly more common for men (n=51) than
for women (n=43).

160
Padrinhos and family living in Beira.
We asked the participants if they had padrinhos living in Beira, either from
baptism or marriage. Most commonly, people told us about marriage padrinhos because
the ones from baptism had died or lived far away. Marriage sponsors are expected to
play a role in helping a couple resolve disputes and give advice for a harmonious
marriage. About 35% of the sample (n=90) reported having padrinhos living in Beira.
Having padrinhos in Beira did not vary with age group, except for the oldest age group of
age 60 and above.
We asked people to tell us which family members currently live in Beira. We
coded this data into four groups: 0=none, l=almost none/a few, 2=many, 3=almost all/all.
Sixteen people (6.1%) reported having no family members living in Beira (outside of
their household members). Twenty percent have at least a few family members living
there, while the vast majority (73%) reported having many (40%) or nearly all (33%) of
their family living in the city. There was no difference across the age groups in the
amount of family members living in Beira. Family was cited most often in the interviews
in phase one as the first choice of where to turn for social support.
Relationships with neighbors and having a close friend.
Neighbors were mentioned quite often in the phase one interviews about social
support, both in a negative and a positive light. Most people stated that neighbors should
not be trusted with personal issues such as marital or financial problems because they
could not be trusted to keep it confidential. On the other hand, neighbors are seen as a
good source of assistance with sudden medical problems, especially if they have a car to
transport the sick person or family members to the hospital. They can also be counted on
to participate in ceremonies for the death of a family member. We asked people whether

161
they had good relations with their neighbors, and the overwhelming majority said yes
(86%). I doubt the validity of these responses, however, given the social desirability to
project an image of getting along with people.
I have more confidence in the responses to the question about having a close
friend. We asked people to tell us whether they have a close friend, one with whom they
can discuss private or person matters. Most of the respondents took time to think over this
question before giving an answer, and their responses seemed weightier. Nearly 62% of
the sample (n= 161) reported having a close friend. Men were slightly more likely to
report having a close friend (65%), than women (59%). There was no significant
difference across the age groups.
Consonance in social support
In addition to the above questions about social support, we asked participants to
tell us how they would respond to five scenarios, who would they consult first, second,
and so on. The five scenarios were: borrowing money, illness in the family, problems
with a partner, conflict at work or at school, and death in the family.
The sample size responding to each of the scenarios varies greatly. Twenty-three
people did not give a response to the question about borrowing money, usually because
they said they do not borrow money from anyone or there is no one they would borrow
from. Eleven respondents could not think of anyone they would turn to in case of illness
of a family member. Only six people could not provide us with an answer for the last
scenario, the case of a death in the family.
A higher percentage of people did not give a response to the other two scenarios.
Forty-seven did not say who they would turn to for help in resolving a problem with their
spouse, either because they are not married, or they do not ask anyone for help with this

162
type of problem. The highest number (59) did not reply to the scenario about what they
would do in case of problems at work or at school, usually because they do not work or
go to school.
Table 6-16 Frequency of First Choice for the Five Scenarios
Death in the
Family
Conflict at
Work
Problem with
Partner
Family Member
Sick
Borrow
Money
Family
133 (52.2%)
78 (38.6)
140 (65.4%)
115(46.%)
110(46.2%)
Neighbors
18(7.1%)
6 (3%)
8 (3.7%)
80 (32.%)
16 (6.7%)
Friends
17(6.7%)
26 (12.9%)
15(7.0%)
22 (8.8%)
49 (20.6%)
Boss/job
29(11.4%)
50 (24.8%)
3 (1.4%)
14 (5.6%)
52(21.8%)
Government
agency
1 (0.4%)
5 (2.5%)
0
1 (0.4%)
4(1.7%)
Colleague
3(1.2%)
35 (17.3%)
1 (0.5%)
6 (2.4%)
2 (0.8%)
Padrinhos
1 (0.4%)
0
33 (15.4%)
0
0
Conterráneos
4(1.6%)
0
1 (0.5%)
0
0
Church/Mosque
49(19.2%)
2(1.0%)
13(6.1%)
12 (4.8%)
5 (2.1%)
Total
255
202
214
250
238
Borrowing money
Following the model for social support elaborated in phase one, most people
(46.2%) turn first to their family members when they need to borrow money. Almost
equal numbers look to their work (20.6%) to give them an advance on their salary as turn
to a friend (21.8) for a loan. Most of the respondents qualified the latter as having to be a
very close friend. Other first choice options were neighbors, church or mosque, a bank, or
a coworker.
Nearly equal numbers of people listed family, friends, or work as their second
choice for borrowing money. Other sources of social support mentioned in second place
were neighbors, colleagues, padrinhos, church/mosque, and bank. Only 153 people
(59%) gave a second choice option for this scenario.

163
When a family member is sick the cultural model indicates that family and friends
are the most appropriate people to turn to first. In this case, neighbors are judged to be
useful if they have transportation or if they are simply closer at hand. Most of the
respondents said that they rely on family (46%) or on neighbors (32%) when a family
member is sick.
Respondents reported that problems with spouse or partner are usually resolved
within the family first (65%) or by turning to the padrinhos (15%). The results are in
accordance with the cultural model elicited in phase one of relying on these two groups,
and rarely taking the problem to others.
To resolve conflict in the workplace or at school people reported turning to their
family members, the boss/supervisor, or to a coworker or schoolmate. Other options
reported include friend, neighbor, church/mosque, and government agency.
We had the most responses to the scenario about death in the family, and several
respondents remarked that this is a time when your social support network is working at
full force. There was a marked preference for the family to be primarily involved, with
friends, coworkers, and the religious community lending their assistance. The role of the
employer is usually to provide transportation and/or financial assistance.
I coded each person's set of responses (we had up to four per question) for each
scenario according to how well it matched the culturally appropriate model of social
support developed in phase one. Each respondent was given a score between 1 -5 for the
scenario, with a score of five meaning that his or her responses matched the model
perfectly. If their answers did not match the model exactly but they listed the categories
that were in the model, they were given a 4, and so on. A score of 1 was given to

164
individuals who listed no one or categories of people who were considered to be
inappropriate according to the model developed in phase one and described in Chapter 5.
I coded the three scenarios that had the most responses from a representative sample,
(borrow money, someone sick in the family, death in the family). Then, I summed theses
scores to have an overall score of how well an individual's social support matched the
cultural model. These summed scores ranged from 5-15.
Blood Pressure Measurements
Methods and values
As described above, I measured the blood pressure measurements of each
respondent three times. The three measurements were summed, and mean diastolic and
systolic pressures were calculated for each person. These mean values were used in most
of the analyses described below.
Table 6-17. Values of Three Measurements of Systolic and Diastolic Blood Pressure.
Minimum
Maximum
Mean
Standard
Deviation
Systolic 1
80
250
127.75
26.33
Systolic 2
82
260
127.57
26.42
Systolic 3
80
231
127.21
26.12
Mean
Systolic
82
246
127.51
25.79
Diastolic 1
55
170
80.79
13.46
Diastolic 2
50
160
80.93
13.89
Diastolic 3
52
150
80.39
13.54
Mean
Diastolic
56
160
80.70
13.14
(n=261)
The range in blood pressure readings was broad. Looking at the mean scores in
Table 6-17, the minimum systolic pressure is 82, while the highest reading was 246.
Similarly, the lowest mean diastolic value is 56, and the highest 160.

165
Hypertensives
When I defined high blood pressure as a mean systolic pressure greater than 140
and a mean diastolic pressure greater than 90, then 45 respondents (17%) had high blood
pressure. With the definition of mean systolic pressure greater than 140 or mean diastolic
greater than 90, the number of people with high blood pressure is 74 (28.4%). Looking at
each measure separately, 50 people (19.9%) had a mean diastolic pressure greater than
90, and 67 individuals (25.7%) had systolic pressure greater than 140.
Men made up a disproportionate share of hypertensives, using either definition.
Of the 45 hypertensives using the strict definition, 27 are men (60%) and 18 are women.
The sex breakdown for the second definition of hypertensive is similar. Fifty-eight
percent (n=43) of the 74 people in this group are men. This apparent sex difference
disappears when I correlated blood pressure by sex but controlled for age. The
hypertensive men are older.
Because I did not collect a random sample of the population of Ponta Gea, these
number cannot be generalized to the neighborhood, much less to the entire city of Beira.
For my sample of adults, however, a significant number of people (45 or 74) had high
blood pressure. We can examine, then, the relative contribution of risk factors for this
population’s variation in blood pressure.
Predicting Blood Pressure
Bivariate equations
In this next section I present the primary variables of interest and blood pressure
in bivariate equations.

