Health Promotion in Multicultural

Populations: A Handbook for

Practitioners
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Foreword
S ome paradoxes face those seeking to pro-
mote health in multicultural institutions,
communities, and societies in which equity
stands as a central value. Some of these para-
doxes arise from the inherently competitive,
if not sometimes contradictory, goals that
multiculturalism and equity seem to pursue.
We prize diversity, but we loathe disparities, at
least in matters of health. Can we protect and
even promote diversity in ethnicity or culture
while seeking to eliminate disparities in health?
Is the culture of a practitioner bound to limit
his or her ability to understand and promote a
vision of health and to find a way of achieving
health within another culture? This handbook
for practitioners should help the practitioner
bridge this cross-cultural divide.
A second paradox arises from the global,
to national, to regional and local, to family
and individual lenses through which multicul-
turalism and equity are variously viewed and
the sometimes contradictory actions taken
at these various ecological levels to achieve
equity. At the global, national, and state levels,
we seek uniform policies that are legislated at
these centralized levels to ensure equity across
regions, while recognizing that the essence of
diversity and multicultural sensitivity depends
on local, family, and even individual auton-
omy. Can practitioners reconcile the policies
they are required to implement with the social
realities, histories, and cultural variations that
they find locally? This handbook for practitio-
ners should help them do so.
A third paradox is that the only way
to achieve equity in the face of inherited
social, economic, and political inequalities and
inequitable societal forces is to treat people
or populations differently. The provinces of
Alberta, British Columbia, and Ontario, for
example, pay higher taxes than some other
provinces to subsidize the Canadian commit-
ment to health equity and universal health
care through revenue sharing and income
transfers to the poorer provinces. More afflu-
ent people must pay higher taxes to subsidize
essential social and health services to the less
affluent. Whole classes and regions, then,
must be treated unequally in the name of
equity. The only alternative to this strategy is
to limit the concept of equity more severely to
include only equality of economic opportunity
and to ignore history, political traditions, prej-
udice, catastrophic illness, and conditions of
birth and inheritance that give people unequal
circumstances and starting points in availing
themselves of their otherwise equal economic
opportunities. This handbook will help make
practitioners more sensitive to the histories,
traditions, and sociocultural circumstances
that matter.
A fourth paradox arises for individuals in
a multicultural society. Each of us must act
toward other people of different ethnic origins
with recognition and respect for their differ-
ences while treating them equally in every
other way. But where do we draw the line in
our behavior between differences and equality
vii
viii HEALTH PROMOTION IN MULTICULTURAL POPULATIONS
to achieve equity? In what ways should we be
equal, and what are the “every other” ways?
We face this daily in our relations between
genders. Affirmative action in hiring or build-
ing ramps for disabled people to have equal
access; avoiding sexual harassment in gender
relations between teachers and students or
between colleagues; and recognizing the disad-
vantages an employee, client, or student had at
the beginning of a professional encounter, all
reflect our efforts to reconcile these paradoxes.
These instances of societal adjustments to
inherent or inherited differences while seek-
ing to achieve equity hold lessons for the
health professions and other sectors seeking
to promote health in multicultural popula-
tions. Cultural differences related to health
can be obvious or subtle; malleable or rigid;
prescribed or proscribed; and dictated by
religious or secular traditions, edicts, norms,
customs, or ideologies. The variable forms
and sources of the differences can be a partial
guide to how they should be treated in plan-
ning, implementing, and evaluating health
promotion programs. But beyond these partial
guides, the humanity of multiculturalism can-
not and should not claim a science as its only
compass. Some combination of philosophi-
cal commitment, cultural knowledge, human
sensitivity, and open communication must
be brought to bear in achieving the balance
and proper trade-offs between distinctiveness
and equality that multiculturalism and equity
demand.
Besides the paradoxes, the diversity issue
presents another challenge for the practitioner.
The tendency of those who produce “best-
practice” guidelines too often generalize too
glibly from the theories and evidence gener-
ated in mainstream populations or from the
experiences of successful health promotion
programs in one population. As guidance
for practice in another population, especially
another culture, this has led many programs
down a primrose path of misplaced precision
and misguided certainty about practices. The
editors of this book, in the previous edition
and in this new edition, have wisely avoided
the overgeneralization or external-validity
trap by addressing the question of promoting
health for each of the major ethnic popula-
tions separately.
With the integration and consolidation of
material from a number of chapters from the
previous edition, Huff, Kline, and Peterson
have achieved a more readable and compact
volume for instructional purposes. As in the
previous edition, the book presents the expe-
rience of health promotion professionals in
their work with specific racially, ethnically,
and culturally identified populations. Each
chapter can be read for the lessons it may
hold for other professionals working with
the same populations. Each can be read, with
some greater caution, for the lessons it may
hold for working with other populations.
