Social Learning, Influence
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Social learning, influence, and ethnomedicine: individual, neighborhood and social network influences on attachment to an ethnomedical cultural model in rural Senegal Abstract The preference in many parts of the world for ethnomedical therapy over biomedical alternatives has long confounded scholars of medicine and public health. In the anthropological literature cultural and interactional contexts have been identified as fundamental mechanisms shaping adherence to ethnomedical beliefs and health seeking behaviors. In this paper, we examine the association between individual, neighborhood, and social network characteristics and the likelihood of attachment to an ethnomedical cultural model encompassing beliefs about etiology of disease, appropriate therapeutic and preventative measures, and more general beliefs about metaphysics and the efficacy of health systems in a rural population in Eastern Senegal. Using data from a unique social network survey, and supplemented by extensive qualitative research, we model attachment to the ethnomedical model at each of these levels as a function of demographic, economic and ideational characteristics, as well as perceived effectiveness of both biomedical and ethnomedical therapy. Individuals’ attachment to the ethnomedical cultural model is found to be strongly associated with characteristics of their neighborhoods, and network alters. Experiences with ethnomedical care among neighbors, and both ethnomedical and biomedical care among network alters, are independently associated with attachment to the ethnomedical model, suggesting an important mechanism for cultural change. At the same time, we identify an independent association between network alters’ cultural models and those of respondents, indicative of a direct cultural learning or influence mechanism, modified by the degree of global 1 transitivity, or ‘connectedness’ of individuals’ networks. This evidence supports the long held theoretical position that symbolic systems concerning illness and disease are shared, reproduced, and changed through mechanisms associated with social interaction. This has potentially important implications not only for public health programming, but for the understanding of the reproduction and evolution of cultural systems more generally. Key words: Social learning, Cultural Models, Social Networks, Ethnomedicine, Population Health 1. Introduction In large parts of world, established ethnomedicines compete in the health services market with those provided under the biomedical model. How do we account for the ethnomedical beliefs of members of these populations? It could be, as is often assumed, that individual characteristics are determinative. Individuals with less formal education, or with limited exposure to Western ideas, for example, may be ignorant of the biomedical model. Religious affiliation and experience with treatment by healers associated with either the biomedical or ethnomedical health system may also be influential. The most persuasive explanation however, a mainstay in medical anthropology since at least Evans-Pritchard’s seminal work with the Azande (Evans-Pritchard, 1937), is that in the cultural and interactional knowledge context in which individuals find themselves, ethnomedicine should be treated as rational, at least in the sense that “all beliefs are on a par with one another with respect to the causes of their credibility” (Barnes & Bloor, 1982, p. 23). In places where biomedical health 2 systems are relatively recent and less extensive, biomedical models for common illnesses are often not widely diffused, while ethnomedical models, including culturally specific natural and supernatural explanations for disease and associated therapeutic regimes, are supported by a broad and interconnected system of beliefs, norms and behaviors reinforced through social learning and influence taking place through interaction (Fabrega, 1975; Kleinman, 1978b; Ngokwey, 1988; Pachter, 1994; Yoder, 1997). 1.1 Cultural models of health, disease and illness The use of culturally constructed cognitive schemas, or abstract, flexible representational and interpretive frameworks for understanding and acting in complex situations, as a key explanatory framework for health belief and behavior has found wide traction within studies of ethnomedicine (Angel & Thoits, 1987; McKee, 2003; Nichter, 1991; Vecchiato, 1997; Yoder, 1997). The organizing framework we use to conceptualize and identify cultural elements related to health, the connectionist schema model, is well suited to identifying social learning and influence mechanisms operating through interaction. Schemas define for an individual what exists symbolically in a particular context (for example, agents of disease), and structure perceived possibilities for action (such as therapeutic options). Schemas, in what is known as the ‘connectionist’ framework, are learned as variably weighted aggregate representations of general contexts with associated possibilities and constraints on action drawn from of repeated imprints of different, particular experiences across heterogeneous yet analogous situations (Strauss 1992; Smith & Queller 2004; Strauss & Quinn 1998). Cultural models, as developed in cognitive anthropology, are hierarchically nested sets of such schemas that reciprocally shape one another (D’Andrade, 1992). Cultural models in this 3 tradition share much with Kleinman’s explanatory model (EM) framework (Kleinman, 1978a). The term ‘cultural model’ is often used in applied research to reference aggregates of belief and behavior using that framework. Though other differences exist, cultural models in the connectionist schema framework are more general, and go further than the EM model in explicitly theorizing mechanisms by which schemas are associated and meaning is constructed at the individual level through interaction. Higher level schemas in the framework applied here include those concerning ontology and metaphysics, associated ultimate causes of illness, and the relative efficacy of competing systems to address it. Mid-level schemas concern the proximal, contextually specific causes of particular illnesses, while lower level schemas concern therapeutic or preventative options. Hierarchical association between these levels occurs where more abstract schemas call upon and constrain the range of lower level schemas available. Lower level schemas and attendant action associated with them in turn shape the context for reproduction and evolution of higher level schemas (Strauss 1992; D’Andrade 1995; D’Andrade 1992). Perceptions of the efficacy of treatment received under one model or the other, for example, may inform beliefs about the proximal cause of illness (either to support or undermine them). These in turn may reinforce or weaken attachment to higher level schemas which support them. 1.2 Social learning and influence Social interaction is a key element of the repeated imprinting of particular experience fundamental to the development and evolution of schemas under the connectionist model. Individual experience (such as with medical care) plays a fundamental role, but is limited in its frequency and variability. By far the most frequent stimuli we are exposed to come through interaction with others, either interpersonal or mediated. Cultural models (including attendant 4 institutions and norms) can be conceptualized as arising from, and evolving, as a function of the heterogeneous distributions of stimuli individual members of a population are exposed to through interaction, and the situated actions they take (c.f. Blau, 1994; Mead, 1967; Tarde, 1895). Central tendencies of these distributions and the resources (or capital, material or human) they reference signal shared experience, or intersectionality. Variability in these distributions as experienced and acted on by individuals creates variation in subjective perception and contingent action, which, over time, allows cultural models to evolve. In health and health behavior, as well as demography, insights concerning social learning and evaluation mechanisms are beginning to expand our understanding of a wide variety of critical issues (Behrman, Kohler, & Watkins, 2002; Berkman & Kawachi, 2014; Sandberg, 2006; Smith & Christakis, 2008; Valente, 2010). Exploiting knowledge of social learning and behavior change processes, particularly through social networks, is currently thought to hold great potential for the development of more efficient public health interventions as well (Latkin & Knowlton, 2015; Valente, 2012; Valente, Palinkas, Czaja, Chu, & Brown, 2015). No research to date, however, has attempted to directly model the influence of social learning on belief systems and cultural models related to health and illness, the goal of this investigation. In this paper, using unique social network data from a small population in Senegal, we test hypotheses concerning the influence of social learning through interaction on attachment to an ethnomedical cultural model through the structural characteristics, health care experiences, and cultural models of health and illness held by respondents’ social network members and neighborhood co-residents. Our aim here is to identify interactional mechanisms through which ethnomedical belief systems are supported and potentially change, but from a more general perspective, of course, how social learning contributes to our understanding of the 5 evolution of culture through interaction in this special case may yield insights into broader processes