166
Table 6-18. Bivariate Correlations and Significance of Blood Pressure with Sex, Age and
BMI (n=261)
Systolic BP
Diastolic BP
Sex
-.087 (.163)
-.065 (.299)
BMI
.200 (.001)
.284 (.000)
Age
.383 (.000)
.216 (.000)
Table 6-18 shows that body mass index is, as expected from world-wide data,
significantly correlated with both diastolic and systolic measures of blood pressure. Men
have higher systolic and diastolic blood pressure than women in bivariate regression
equations, although the difference is not statistically significant. (Men are coded as 0 and
women are coded as 1, giving the negative correlation.) Blood pressure rises with age and
this association is statistically significant, as expected.
Family History of Hypertension
Seventy-two percent of the sample told us that a relative had been diagnosed with
hypertension, living or dead. When we asked who the person was, we were told about
first and second degree blood relatives, as well as people related by marriage. I coded the
data according to which relative suffered from hypertension into two variables, first-
degree relatives (parent, sibling, child), and second-degree relatives (aunt/uncle, cousin,
grandparent).
More than 46% of the sample (n= 121) reported a first-degree relative suffering
from high blood pressure, and 12.6% reported a second-degree relative. The rest of the
reports of a relative with high blood pressure were kin related through marriage, usually a
spouse or mother-in-law. Reporting a first-degree relative with high blood pressure was
not associated with systolic or diastolic blood pressure for the respondent. Nor was it a
significant predictor in regression equations (including age and BMI) to predict diastolic

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or systolic blood pressure. According to the literature, first-degree family history of
hypertension is often predictive of hypertension in the respondent.
Table 6-19. Blood Pressure Mean and Standard Deviation of People Reporting or not
Reporting
a First Degree Relative with
High Blood Pressure.
First degree relative
Mean Diastolic
(standard deviation)
Mean Systolic
(standard deviation)
No (n=140)
80.64 (12.69)
128.51 (25.46)
Yes (n=121)
80.78 (13.68)
126.36 (26.22)
Total (n=261)
80.70(13.14)
127.51 (25.79)
Lifestyle
Table 6-20 presents the correlation of the three lifestyle scores, income and
education with both measures of blood pressure. All three are significantly associated
with diastolic but not systolic blood pressure.
Table 6-20. Lifestyle Scores, Income and Education Correlated with Blood Pressure
Systolic BP
Diastolic BP
Lifestyle 1
Pearson Correlation
.041
.127
(n=255)
Significance (2-tail)
.512
.043
Lifestyle 2
Pearson Correlation
.042
.122
(n=255)
Significance (2-tail)
.507
.051
Lifestyle 3
Pearson Correlation
.051
.134
(n=255)
Significance (2-tail)
.415
.033
Income
Pearson Correlation
.042
.168
(n=242)
Significance (2-tail)
.517
.009
Education
Pearson Correlation
-.101
.013
(n=261)
Significance (2-tail)
.104
.829
Income also significantly predicts diastolic but not systolic blood pressure. The
positive connection between income and blood pressure was expected, given this overall
pattern in other African samples.
Education level is not significantly correlated with either measure of blood
pressure. Interestingly, the effect of education on diastolic pressure appears to be the
opposite of its effect on systolic pressure, although the former is quite weak.

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Perceived stress and blood pressure
The Cohen perceived stress score did not predict either diastolic or systolic blood
pressure in the sample in bivariate analyses. In multiple regression equations, including
age and BM1, the Cohen scale did not account for any of the variance.
I wanted to test the relationship between income and perceived stress, so I put
them into a linear regression equation. Income significantly predicts the Cohen score
(beta = -.137, p=.05). People with higher income have lower perceived stress. 1 wanted to
see if sex, age, race, or household size predicted the Cohen score, but none of them did.
Life events and blood pressure
None of the individual life events predicted systolic or diastolic blood pressure.
The total score for the life event scale (sum of all the Life Change Units for the reported
life events) was not predictive of blood pressure in bivariate models. In fact, the slope is
negative for both diastolic and systolic blood pressure.
Social support, lifestyle, and blood pressure
Table 6-21 presents blood pressure values by religion.
Table 6-21. Mean Blood Pressure and Standard Deviation by Religion.
Religion
Diastolic
Systolic
Catholic (n=140)
80.23 (14.79)
127.57 (28.67)
Protestant (n=64)
80.34(11.76)
125.87 (22.23)
Muslim (n=46)
82.43 (8.91)
128.75 (22.75)
None (n=ll)
81.55(14.12)
131.21 (19.76)
Total (n=261)
80.70(13.14)
127.51 (25.79)
It appeared that Muslims have slightly higher blood pressure, so I created a new
variable to test this. I added the dichotomous variable (Muslim or not) to a regression
equation including age and BMI. The variable "Muslim" did not predict either systolic or
diastolic blood pressure. I wanted to see if religiosity (frequency of attendance as church

169
or mosque) served to lower blood pressure. I put each variable into a regression equation
with age and BMI, and neither church nor mosque attendance had any predictive value of
systolic or diastolic blood pressure.
I made a composite variable of the following indicators of social support;
membership in a religious community, having a close friend, amount of family members
in Beira, having a padrinho in Beira, and having good relations with your neighbors.
When this variable was added into a regression equation (along with age and BMI) to
predict blood pressure it significantly predicted systolic blood pressure (p= .035), but not
diastolic blood pressure (p= .217). As the measure of social support increased both
measures of blood pressure decreased.
Because of the relationship between income and perceived stress mentioned
above, I wanted to see if income was associated with social support, i.e., if poorer or
wealthier people have better social support. I found no association between income and
social support.
As described above, I created a new variable reflecting the ability of each
individual to access culturally appropriate social support. For this variable, I coded their
responses to questions about three scenarios (borrowing money, and illness or death in
the family). Higher scores on this variable reflect social support that is closest to the
cultural model, or more consonant.
In bivariate equations this measure of social support is correlated weakly with
diastolic and systolic blood pressure. Interestingly, the association is positive, meaning
that the higher a person's ability to access culturally appropriate social support, the higher
their blood pressure. I wanted to investigate the relationship between income and social

170
support to see if wealthier people have better social support. The slope of the line is
completely flat and the significance is .99.
Multivariate Regression
I begin by predicting blood pressure using multivariate linear regression, using the
known risk factors for hypertension and other demographic variables. Then, I add in the
measures of psychosocial stress (Cohen, Life Events, three measures of lifestyle, three
measures of mobility), and the indicators of social support.
The first equation includes age, BMI, and sex, which are significant predictors of
diastolic blood pressure (DBP) in bivariate analyses. DBP is positively and strongly
predicted by age and BMI, the relationship predicted in the blood pressure literature.
Being male is also associated with higher DBP (male=0, female=l, hence the negative
slope).
I added income into the variable list for the second equation. Age and BMI
remain strong predictors of DBP. Income is not a significant predictor of DBP, and its
inclusion also lowers the significance of sex.
This highlights a couple of problems with the variable INCOME. Men report
higher incomes, by about $40 per month, a significant amount where the average income
is $234 per month. Income represents total household income, so the difference in the sex
of the respondent should not matter. In reality, men know what the household income is
more often than the women. Remember that about 8% of the sample did not report a
household income due to privacy or just not knowing what it is.
Because income and BMI are strongly correlated (.001), I decided to leave BMI
out of the third equation. Interestingly, the predictive strength of age increases, income
becomes significant, and sex is not significant.