Generalizability may be the least appropriate
scientific construct to be brought to bear in
multicultural health promotion.
Even within the culturally identified catego-
ries used in the chapter titles, such as Latino,
African-American, American Indian, Alaska
Native, Asian-American, Pacific Islander,
and Arab-American, one finds vastly varied
populations. One must exercise similar cau-
tion in generalizing from these categories
to their counterparts living under national
conditions other than the United States. The
American Indian and Alaska Native counter-
part “First Nations” populations of Canada
and Aboriginal populations of Australia, for
example, have some common historical colo-
nization, economic disadvantage, and cultural
characteristics vis à vis their respective major-
ity neighbors. But each has distinct features
and circumstances that would make some
generalization from the American experiences
in this book misguided if not hazardous
for health promotion professionals working
cross-culturally in other countries.
Foreword
These cautions notwithstanding, the
authors of the chapters in this anthology of
multicultural experience offer a wealth of
insight and a treasure of stories and case stud-
ies that can enlighten the cultural knowledge
and awaken the cultural sensitivity of practi-
tioners everywhere. As a handbook for prac-
titioners, this volume promises to serve health
promotion well.
One overriding lesson, principle, or predic-
tion to be drawn from the multicultural experi-
ences reflected in this handbook would be that
promoting health in multicultural populations
must ultimately be from within the cultures
intended to benefit from the health promotion.
Yes, collaboration between an ethnic minority
population and professional practitioners from
the majority culture can be helpful and produc-
tive, but such collaboration must be in the spirit
of participatory research. Why participatory
research? Because the health promotion task
in every community is first to understand itself,
second to communicate that understanding with
consistency and credibility, and third to produce
action from the understanding and commitment
mobilized by its communication. These are the
three elements of participatory research: system-
atic investigation or self-study, colearning, and
action. Practitioners working cross-culturally
can only participate in the self-study, learning,
and action process effectively if the population
affected by the issues is actively engaged in all
three.
Each of the chapters in this book brings a
unique set of perspectives from the multicul-
tural encounters represented by it. Each rep-
resents such encounters within the American
context of multiculturalism, except one. The
chapter by Frankish, Lovato, and Poureslami
ix
from Canada reminds us that we risk fall-
ing into another level of ethnocentrism if we
view the issues of multiculturalism strictly
through the American lens of health promo-
tion or of interethnic encounters in the United
States. The very naming of the ethnic groups
as African-American, Asian-American, and
Native American, for example, might lull us
into parochialism about these ethnic popula-
tions. Thus, we would miss the opportunity
to study and understand their counterparts
in Canada, Australia, and other countries
absorbing immigrant and indigenous popu-
lations and seeking to nurture the mainte-
nance of their cultural heritages together
with the inevitable experience of acculturation
and assimilation into their mainstreams. The
Canadian First Nations and the Australian
Aboriginal populations, for example, have
much to teach us about the multicultural expe-
riences in health promotion, and the compara-
tive study of these experiences can enlighten
the efforts in all countries that must grapple
with them. The contemporary European expe-
rience of immigration from Muslim countries
and the massive refugee movement across the
borders of war-torn countries in Africa and
the Middle East make the subject addressed
by this book all the more urgent in the broader
global perspective.
—Lawrence W. Green, DrPH
Adjunct Professor, Department of
Epidemiology and Biostatistics
School of Medicine
Co-Leader, Society, Diversity
and Disparities Program
Comprehensive Cancer Center
University of California at San Francisco
Preface
I t has been over seven years since the release
of the second edition of Health Promotion
in Multicultural Populations: A Handbook
for Practitioners and Students. In that period,
the United States has continued to grow more
ethnically diverse. The editors recognize that
ethnicity is a rather broad way in which
to examine special populations. However,
categorization by ethnicity does make it pos-
sible to focus on the unique characteristics
of ethnic groups and their subgroups with
respect to their cultural values, beliefs, cus-
toms, and mores and how these may affect
programs seeking to improve their health and
well-being. Regardless of the special popula-
tions being treated, we recognize that with
the passage of time, many of these special
populations have produced second or more
generations of native-born children of native-
born parents. In most instances, with or with-
out mixed marriages, they straddle two or
more cultures and face the challenges of living
in both while seeking their own identities and
lifestyle patterns. In addition, the number of
recent and new immigrants coming from a
myriad of countries has brought forth a vari-
ety of old and new health problems that now
must be addressed. These problems and needs
will require health practitioners and students
of Health Promotion and Disease Prevention
(HPDP) to think and act in new ways to effec-
tively address the health care needs of these
special population groups as well as those
groups who are underserved and have been
x
living in the United States going back even
before its very beginning. There are, obviously,
a number of difficulties associated with defin-
ing special population groups that present
some challenges to a book such as ours. These
include a variety of issues such as age, gender,
and generational differences in which adop-
tion of Western health care practices might be
in conflict with more traditional practices
(i.e., folk medicine, shamanism, tribal medi-
cine practices, etc.).