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In equation 4,1 added education into the variable list, even though I do not expect
it to have any predictive value. The problem with this equation is that many of the
variables are strongly interrelated: men have more education and report more income,
and BMI goes up with education, income, and age. Because of this, I decided to include
age and BMI in the rest of the analyses. These two factors are strong and consistent
predictors of DBP in my sample, in accordance with other studies of blood pressure
around the world.
Table 6-22. Four regression equations to predict diastolic blood pressure, Slope and
(significance).
Variable
Equation #1
Equation #2
Equation #3
Equation #4
Age
.172 (.004)
.171 (.006)
.209 (.000)
.159 (.015)
Sex
-.133 (.032)
-.118 (.075)
-.021 (.740)
-.134 (.057)
BMI
.309 (.000)
.271 (.000)
.273 (.000)
Income
.097 (.122)
.163 (.010)
.116 (.092)
Education
-.050 (.494)
I repeated these equations to predict systolic blood pressure (SBP); the results are
shown in Table 6-23. Age and BMI continue to have strong predictive value. Being male
is not a significant predictor of SBP. Income and education are not predictive of SBP.
Table 6-23. Four regression equations to predict systolic blood pressure.
Variable
Equation #1
Equation #2
Equation #3
Equation #4
Age
.353 (.000)
.338 (.000)
.367 (.000)
.318 (.000)
Sex
-.098 (.105)
-.102 (.113)
-.028 (.641)
-.128 (.061)
BMI
.201 (.001)
.206 (.002)
.210 (.001)
Income
-.016 (.795)
.034 (.575)
.015 (.824)
Education
-.081 (.254)
Adding in psychosocial stress
I began this analysis with the Cohen scale, the life events scale and then the three
measures of consonance with lifestyle. The Cohen score of self-perceived stress was not
predictive of either systolic or diastolic blood pressure. Strangely, the slope for the Cohen

172
score in both equations is (mildly) negative, indicating that the higher the Cohen score,
the lower the blood pressure.
Table 6-24. Predicting Blood Pressure with Age, BMI, and the Cohen Self-Perceived
Stress Scale.
Systolic Blood Pressure
Diastolic Blood Pressure
Age
.358 (.000)
.174 (.000)
BMI
.172 (.008)
.269 (.000)
Cohen score
-.015 (.818)
-.051 (.433)
Table 6-25. Slope and Significance of Blood Pressure with Age, BMI and the Life Events
Scale (n=260).
Systolic Blood Pressure
Diastolic Blood Pressure
Age
.369 (.000)
.194 (.001)
BMI
.168 (.004)
.266 (.000)
Life events score
-.020 (.729)
-.014 (.807)
None of the measures of cultural consonance with lifestyle predicted diastolic or
systolic blood pressure in the equations. See Tables 6-26 and 6-27. All three measures of
consonance with the lifestyle model appear to be measuring the same domain, but are not
predictive of blood pressure. The slopes of the lifestyle measures are positive.
Table 6-26. Predicting Diastolic Blood Pressure with Age, BMI and Three Measures of
Lifestyle.
Equation #1
Equation #2
Equation #3
Age
.192 (.001)
.192 (.000)
.191 (.001)
BMI
.258 (.000)
.260 (.000)
.258 (.000)
Lifestyle 1
.038 (.543)
Lifestyle 2
.032 (.606)
Lifestyle 3
.037 (.559)
Table 6-27. Predicting Systolic Blood Pressure with Age, BMI and Three Measures of
Lifestyle.
Equation #1
Equation #2
Equation #3
Age
.369 (.000)
.369 (.000)
.369 (.000)
BMI
.818 (.003)
.181 (.003)
.182 (.003)
Lifestyle 1
-.029 (.631)
Lifestyle 2
-.031 (.608)
Lifestyle 3
-.032 (.604)

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I suspected that BMI and the consonance with lifestyle scale were measuring the
same thing. So, I did bivariate comparisons of BMI and the three measures of lifestyle
(see Table 6-28). There is a strong correlation between BMI and cultural consonance with
lifestyle in this sample, the opposite result that Dressier has found in the U.S. and Brazil.
He found that dissonance with the cultural model of lifestyle was associated with
increased BMI. In my data, however, people who are consonant with the lifestyle model
have higher BMI. This is consistent with the African pattern of wealthy people eating
well and doing limited physical activity.
Table 6-28. Lifestyle and BMI (n=255) Pearson Correlation and (significance).
Lifestyle 1
Lifestyle 2
Lifestyle 3
BMI
.317 (.000)
.314 (.000)
.329 (.000)
I decided to regress consonance in lifestyle and age against blood pressure,
leaving out BMI. In these simplified equations, the lifestyle consonance measures are
significant predictors of diastolic, but not systolic, blood pressure (.05).
Adding in social support
In the bivariate analyses, the two measures of social support had opposite effects
on blood pressure. The composite measure of membership in a religious community,
having family, padrinhos, or a close friend in Beira, and good neighborly relations was
negatively correlated with blood pressure. This relationship is what is expected if social
support buffers people from psychosocial stress or allows them to cope better with it. The
score of people's answers to three of the five scenarios (cultural consonance with the
cultural model of social support) had a positive relationship with blood pressure,
however.

174
I wanted to test if these two measures of social support could predict blood
pressure in an equation with age and BMI. Tables 6-29 and 6-30 and report the results of
this multivariate regression.
Table 6-29. Age, BMI, and Composite Measure of Social Support. (n=248)
Systolic Blood Pressure
Diastolic Blood Pressure
Age
.369 (.000)
.208 (.001)
BMI
.180 (.002)
.292 (.000)
Composite
-.122 (.035)
-.074 (.217)
Table 6-30. Age, BMI and Cultural Consonance in Social Support (n=260)
Systolic Blood Pressure
Diastolic Blood Pressure
Age
.378 (.000)
.202 (.001)
BMI
.158 (.006)
.255 (.000)
Social Support
.084 (.142)
.085 (.153)
I found a pattern similar to what emerged in the bivariate equations. Consonance
with the cultural model of social support, as determined through the scenarios, has a
positive slope and does not significantly predict blood pressure. The composite measure
of social support has a negative slope, and significantly predicts systolic blood pressure.
Lifestyle and Social Support to Predict Blood Pressure
Here I combine AGE, BMI, consonance with lifestyle, and social support into one
model. Because the three measures of consonance with the lifestyle model are all
measuring the same thing, I decided to use the second lifestyle measure (weighted
according to the ranking scores) for these analyses. I first included the social support
score derived from the scenarios, and later the second composite score of social support.
Table 6-31. Lifestyle, Social Support and Systolic Blood Pressure.
Beta
Significance
Age
.366
.000
BMI
.193
.002
Lifestyle
-.018
.774
Social Support
-.130
.027

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Table 6-32. Lifestyle, Social Support and Diastolic Blood Pressure.
Beta
Significance
Age
.205
.001
BMI
.283
.000
Lifestyle
.053
.401
Social Support
-.085
hL57
The measure of consonance in the social support variable does not predict lower
blood pressure. On the contrary, the slope indicates that having good social support leads
to higher blood pressure, although this is not significant. This is extremely odd, especially
because the measure of social support I created, based on participant observation,
indicates the opposite trend. In this analysis, I used the composite score, discussed
below. Perhaps the scale based on the social support scenarios needs to be reformulated
or expanded to include the two scenarios that were excluded because they had too few
cases.
When the composite score of social support is added into the equation with
lifestyle, age and BMI, it continues to lower blood pressure, and here the result is
significant (Tables 6-33 and 6-34). People with more family members and/or apadrinho
in town, who belong to a religious community, who have a close friend, and who have
good relations with their neighbors have lower systolic blood pressure. The lifestyle
measure does not predict blood pressure when it is a variable in these multivariate
equations.
Table 6-33. Lifestyle, Consonance in Social Support and Systolic BP
Beta
Significance
Age
.378
.000
BMI
.170
.006
Lifestyle
-.041
.502
Scenarios
.097
.098

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Table 6-34. Lifestyle, Consonance in Social Support and Diastolic BP
Beta
Significance
Age
.201
.001
BMI
.248
.000
Lifestyle
.087
.148
Scenarios
.029
~639
Variation Explained
Finally, these analyses allow us to address, at least partially, the question posed by
the title of my dissertation: How much of the intracultural variation in blood pressure is
accounted for by factors related to psychosocial stress? The three variables AGE, SEX,
and BMI account for 13.5% of the observed variation in diastolic blood pressure, and
18.9% for systolic blood pressure. When LIFESTYLE is added into the regression
equation (in another model) there is no change in the variation in diastolic blood pressure
(DBP) explained, and it accounts for just 0.2% of the variation in systolic blood pressure
(SBP). The composite variable for social support explains 0.5% of the variation in DBP,
and 1.5% for SBP. These findings are discussed below, in Chapter 7.