The editors also recognize that special
populations can be defined on the basis of
shared similarities, including chronic or acute
health problems, disabilities, sexual orienta-
tion, and any number of other variables one
might consider when trying to categorize
people. It is not the aim of this book to try
to address all these issues. Rather, we seek to
combine theory, practice, and ethnic consider-
ations that address the broad range of special
population characteristics in the belief that,
through this approach, practitioners and stu-
dents can adapt these to their particular needs
and issues.
We recognize that the book is primarily
focused on populations living in the United
States and on practitioners and students work-
ing with these groups. Thus, making general-
izations from the American experiences and
practices covered in the text to other multi-
cultural populations outside the United States
should be done with caution. That said, we
certainly want to encourage health promotion
Preface
students and professionals working in other
countries (outside the United States) to use the
book because it does contain many methods,
approaches, and take-off points that can be
of value regardless of national differences.
But, again, there must be an awareness of the
differences and limitations as they attempt to
transfer the information and experiences into
their multicultural settings particularly in light
of major system differences—that is, in politi-
cal, economic, ecological, health care, and
sociocultural climates and in the confusing
use of different labels and categories by which
target populations are described.
Lawrence Green, in the Foreword to this
third edition wrote, “promoting health in
multicultural populations must ultimately be
from within the cultures intended to benefit
from the health promotion. Yes, collaboration
between an ethnic minority population and
professional practitioners from the majority
culture can be helpful and productive, but such
collaboration must be in the spirit of participa-
tory research.” Participatory research should
occur in all multicultural settings regardless
of geographical locale. The need for intensive
collaboration between the target group, com-
munity members, and practitioners should be
emphasized from the outset of a program or
intervention. This book, throughout, strongly
encourages collaborative processes that can
better ensure that any programs or interven-
tions ultimately developed must be tailored
to the needs, interests, and concerns of each
specific target group.
In the time period that has elapsed since
the second edition, there have been many
advances and improvements in theory and
practice in health promotion and disease
prevention (HPDP) including passage of the
Patient Protection and Affordable Health Care
Act signed into Public Law on March 23,
2010, with most of its major provisions effec-
tive by 2014. Given all of this, there has been
an increased awareness of the impact of cul-
ture, cultural diversity, cultural competency,
xi
national differences, and health disparities on
practitioners, instructors, and students. This
increased awareness requires timely, relevant,
appropriate, and current information con-
cerning best practices and processes used in
the field when working across multicultural
population groups.
This book has been written for a variety
of practitioners and students representing the
many disciplines involved in the fields of health
promotion and education, public health, nurs-
ing, medicine, psychology, medical anthropol-
ogy, sociology, social work, dentistry, physical
therapy, radiologic technology, and all other
helping professions that are in daily contact
with culturally diverse population groups. It is
our hope that this book will help to facilitate
knowledge and practice activities that result
in systematically designed and culturally sensi-
tive, appropriate, and relevant HPDP activities
and services for all those we serve.
OVERVIEW OF THE BOOK
This book is grounded in the premise that
working within multicultural settings to pro-
mote health and prevent disease requires an
understanding of the basics of program plan-
ning and an in-depth understanding of the
cultural group and locale being targeted. The
awareness of who these people are requires
knowledge of their history and immigration
patterns, cultural values and norms, cosmol-
ogy and religious practices, social and politi-
cal systems, health disparity status, health
beliefs and practices, and other culture-specific
demographic variables that characterize the
population and/or subpopulations of interest.
The structure and format of the third edi-
tion is similar to the second edition in that it
has been written for practitioners in the field
but also with students and instructors in mind.
Thus, objectives at the beginning of each chap-
ter as well as suggested discussion topics and/
or exercises following each chapter have been
maintained. Wherever possible, transitions
xii HEALTH PROMOTION IN MULTICULTURAL POPULATIONS
between chapters has been included to facili-
tate better cross-referencing of material so
that material learned in earlier chapters can
be built on in later chapters as the reader
progresses through the various sections of the
book.
As a classroom text, the authors offer the
following suggestions for how this book can
be used. Some of these guidelines come from
their personal experiences with using the book
in their own public health education classes.