CHAPTER 7
CONCLUSION
A Review of the Findings
From the data gathered in this project, the people of Ponta Gea exhibit strong
variation in blood pressure. What explains this variation? I begin this chapter by
reviewing the results reported in the previous chapter, comparing them to data from
Brazil and the U.S., and discussing how they disproved or failed to disprove the
hypotheses presented in Chapter 4. Then, I discuss how my findings can be understood in
the Mozambican cultural context and the implications of this research for anthropology
and for public health.
Age and BMI have been proven time and time again to explain a good part of the
variation in blood pressure. In my data from Ponta Gea, age, sex, and BMI explain about
14% of the variation in diastolic blood pressure and just over 20% of systolic blood
pressure. William Dressier reports that the same three variable account for 28.2% of the
variance in systolic blood pressure in Brazil, and 12.5% of systolic blood pressure in
Tuscaloosa, Alabama (Dressier pers. comm.).
Having a close family member with high blood pressure is often cited as a risk
factor for hypertension. In my research, people reported whether, to the best of their
knowledge, a family member suffered from high blood pressure. The data I collected
does not show an association between a family history of hypertension and elevated
blood pressure in the person. It is difficult to collect accurate information about the health
of family members in the type of door-to-door survey I did. I believe that many people
177

178
we interviewed do not know whether a close family has (or had) hypertension because
many of their relatives do not even know themselves. In the sample I interviewed, 73% of
the people whom we found to have high blood pressure had previously responded yes
when asked if they have high blood pressure. Another fifty-one people told us they had
high blood pressure, but when I measured it, it was below the cut-points.
Consonance with lifestyle predicts diastolic but not systolic blood pressure. I
expected that people who live closer to the model of a successful lifestyle developed in
phase one would have statistically higher blood pressure This was, in fact, the case, but
consonance in lifestyle explains none of the variance for DBP and just 0.2% for SBP. In
Brazil and in Alabama, Dressier (pers. comm.) reports that consonance in lifestyle
explains more of the variance in blood pressure, 3.4% and 1.0% for SBP respectively.
When I measured social support using the scenarios, the results were inconclusive
and not significant. I created a composite social support scale based on what I was told
and saw during the ethnographic stage of the research. This composite scale of five
measures of social support (e.g., having family near by and degree of religiosity) does
appear to measure a domain that has a buffering effect on blood pressure. It explains
1.5% of the variation in SBP and 0.5% for DBP. In his most recent study in Brazil,
Dressier found that social support explains more than 4.5% of SBP and just over 1.0% for
DBP.
The most important element of the composite scale for Ponta Gea was the
question about having a good friend. Simply having a friend accounted for 0.3% of the
variation in blood pressure, lowering an individual’s blood pressure significantly. This
finding is consistent with the extensive work done by Berkman (cf., 1977, 1983) and

179
others on the positive health impact of good social support. Two published scales of
psychosocial stress (Cohen self-perceived stress and the life events scale) do not
significantly predict blood pressure in my sample. This confirms that these scales are not
a good measure of psychosocial stress in populations other than the ones in which they
were developed and validated.
Lack of Expected Associations
Direction of the relationship
Blood pressure is not associated with cultural consonance in lifestyle in the same
direction that Dressier found in Brazil and in the U.S. This is in line with findings from
Africa, where blood pressure positively associated with wealth. As 1 pointed out in
Chapters 1 and 3, blood pressure increases with wealth in most countries in Africa (with
the exception of some populations in South Africa), but it decreases with wealth in the
western hemisphere.
The John Henry scale
The John Henry scale of Active Coping was dropped from the survey
questionnaire for two reasons. Respondents were having difficulties in choosing one
answer along the Likert scale and their answers were subject to the social desirability of
the questions being asked. Among the first 40 respondents who completed the twelve
questions that make up this scale, almost all of them scored between 55 and 60 on the
sixty-point scale. These high scores could indicate that most people were employing
active coping, or that they were giving the answers they thought we wanted to hear. I
believed it was the latter and dropped the scale.

180
Discussion
The results indicate that consonance with the cultural model of a successful
lifestyle is stressful, when stress is measured by blood pressure. This positive relationship
between consonance in lifestyle and blood pressure is the opposite of what Dressier
hypothesizes, and what his research suggests. In Brazil, dissonance with the lifestyle
model is stressful in terms of blood pressure. This brings up the question of why should it
be stressful in Mozambique to live the way that most people want to live? Dressier does
not use the term “ideal lifestyle,” but I believe that my model of the successful lifestyle
could be called the ideal lifestyle for that setting. So, why would people who live the
ideal lifestyle have more stress in their lives? Increasing income is associated with
increasing diastolic blood pressure, after controlling for age and body mass index, and
income accounts for 2% of the variance in blood pressure, in addition to the effects age
(12%) and BMI (17%). This is, as noted, the opposite of the association found among
African Americans and Brazilians income and blood pressure.
If blood pressure is a proxy for stress, why is it stressful for Mozambicans to be
wealthy and not for African Americans and Brazilians? First, if you are wealthy,
members of your extended family - and even people who are not members of your family
- look to you for help. Second, you cannot be sure how long you can maintain the high
status that comes with wealth. And third, under conditions of poverty, a successful
lifestyle is highly visible and subject to envy and/or criticism. I have not been able to find
published literature that argues this point, but it is clear from my observations and
interviews.
One informant told me, "a wealthy person may have a lot of money, but he has to
help a lot of people who come to him asking for money; his family, workers, and others1'.

181
She continued, suggesting ways to help people reduce their stress level: "for wealthy
people, it is hard to convince them to reduce stress in their lives. One thing you have to
do is to keep your family from begging from you. Give them a little bit of money and tell
them to start a business and then live off of it" (interview 7) Another person observed,
"it’s hard to hold onto what you already have. [A rich person] has a lot, but also worries a
lot and can suffer from tensáo alta. He doesn’t want to lose his status" (interview 4). The
stresses go beyond obligations to friends and family. "Well, everyone has problems, even
rich folks. Maybe they worry about their business or if they owe money to a bank and can
not pay, or the bank will not give them a loan” (interview 11).
The road to wealth can also be stressful and may contribute to ill-health,
according to the semistructured interviews from phase one. "Rich people have a good
life, but I guess they have worries too. Ambitions can cause rich people to be sick or be
worried (interview 9). "If you think too much or force yourself too much then you can get
sick. You can also get thrombose. Rich people also can have heart problems or cancer
too” (interview 10).
It appears that the consonance in lifestyle scale developed for Mozambique is not
measuring the same thing as the scale Dressier developed in Brazil. It may be measuring
style of life in both population, but it is not measuring stress in the same way. A similar
situation presents itself with regards to the Cohen Self-Percieved Stress Scale and the
Holmes and Rahe Life Events Scale. Both were developed on Western populations and
have not been extensively applied to non-western settings. It was easier for the
respondents to answer the questions that constitute the recent life events scale but validity
is still an issue.

182
Participants had trouble answering the questions on the Cohen scale even though
we made several attempts to adapt it for their ease in answering. The response options
were reduced from five to three, and the number of questions decreased from ten to four.
Still, most of the people seemed to be giving an answer simply to be able to move on in
the interview, which was not the case on most of the other questions. I have little faith
that their answers were well thought out or accurately reflected the amount of stress they
perceive in their lives.
As I mentioned earlier, we encountered problems with the many of the
respondents' inability to understand and respond appropriately to questions using Likert
scales (Kennedy and Barkey n.d.). I dropped the John Henry scale and had to adapt the
Cohen scale. Often, scales developed to evaluate an individual's state of mind or
perceptions rely on this format. It is my experience, (in this study and others), that people
who are not accustomed to the Likert format do not provide meaningful answers. This is
not because they are unwilling to be truthful or cooperative, but because they are
unfamiliar with ranking their feelings or squashing their perceptions into pre-ordained
categories.
The Mozambican Context
At this point I want to return to the genesis of this research. I originally went to
Mozambique in 1999 to assess the long-term impact of war trauma on health. I was told
repeatedly that the main source of stress in people's lives stemmed not from their wartime
experiences but from the profound changes in their social and economic realities since
the end of the war. Many of the people I interviewed during this visit made the link
between these changes, stress, and blood pressure. The term they used is tensao alta,

183
which may or not be the equivalent of clinical hypertension. It may in fact be more
similar to nervios in Spanish-speaking populations (Guamaccia 1993).
I am convinced that a segment of the population is suffering a form of
psychosocial stress because of the recent structural and social changes in Mozambique.
What is less clear is whether we can measure that change using the scales we currently
have at our disposal or whether blood pressure is the best way to evaluate this stress. The
Mozambicans I spoke with and observed feel and recognize that something is wrong and
that it is making them feel unwell. Having done that, the responsibility shifts to the
researcher to pinpoint the sources of the stress, how they can be measured, and the effects
they are having on physical or mental health.
The research problem explored here was suggested by people during my initial
visits to Mozambique. This is one strength of the study, but there is one aspect of it that
troubles me. I may not have fully understood the situation that was being described,
owing to cultural gaps and the use of terminology that I may not have fully understood.
What if I failed to understand exactly what was going on or what people were describing
to me? If a Mozambican social scientist had helped me to define psychosocial stress and
social support, and had worked together with me to operationalize these constructs, then
she or he could have drawn on emic and etic understandings of the situation.
The field of cross-cultural psychology can provide assistance in understanding the
type of stress Mozambicans are experiencing and also the appropriate tools with which to
measure. It s possible that the stress being felt and described is along the lines of anxiety
and "nerves", rather than changes in blood pressure. In the semi-structured interviews and
in the survey, I asked people to describe the symptoms of tensao alta. Many of the