Because the text is a handbook and includes a
number of sections that highlight diverse cul-
tural and ethnic groups, having students read
the entire text may not be the best way to use
this book. Rather, the book should be used as
a sampler where students seek out information
and skills about different cultural groups that
can be used as a basis for classroom discus-
sion and related activities. That is, depending
on the focus of the course, the instructor may
have the class concentrate on the opening
eight foundation chapters and then break
the class into small groups to explore other
sections as a group work assignment. Then,
groups can come together to share their read-
ings, compare and contrast similarities and
differences between the multicultural groups
that were assigned, and then look at how they
might design health education and promotion
interventions for specific problems the instruc-
tor might identify. This provides students with
an opportunity to delve more deeply into their
assigned multicultural group by studying the
pertinent literature in depth on that group
and the HPDP interventions that have been
employed and reported on in the literature.
This can lead to classroom presentations and
or papers that explore their assigned multicul-
tural group in much greater depth than the
book is able to do.
In the course we teach, students are required
to read Part I of the book over several weeks.
Issues are then discussed in class each week
from the readings including the use of sug-
gested “Discussion Questions and Activities”
at the end of each of the chapters. Then, all
members of the class are given an opportu-
nity to select a multicultural group they are
interested in for their individual research
projects. We then focus on health disparities,
cultural assessment and program planning,
implementation, and evaluation using the
chapters in the book as the basis for these dis-
cussions. As the semester progresses, students
are required to prepare short presentations
about their target group, including a histori-
cal overview of the target group, its migration
and immigration to the United States, and its
acculturation and assimilation practices; the
health beliefs and practices relevant to that
target group; suggestions for how to intervene
with a HPDP program(s); and tips that others
in the class could use if they found themselves
working with that population group. Students
are required to target a culture group living
in a specific geographical locale and with
a particular health issue they will focus on.
There are many ways a text such as this one
can be used in the classroom to help develop a
sense of cultural competence and sensitivity as
students prepare to enter their chosen profes-
sional fields, and we encourage instructors to
share their experiences with us as they use the
book in their classrooms. In the second edition
of the book, there were six “Tips” chapters
following each major part of the text. Each of
these tips chapters have now been combined
into a separate, comprehensive chapter bro-
ken down into general and specific tips for
working with multicultural populations that
practitioners and students can review and
incorporate into their HPDP activities. We felt
this would reduce redundancy from the sec-
ond edition and improve usability of the book
for all who read it.
References from the second edition have
been expanded in the process of chapter
updating. Some selected web sites for increas-
ing the student and the practitioner’s knowl-
edge of valuable resources and supplementary
materials will be found throughout the book.
Preface
We also hope these changes will appeal to
health professionals using the book as a hand-
book or reference guide and make it easier for
them to access important information they
may need in their practice settings.
This new edition has been reduced from
29 chapters to 20 chapters. We did this to
enhance readability and utilization by practi-
tioners, classroom instructors, and students.
By doing so, it has allowed us to add six new
chapters to the text. Specifically, two brand
new chapters (Overview and Case Study)
focused on Pacific Islander populations; a
new American Indian Case Study focused on
mental health; two new chapters (Overview
and Case Study) focused on Arab-Americans;
and a new chapter focused on cross-cultural
communication and health literacy. The third
edition then is divided into four parts.
Part I includes eight chapters that seek to
establish a foundation for the parts that follow
and include, define, and discuss (1) culture,
health promotion, and cultural competence;
(2) traditional concepts of health and disease;
(3) ethical issues when working with multi-
cultural population groups; (4) an overview
of current theories and models of behavior
change as they relate to health promotion
with multicultural populations and groups;
(5) an overview of health disparities in multi-
cultural population groups and discussion of
the Patient Protection and Affordable Health
Care Act; (6) a presentation and discussion
of the cultural assessment framework; (7) an
overview of health promotion and educa-
tion planning models, theories, and practice
issues; and (8) a presentation and discussion
of health communication and health literacy
when working with multicultural populations
in the United States.
Part II of the book presents six chapters
focused on specific multicultural population
groups and includes the following: Hispanic/
Latino, African-American, American Indian
and Alaska Native, Asian-American, Pacific
xiii
Islander, and Arab-Americans. Each of these
chapters present an overview devoted to
understanding these special populations from
a variety of perspectives including terms to
define subgroups within the broader popula-
tion, historical and demographic characteris-
tics, immigration patterns, health and disease
issues and concerns, health beliefs and prac-
tices, and considerations when working with
these groups in HPDP.
Part III of the book presents four case stud-
ies reflective of the groups discussed earlier
and which have been included to help empha-
size points made in Parts I and II of the text.