184
symptoms could easily be used to describe a case of anxiety, depression, or nervios
(Guaranaccia 1993).
Future Research
The research described in this dissertation builds on work by Norman Scotch
(1963a and b), John Cassel (c.f., Cassel and Tyroler 1961, Cassel 1976), and William
Dressier, among others, in assessing the impact of modernization and social change on
health status. It explicitly uses Dressler's methods and theories regarding consonance in
lifestyle and social support, and applies them to a continent where they had not been
tested previously. My results do not replicate Dressler’s findings, yet they expand our
knowledge about and approach to these topics. The model he has proposed can be
expanded or revised to include the information from this African population.
It is time to develop new methods with which we can measure psychosocial stress
and social support cross-culturally. It is clear to me that the existing methods do not
measure these two constructs in the population I was working with. I think that it is
preferable at this point in time to begin from scratch to create these methods. I do not
want to ignore the important work that has been done in these areas, but I question the
applicability of scales and questionnaires from one setting to another, especially given the
sensitive nature of these constructs. I advocate basic research into the meanings of stress
and social support in various populations as the first step. We may find that stress and
social support are so highly culture-dependent that one tool or suite of methodological
tools may be salient in one culture but not elsewhere.
Methods also need to be developed to measure the relationship between lifestyle
and blood pressure in a population where we see blood pressure increasing with income.
The goal here is to identify the mechanism(s) through which income leads to increasing

185
blood pressure. These new tools would isolate the independent effects of income from the
effect of income on obesity and high blood pressure.
One topic I have discussed with colleagues in the field is the possibility of a
transition point at which blood pressure stops increasing with income and begins to
decline. It could be analogous to the epidemiologic or demographic transitions occurring
throughout the world with modernization. A population might reach a certain point
during acculturation or modernization at which the directionality of blood pressure and
income becomes inverted. Knowing that most African countries exhibit the opposite
pattern from African diaspora populations in the U.S., the Caribbean, and South America,
I wonder where the change occurred in the latter populations.
South Africa would be an excellent place to test new measures of psychosocial
stress, social support and consonance with lifestyle. This country is home to several
African populations who have already undergone the transition in blood pressure and
socioeconomic level described in the last paragraph. It is a highly modernized country on
the African continent that is home to many different ethnic groups. Within these groups
there is diversity in level of acculturation and urbanization. There is baseline data on
blood pressure collected by researchers and an interest in the contribution of social
factors to the development of disease.
Applications of the Research
In the field of anthropology, this research contributes to our understanding of
culture change and its effects on health. Methodologically, it will help assist in the testing
of existing tools, and the development of new ones, to measure psychosocial stress cross-
culturally.

186
The study makes two contributions to the domain of public health. The
information on age, BMI, income, and other variables will be helpful to efforts to combat
the increasing burden of chronic disease in Africa, specifically cardiovascular disease. I
hope that the research findings will also help us to understand hypertension better in
African-Americans.
The results of this study indicate that the contribution of cultural consonance in
lifestyle and social support to the development of hypertension in Africa is minimal.
There are two possible explanations for this. One is that we simply do not have tools with
which to measure cultural consonance in Africa. Another possibility is that cultural
consonance contributes less in Africa to blood pressure than it does in other parts of the
world. In either case, we need better tools for measuring culturally appropriate levels of
consonance with sought-after lifestyles and for measuring other potential sources of
psychosocial stress. As these tools are developed, the results they generate will be
applicable to the study of hypertension, not only in Africa, but also around the world.

APPENDIX A
LEGEND AND MAP OF PONTA GEA
Legend:
1. DANMO Garage
2. Sport Pavilion
3. School for Handicapped Children
4. E. Mondlane Primary School
5. City Education Office
6. Zimbabwean Consulate
7. Marriage Palace
8. Oceana Bar and Restaurant
9. Miramar Restaurant
10. Miramar Hotel
11. Airplane Park
12. Pensao Moderna
13. Provincial Library
14. Worker’s Union (ex-clinic)
15. Universal Kingdom of God Church
16. World Food Program / U.N.
17. Golf Club
18. Ponta Gea Hospital
19. Meteorology Station
20. Hotel Savoy
21. Government Garage
22. Diocese Offices
23. Gas (Petrol) Station
24. ANDEL (NGO)
25. Greek Church
26. Provincial Office of Agriculture and
Rural Development
27. Bank Offices
28. Beira Sports Club
29. Mozambique Railroad Housing
30. Beira Corridor Housing
31. Platform for the Pope’s Mass
32. Mozambique Association to Fight
Against AIDS
33. UP Professor Housing
34. Mormon Church (LDS)
35. Ponta Gea Primary School
36. German Cooperation (GTZ)
37. SISE (Intelligence Service)
38. Former NGO Offices
39. National Institute for the Blind
40. Bairro Secretary’s Office
41. Ponta Gea Market
42. May 1st Teacher’s Housing
43. Professor Housing
44. Nursery School (Créche)
45. Mozambique Red Cross
46. Military Camp
47. Snack Bar
48. Police Station
49. Traffic Police Station
187


APPENDIX B
LIFESTYLE ITEMS FROM TWENTY TWO FREELISTS
Table B-l Complete list of lifestyle items.
Number
of
Listings
Average
percent
Average
rank
Smith's S
Car
16
73
5.875
0.503
Own a house
15
68
2.467
0.597
Travel outside Beira
13
59
10.385
0.197
TV
12
55
7.25
0.318
Children to private school
11
50
10.727
0.207
Refrigerator
8
36
6.625
0.234
Private health care
7
32
6.143
0.203
Cellular phone
7
32
13.143
0.102
Satellite TV
7
32
9.714
0.158
Good Job
7
32
2.571
0.275
Freezer (free-standing)
7
32
7.857
0.181
Have a maid
7
32
10.286
0.128
Electricity
7
32
7.571
0.187
Stereo system
7
32
6.571
0.199
Telephone
7
32
10.143
0.163
Running (piped) water
6
27
9.667
0.145
Air Conditioning
6
27
6
0.166
Video player
6
27
7.333
0.154
Philanthropy
6
27
10.167
0.101
Speak some English
6
27
11.333
0.088
Speak Portuguese at home
6
27
13.33
0.064
Stove (not hot-plate)
6
27
5.833
0.172
Eat out in restaurants
5
23
11.4
0.106
Matching iumiture set
5
23
6.4
0.155
Mixed Portfolio
5
23
(L2
0.151
Enough money
5
23
4
0.165
Girlfriend (Mistress)
4
18
12.25
0.053
Stable life
4
18
1.5
0.176
Water tank
4
18
8.25
0.101
Expensive shops
4
18
11
0.064
Not lack (anything)
3
14
10.667
0.033
Generator
3
14
11
0.062
Computer
3
14
11.667
0.047
189

190
Table B-l continued.
Number
of
Listings
Average
percent
Average
rank
Smith's S
College degree
3
14
4.333
0.098
Water pump
3
14
6.333
0.077
Driver's license
3
14
6.667
0.083
Washing machine
3
14
8.667
0.036
Limit # of children
3
14
7.667
0.067
Enough food
3
14
3.667
0.104
Western food
3
14
11
0.038
Bedroom furniture
2
9
8
0.051
Clothes for the children
2
9
6.5
0.063
School supplies for the
children
2
9
6.5
0.057
Serve good liquor
2
9
12.5
0.023
Conspicuous consumption
2
9
7
0.055
Contact with other people
2
9
8.5
0.04
Have friends over
2
9
9.5
0.043
Bicycle
2
9
10.0
0.037
Bathtub
1
5
12
0.018
Wood floors
1
5
3
0.04
Aquarium
1
5
7
0.027
Home office and library
1
5
8
0.024
Education
1
5
5
0.027
Yard
1
5
16
0.008
Three bedrooms
1
5
1
0.045
Enough towels
1
5
9
0.025
Toothbrush and toothpaste
1
5
10
0.023
Bath soap
1
5
11
0.02
Yacht
1
5
12
0.012
Toilet
1
5
13
0.015
Sink
1
5
14
0.013
Ornaments on the veranda
1
5
15
b.oi
Sofa
1
5
1
0.045
Shelving unit
1
5
2
0.042
Cruise around the world
1
5
13
0.009
Throw rugs
1
5
8
0.028
Technical training school
1
5
14
0.009
Simple but nice furniture
1
5
4
0.036
A medical center
1
5
16
0.003
Not rely on other people to
solve my problems
1
5
8
0.006
Microwave
1
5
10
0.008
Children
1
5
3
0.036

191
Table B-l continued.
Number
Df
Listings
Average
percent
Average
rank
Smith's S
Hair dryer
1
5
9
0.009
Floor waxer
1
5
10
0.005
Garage
1
5
14
0.006
Landscaping
1
5
15
0.003
Go to the beach
1
5
6
0.031
Wife
1
5
2
0.042
Research center (market and
public opinion)
1
5
15
0.006
Internet
1
5
9
0.023
Contact with the outside
world
1
5
11
0.017
A good future for the
children
1
5
8
0.021
Motorcycle
1
5
11
0.01
No debts
1
5
10
0.008
Curtains
1
5
2
0.043
Assimilado lifestyle
1
5
11
0.008
Dining room set
1
5
4
0.038
Sheets
1
5
6
0.033
Wardrobe
1
5
7
0.03
Go out dancing
1
5
5
0.035
Video games
1
5
15
0.01
Visit family on holidays
1
5
18
0.003
No problems or worries
1
5
3
0.041
Fax machine
1
5
9
0.021
Matching set of chairs
1
5
7
0.032
Game room
1
5
9
0.028
Recreation opportunities
1
5
14
0.017
Go out to bars
1
5
16
0.013

APPENDIX C
QUESTIONNAIRE DM ENGLISH
QUESTIONNAIRE
1. Interview code (ID): Date
2. Interviewer
Section A) Demographic Questions
3. Age
4. Sex: Female Male
5. Marital Status (read)
Single (1)
Married (2)
Common-law (3)
Divorced/Separated (4)
Widow (5)
6. Do you work? Yes (1) No (0) Retired (2)
6a. What is your profession?
7. What's the highest grade in school you have completed? Grade Class
7a. When did you finish (year)?
8. Do you have children? Yes (1) No (0)
8a. If yes, how many?
9. How many adults live here at home?
9a. How many adults?
10. Are there children here who go to school? Yes No
10a. Where do they study?
11. Where were you bom?
12. How long have you lived in Ponta Gea?
192

193
13. In what language did you learn to talk?
14. Do you smoke? Yes(l) No (0)
Section B) Lifestyle
1. Your house is rented (1), owned (2), given (3), work (4),
other(specify)
2. Do you have running water in your house? Yes (1) No (0)
3. Do you have a water tank? Yes (1) No (0)
4. Do you have electricity at home? Yes (1) No (0)
5. Do you have a phone at home? Yes(l) No (0)
6. Do you have a cellular phone? Yes (1) No (0)
7. Where did you spend your last vacation (time off)?
8. Do you have a driver's license? Yes (1) No (0)
9.Do you own a car? Yes (1) No (0)
10. What language do you speak most often here at home?
11. Do you speak English? Yes (1) A little (2) No (3)
12.When someone is sick do you usually go to a private, public , both types
of hospital?
13. Do you have workers here at home? Yes (1) No (0)
14. Do you have a television? Yes (1) No (0)
14a. What TV program do you like most?
15. Do you have video player? Yes (1) No (0)
16. Do you have satellite TV? Yes(l) No (0)
17. Do you have a sound system? Yes (1) No (0)
18. Do you have a fridge? Yes (1) No (0)

194
19. Do you have a freezer? Yes (1) No (0)
20. Do you have a stove with 4 burners (oven)? Yes(l)_ No (0)
21. Do you have air conditioning? Yes(l) No (0)
22. Do you go out to eat in resturaunts? Yes (1) No (0)
22a. If yes, how many times per months?
23. Approximately, what is your monthly household income? , Don't
know
Section C) Social Support
1. What is your religion?
Catolic (1)
Protestant (2)
Muslim (3)
Don't have (4)
Don't know (5)
Other
la. Do you regularly go to Mosque on Fridays? (for muslims) Yes (1) No (0)
lb. How many times per week do you go to church? (for Christians) times per
week
lc. Are you part of a small group at your church or mosque? Yes (1) No (0)
2. Do you have godparents here in Beira Yes (1) __ No (0)
3. Who from your family lives in Beira?
4. Are you on good terms with your neighbors? Yes (1) No (0)
5. Do you have a close friend, with whom you can discuss personal things? Yes (1)
No (0)
I have a list here of people who can help you out when you need it.: Family, Friends,
Godparents, Boss, Co-workers/schoolmates, Neighbors, People from your home region,
Church members, Other.
I am going to read five scenarios and I want you to tell me who you turn to in each case,
using the categories on this card.

195
6.When you need to borrow money, where do you turn first? , and
then , , ,
7.When a family member is sick where do you go first for help?
8.When you have (had) problems with your spouse?
9.If you have (had) problems at work or school?
10.When someone in the family dies where do you look for help (material/emotional)?
Section D) Self Assessment of Stress (Cohen)
For the next set of questions, tell me how often you have felt this way in the last month:
[responses: l=never; 2=sometimes; 3=almost all the time]
In the last month, how often have:
1. You felt that you were really realizing your goals?
1 2 3
2. You felt that you could solve the problems in your life?
1 2 3
3. You felt upset or stressed (worn out, irritated)?
1 2 3
4. You felt angry or frustrated because things happened you could not control?
1 2 3
Section E.) Life events
Please tell me if during the last 12 months (since June/July 2000), the following things
happened:
1. Yes No Moved to a new house.
2. Yes No Someone in your family died (who?) _
3. Yes No You were seriously ill or had an accident (in hospital).
4. Yes No Lost your job.
5. Yes No Gotanewjob.
6. Yes No Had a baby, were pregnant (new baby in home)
7. Yes No Finished a course. Type
8. Yes No Got married.
9. Yes No Got divorced or separated.
10. Yes No Spent time in prison.
11. Yes No Retired.

196
12. Yes No A close friend died.
13. Yes No Got back together with your partner.
14. Yes No A change in the intensity of conflicts with partner.
15. Yes No Your spouse got a new job or lost a job.
Section F.) Hypertension
Finally, I'd like to ask you some questions about hypertension in your family and in
general.
1.Have you ever been told you have hypertension? Yes (1) No (0)
la. If Yes, who told you? When (year)?
lb. Did you take any medicines for hypertension? Yes (1) No (0)
lc. What was the medicine?
ld. How long did you take it?
le. Did you have any symptoms or manifestations?
2.Does someone in your family have hypertension? Yes (1) No (0) Don't
know (2)
2a. If Yes, who? and what symptoms do they (did they) have?
3.Do you know people who have tensao alta? Many (2) Some (1) None (0)
Section G) Anthropometry
Weight:
kg
Height:
cm
BP1:
/
mmHg
BP2:
/
mmHg
BP3:
/
mmHg

APPENDIX D
QUESTIONNAIRE IN PORTUGUESE
QUESTIONÁRIO
3. Codigo da entrevista: Dati
4. Entrevistador
Sec^ao A) Perguntas Demográficas
3.Idade
4. Sexo: Feminino Masculino
5. Estado Civil (leia)
Solteiro (1)
Casado (2)
Uniao Marital (3)
Divorciado/Separado (4)
Viuvo (5)
6. Voce trabalha? Sim (1) Nao (0) Reformado (2)
6a. Qual é a sua profissao?
7. Qual é o nivel ou classe mais elevada concluido? Nivel Classe
7a. Em que ano concluio?
8. Tem Filhos? Sim (1) Nao (0)
8a. Se é sim, quantos tem?
9. Quantos adultos vivem aqui em casa?
9a. Quantas crianzas?
10. Há crianzas aqui em casa que váo á escola? Sim Nao
10a. Onde estudam?
11. Onde voce nasceu?
12. A quantos anos vive neste bairro?
197

198
13. Em que lingua aprendeu a falar?
14. Fuma? Sim (1) Nao (0)
Secfao B) Estilo da Vida
1. A casa é alugada( 1), própria(2), cedida(3), serv¡9o(4),
outra(especificar)
2. Tern agua canalizada dentro da casa? Sim (1) Nao (0)
3. Tem tanque de agua? Sim(l) Nao (0)
4. Tem energía em casa? Sim (1) Nao (0)
5. Tem telefone fixo? Sim(l) Nao (0)
6. Tem telefone celular? Sim(l) Nao(0)
7. Onde passou as últimas ferias?
8. Tem carta de conduqao? Sim (1) Nao (0)
9.Tem carro próprio? Sim(l) Nao (0)
10. Qual é a lingua que falam com ffequéncia aqui em casa?
11. Fala Ingles? Sim(l) Umpouco(2) Nao (3)
12.Quando alguem estiver doente custuma ir no hospital privado, estatal,
os dois?
13. Tem empregados aqui em casa? Sim (1) Nao (0)
14. Tem televisor? Sim (1) Nao (0)
14a. Qual é o programa preferido?
15. Tem video? Sim (1) Nao (0)
16. Tem antena parabólica? Sim(l) Nao (0)
17. Tem aparalho da música? Sim (1) Nao (0)
18. Tem geleira? Sim (1) Nao (0)
ou

199
19. Tem congelador? Sim(l) Nao(O)
20. Tem fugáo com 4 bocas? Sim(l) Nao (0)
21. Tem aparelho de ar condicionado? Sim(l) Nao (0)
22. Tem ido passar refeiqóes no resturante? Sim(l) Nao (0)
22a. Se é sim, quantas vezes por mes?
23. Aproximadamente, qual é o rendimento mensal do agregado?
Nao Sabe
Secado C) A Vida Social
2.Qual é a sua religiao?
Católica (1)
Protestante (2)
Muqulmano (3)
Nao Tem (4)
Nao Sabe (5)
Outra
la. Vai regularmente ñas sextas feiras na mesquita? (os muspulmanos) Sim (1)
Nao (0)
lb. Quantas vezes vai a igreja por semana? (os cristaos) vezes por semana.
le. Voce faz parte de urna comunidade dentro da sua igreja ou mesquita? Sim (1)
Nao (0)
2. Tem padrinhos aqui na cidade Sim (1) Nao (0)
3. Quem da sua familia está viver na Beira? -
4. Voce tem boas relacoes com os seus vizinhos? Sim (1) Nao (0)
5. Tem um amigo próximo com quem pode falar da coisas pessoais? Sim (1)
Nao (0)
Tenho urna lista das pessoas que podem adjudar quando alguém está precisando:
Familiares, Amigos, Padrinhos, Patrao, Colegas, Vizinhos, Conterráneos, Irmáos da
igreja, Outra.

200
Vou ler algums casos e quero que voces me disse a quem voce recorre neste caso, usando
as categorías escritas na carta.
11.Quando necessita de dinheiro onde vai prímeiro pedir? , e depois
12.Quando um membro da familia estiver doente onde é que pede ajuda prímeiro?
13.Quando tiver problemas com seu(a) esposo(a) á quem recorre?
14.Se tiver problemas no servifo ou na escola a quem se dirige?
15.Em caso de falecimento de um membro da familia a quem vai pedir ajuda?
Sec^ao D) Percepcáo de Stress (Cohen)
Para as questoes abaixo, fale-me sobre quantas vezes vocé sentiu isso durante o més
passado.
[categorías de respostas: l=nunca; 2=as vezes; 3=quase todos dias]
Durante o més passado, com que ffequéncia:
1. Vocé sentiu que estava realmente conseguindo os seus objectivos?
1 2 3
2. Vocé foi capaz de resolver os problemas na sua vida?
1 2 3
3. Vocé se sentiu nervoso ou estressado (cansado, irritado)?
1 2 3
4. Vocé se sentiu zangado ou frustrado porque aconteceram coisas que vocé nao podia
controlar?
1 2 3
Sec?5o E.) Acontecimentos na vida
Pode me dizer se durante os 12 meses anterior (Junho/Julho 2000), aconteceu alguma
coisa como:
1.
2.
3.
4.
5.
6.
Sim
Sim
Sim
Sim
Sim
Sim
Nao Mudou de casa.
Nao Morreu alguém da familia (quem?)
Nao Voce teve alguma doenpa grave ou um acident.
Nao Perdeu emprego.
Nao Conseguiu novo emprego.
Nao Deu parto, ficou gravida (tem novo filho)

201
7. Sim Nao
8. Sim Nao
9. Sim Nao
10. Sim Nao
11. Sim Nao
12. Sim Nao
13. Sim Nao
14. Sim Nao
15. Sim Nao
Recebeu diploma. De
Casou-se.
Divorcio-se ou separou-se.
Passou tempo na prisao.
Foi reformado.
Morreu um amigo muito próximo.
Reconciliaiao com a esposa/marido.
Mudanza da intensidade dos conflitos com a esposa.
Sua esposa come^u ou parou de trabalhar.
Sec9áo F.) Hipertensao
Finalemente, gostaria de fazer algumas perguntas sobre hipertensao na sua familia e em
geral.
1.Vocé iá foi informado por alguém que sofre de hipertensao? Sim (1) Nao (0)
la. Se é sim, quem informou? Quando?
lb. Tomou algum medicamento para tratar a hipertensao? Sim (1) Nao (0)
le. Qual foi o medicamento?
ld. Tomou durante quanto tempo?
le. Voce tinha quais sintomas ou manifesta9oes?
2.Alguém na sua familia teve ou tem a hipertensao? Sim(l) Nao (0) Nao
Sabe (2)
2a. Se é sim, quem? e quais sao ou quais eram as manifesta?oes ou
sintomas?
3. Conhece as pessoas que sofram de tensao alta? Muitas (2) Algumas (1)
Nenhuma (0)
Sec^ao G) Antopometria
Peso: kg
Altura: cm
TAI: / mmHg
TA2: / mmHg
TA3: / mmHg

APPENDIX E
ORAL CONSENT - INSTITUTIONAL REVIEW BOARD
liitraoultural Variation in Blood Pressure in Central Mozambique. Oral Conscnt/English.
My name is Nanette Barkey and I am a student ai the University of Florida working under the
supervision of H. Russell Bernard, Ph.D. I am doing a study in the Ponta Gea neighborhood
on high blood pressure and the social factors that contribute to it. I would like to talk to you
about your life, how you live, what is happening in your life, and some of your concerns. At
the end of the interview we would like to measure your blood pressure, height and weight.
All of this should take between 20 to 30 minutes. There are no anticipated risks or direct
benefits associated with participating in this study. If you are found to have high blood
pressure, Í will give you a referral to a local hospital where you can receive treatment.
All of your answers are confidential to the extent provided by law and we will not be asking
you for your name. Everything you tell us today will be kept private, we will not share any
of this information with anyone outside of the research group. If you do not want to answer a
question or you want to stop the interview at any time, that is tine. If you have any questions,
you may contact me at or my supervisor. Dr. Bernard,
at Box 117305 Gainesville, FL 32611 USA. Questions about your rights as a research
participant can be directed to the UFIRB at Box 112250 Gainesville, FL 32611 USA Do you
have time to do the interview today?
Intracultural Variation in Blood Pressure in Central Mozambique. Oral Consent/Portuguese
Mcu nome é dra. Nanette e sou urna aluna da Universidade da Florida. Estou aqui fazendo
um estudo no bairro da Ponta-Géa sobre hipertcnsáo e os tactores sociais que podem scr
associados a ela. Gestaría de talar com vocé sobra a sua vida, como que voec vive, alguns
acontecimenlos na sua vida, e suas preocupacGes. Depois da entrevista, gostariamos de medir
a sua altura, tensáo arterial e o seu peso. Tudo isso leverá mais ou menos 20 a 30 minutos.
Todos os dados sáo confidencias e nao vamos pedir o scu nome. A nossa conversa hoje é
privada e nao vamos dizer o que vocé nos disse a ninguem. Se vocé nao quiser reponder a
urna pergunta ou quiser ¡nteromper a entrevista a qualquer momento, nüo ha nunhum
problema. Vocé tem tempo para talar conosco hoje?
ev
University o1 Florida
liisiKutional Review Boars (IR8 Ó2)
Protocol# ¿u.'1-s-.1?
for Usa Through
202

APPENDIX F
CODE SHEET FOR SURVEY DATA
Section A (Demographics)
Age = years
Agegroup
3=30-39
4=40-49
5=50-59
6=60+
Sex l=male. 2=female
(re-coded to 0=men„ l=women)
Marital Status
l=single
2=married
3=commonlaw
4=divorced/separated
5=widowed
Children
Enter the number living
Currently Working
0=no
l=yes
2=retired
Profession (in English)
Education
Use census categories
Educyear = last year in school
Adulthouse # => age 18 who live there
Childrenhouse # < age 18 who live there
Birth = where the person was bom
1=BEIRA
2=Sofala (outside Beira)
3=Manica
4=Tete
5=Inhambane
6=Gaza
7=Maputo
8=Nampula
9=Zambezia
10=Cabo Delgado
ll=Niassa
12= outside Mozambique
YearsPG = years lived in bairro
Maternal Language
l=Portuguese
2=Indian languages
3=Cindau
4=Cisena
5=Nyungwe
6=Shangane
7=Rhonga
8= Xitswa
9=Chuabo
10=Nyao
ll=Macua
12=Bitonga
13=Makonde
14=Chope
15=Lomwe
16=Kiswahili
17-Shona
203

204
18=English
19=Karungo
Child in School
20=Nyanga
0=no
21= Zulu
22=Maito
l=yes
23=Nyawinga
24=Cichewa
Type of school
0=public
Smoke
l=private
2=church
0=No
3=university level
l=Yes
Vacation
Section B (lifestyle)
l=Beira
Housing
2=outside Beira
3=putside Moz.
l=renting
2=o wn
3=given
4=work
Driver’s License
5=other
0=no
Running Water
l=yes
Car
0=No
l=Yes
0=no
l=yes
Water Tank
0=no
Home language
l=yes
l=Portuguese
Electricity
2=other
0=no
Speak English
l=yes
0=none
Telephone
l=a little
2=yes
0=no
l=yes
Hospital
Cellphone
l=private
0=no
2=state
l=yes
3=both

205
Maid
0=no
l=yes
TV
0=no
l=yes
TVProgram
l=sports
2=news/telejomal
3=novelas
4=debates
5=other
Video
0=no
l=yes
Satellite
AC
0=no
l=yes
Eat out
0=no
l=yes
Income = value in meticais
Incomegroup
0=don’t know
1 = <1 million
2 = 1 to <1.5 million
3 = 1.5 to <3 million
4 = 3 to <6 million
5 = 6 to <10 million
6 = >10 million
0=no
l=yes
STEREO
0=no
l=yes
FRIDGE
Section C (social support)
Religion
l=catholic
2=protestant (not catholic)
3=muslim
4=none
5=don’t know
0=no
l=yes
FREEZER
0=no
l=yes
Oven
0=no
l=yes
Mosque on Fridays
0=no
l=yes
Frequency at Church
# of times per week
Community
l=yes
0=NO

206
Padrinhos
0=no
l=yes
FamilyBeira
0=none
l=almost none/few
2=some
3=almost all/all
Neighbor
0=no
l=yes
Close Friend
0=no
l=yes
Scenarios
0= no one
l=family
2=neighbors
3=friends
4=job/patrao
5=bank
6=colleagues
7=igrej a/mesquita
8=conterraneos
9=padrinhos
10 =state agency (OMM, tribunal)
0-5 scores for how well each person
could access social support for each
scenario.
Section D (Cohen scale)
Objectives
Problems
1= never
2=sometimes
3=all the time
Stressed
1= never
2=sometimes
3=all the time
Frustrated
1= never
2=sometimes
3=all the time
Cohenmotmeet + notsolv + stress + frust
Section E (Life Events in last year)
Moved
0=no
l=yes
Deathfam
0=no
l=yes
Whodied (in english)
BEENSICK
0=no
l=yes
lostiob
0=no
l=yes
newiob
0=no
l=yes
newbabv
0=no
l=yes
diploma
0=no
1= never
2=sometimes
3=all the time

l=yes
marry
207
typemeds
0=NO
l=yes
DIVSEPAR
0=no
l=yes
prison
0=no
l=yes
retire
0=no
l=yes
friendie
0=no
l=yes
reconcil
0=no
l=yes
famconfl
0=no
l=yes
spouseiob
0=no
l=yes
Section F (BP historv/measurementsl
haveHBP
0=no
l=yes
whotold
l=doctor
2=hospital
3=nurse
4=tech
5=other
whentold - year told
Otherel
Second-degree relative has HBP
FamilyHBP
0=no
l=yes
whofam
relationship of the person who has HBP
to the respondent
closerel
first degree family member had HBP
OtherHBP
0=none
1 =some
2=a lot
weight (kg)
height (cm)
systl
diasl
syst2
dias2
syst3
DIAS3
Variables created
Hidiasl=l if diasl =>90
HIDIAS2=1 IF DIAS2 => 90
Hidias3=l if dias3 => 90
Hidias = 1 if hidiasl, 2, or 3=1
takemeds
l=yes
medstime
0=NO
Meandias = avg of three diatolics
Hidimean =1 if meandias=>90
Hisystl=l if systl=>140
Hisyst2=l ifsyst2=>140
Hisyst3=l ifsyst3=>140
HOW LONG TOOK MEDS

Hisvst=l if hisystl,2, or 3=1
208
Meansyst = avg of three systolics
Hisymean=l if meansyst=>140
HiBPmean=l ifHidimean or
Hisymean=l
HBPmean=l ifHidimean and
Hisymean=l
Dollars = income divided by 20,000
Dollgrp= dollars divided into terciles
1=10-99 dollars
2=100-230 dollars
3 = 231-1750 dollars
ownhome= person owns the house
0=NO
l=yes
owns= household owns the following
(15 items) running water, tank,
electricity, car, phone, cellphone, home,
tv, video, satellite, stereo, fridge, freezer,
stove, and ac,
school = private school (1) or not (0).
Dohave = score (0-8) of following
behaviors: speak Port at home, speak
some English, children to private school,
private doc, eat out, go away for
vacations, maid, driver's license.
Porthome = speak Port at home
Speakeng = speak some English
Privdr = access to private doc
Goawav = leave Beira on vacations
Lifesty = score (1-23) of lifestyle items
(dohave + owns)
Lifestygp = terciles of lifesty
1=0-7
2=8-13
3=14-23
langgp
If maternal language is Portuguese=l
If maternal language is sena/ndau=2
If maternal language is other = 3
Nuclear family = 1 if nuclear family
member died in the last year (spouse,
child, parent, sibling), otherwise =0.
hhold = total # of people living in hhold
black = black (1) or not
(Indian/White=0)
tvowner: preferred TV show (tv owners)
Inchhold = income in dollars divided by
number of people in the household.
Dollars/hhold.
Muslim = 1= muslim on religion,
otherwise =0.
Socsuppl=belong to a
community + padrinhos in town +
family in Beira + neighbor + have a
good friend.

APPENDIX G
TABLE OF EDUCATIONAL CATEGORIES FROM THE MOZAMBICAN CENSUS
Pergunta PI9. Que nivel dee
tino frcquenta ou o male elevado que frequentou (mesmo que seje incompleto)?.
:-
Recenseamento 1997
Sistema Nacional de E&ycasioiSNE)
Anttgg Sistema
1 - Alfabetizado
Alfabetizado (1® e 7° ano)
2 - Ensíno primario 1" Grau
Ensino Primarlo 1° Grau (1“/5* classo)
Pre-4“ classo
3 • Ensíno Drimário 2® Grau
Ensíno Primario 2° Grau (6V7* classe)
Ciclo Preparatorio 1° ■ 2” ano
4 - Ensíno Secundario Geral - 1o Ciclo
Ensíno Secundário Geral (8*/10* classe)
Liceu - 2® ciclo 3® - 5° ano
5 - Ensino Secundario Geral - 2° Ciclo
Ensíno Pre-Universitáno |11a/12a classe)
Liceu - 3® ciclo S® - 7° ano (incluí Seminario)
6 - Ensino Técnico Elementar
Ensino Técnico Elementar
Ensino Técnico Eleinontar
7 - Ensino Técnico Básico
Ensíno Técnico Básico
Seed® Preparatoria
8 - Ensino Técnico Medio
Ensino Técnico Médio
Instituto
9 - Curso de Formado de Professor
Curso de Formado de Professor
Curso de Formad0 °® Professor
10 - Superior
Superior
Superior
209

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BIOGRAPHICAL SKETCH
Nanette Barkey received her Bachelor of Arts from Case Western Reserve
University in Cleveland, Ohio, with a major in medical anthropology and a minor in
nutrition. She served as a public health volunteer in Zaire and has worked on health
projects in Angola, Haiti, Laos, Cote d'Ivoire, and Mozambique, as well as in the United
States. She holds a Master of Science in Public Health (MSPH) from the University of
South Florida.
225

I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and
quality, as a dissertation for the degree of Doctor of Philosophy.
¿sell Bernard, Chairman
Professor of Anthropology
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and
quality, as a dissertation for the degree of Doctor of Philosophy.
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and
quality, as a dissertation for the degree of Doctor of Philosophy.
¡LA 1*.
Leslie Lieberman
Professor of Anthropology
I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope and
quality, as a dissertation for the degree of Doctor of Philosophy.
This dissertation was submitted to the Graduate Faculty of the Department of
Anthropology in the College of Liberal Arts and Sciences and to the Graduate School
and was accepted as partial fulfillment of the requirements for the degree of Doctor of
Philosophy.
December 2002
Dean, Graduate School

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