The final section of the book (Part IV) pres-
ents a tips chapter discussed previously and
then concludes with a final chapter discussing
ongoing and future dilemmas and concerns
that will be faced by practitioners and students
working with multicultural populations in a
variety of health care and community settings.
ACKNOWLEDGMENTS
The editors deeply thank all those who helped
in the preparation of this book. We especially
thank our SAGE team of editors, Reid Hester,
Sarita Sarak, and Jane Haenel; and our mar-
keting manager, Nicole Elliott. We also want
to thank Lana Todorovic-Arndt for her dili-
gent copyediting of the entire draft. Finally, we
thank our families for their support, encour-
agement, and patience during the preparation
of this third edition.
PUBLISHER’S ACKNOWLEDGMENTS
SAGE Publications gratefully acknowledges the
contributions of the following reviewers:
Justin Coran, University of Florida
Mary Lou Gutierrez, Walden University
Meghan Moran, San Diego State University
Larry Williams, North Carolina Central University
About the Editors
Robert M. Huff is emeritus professor of
public health education at California State
University, Northridge (CSUN). Prior to
joining the faculty at CSUN, he was a
health education practitioner for the Charles
Drew Postgraduate Medical School in Los
Angeles, where he was actively involved
in community hypertension education,
screening, referral, and follow-up activities
and in the Martin Luther King, Jr., General
Hospital, where he directed patient education
programming in the Department of Internal
Medicine. He later moved to the Ventura
County Health Care Agency–Public Health
Services and the Ventura County Medical
Center, where he established and directed
the Department of Patient Education for
inpatient and outpatient services and was the
health education consultant for the hospital’s
Family Practice Residency Program. He
also organized and managed an agencywide
teleproduction facility; codeveloped and
managed a countywide health promotion
center; and consulted on a variety of public
health programs, including chronic disease
prevention, family life education, and HIV/
AIDS awareness and prevention, where he
was also an HIV alternative test site counselor
for Public Health Services.
He teaches both undergraduate and gradu-
ate courses in public health education in the
areas of program planning and evaluation;
health behavior change; communications and
media; cross-cultural issues in public health;
xiv
holistic health; ethics, human rights and cul-
tural diversity, and other related courses.
He has been an evaluation consultant for a
variety of organizations and projects, includ-
ing the VA Hospital in Sepulveda, California;
the Violence Prevention Project with Ventura
County Public Health Services; an alcohol and
drug project in the student health center at
CSUN; and the Youth Wellness Village Project
funded by the California Wellness Foundation
in Ojai, California. He also was an editorial
consultant and coeditor for the Journal of
Drug Education.
His research interests combine his under-
graduate training in anthropology with his
graduate training in public health education
to focus on multicultural health promotion
and disease prevention programs in a variety
of settings. He has a special interest in medical
anthropology, traditional medicine, shaman-
ism, and complementary and alternative medi-
cine practices. He received his MPH degree
in health education from CSUN and his PhD
in confluent education from the University of
California, Santa Barbara, Graduate School of
Education.
Michael V. Kline is emeritus professor of
public health at California State University,
Northridge. He taught undergraduate and
graduate courses involved with training
students and practitioners to design,
implement, and evaluate health promotion
and education programs within a variety
About the Editors
of health settings, population groups, and
public sector and community organizations.
He directed the Master of Public Health
Program for 12 years. Through the years,
he has been actively involved in community
organization activities relevant to assisting
special populations to plan and organize
health programs in their neighborhoods.
He served in the capacities of editorial
consultant, associate editor, and executive
coeditor of the Journal of Drug Education.
He continues his long association as behav-
ioral sciences consultant with the Research
and Evaluation Section, Planning Division,
Alcohol and Drug Program Administration,
Department of Public Health, County of Los
Angeles. He has worked in several areas: alco-
hol prevention and education consultation,
assistance in the development of data manage-
ment and information systems, alcohol client
tracking activities, and alcohol and drug pro-
gram evaluation systems. He formerly was the
executive director of several alcohol and drug
treatment programs in Los Angeles, including
the Edgemont House social model prototype
program and the Golden State Community
Mental Health Center Comprehensive NIAAA
(National Institute on Alcohol Abuse and
Alcoholism) alcohol treatment program. He
was the director of the Los Angeles County
Alcohol Training Consortium and associ-
ate state director of the California Alcohol
Foundation. He also has been involved in
providing extensive technical consultation and
education in the development and evaluation
of drinking driver programs. He formerly
was the district director of health educa-
tion, Southeast Region, Department of Health
Services, County of Los Angeles. He also
served as the medical care organizer for the
Department of Health Services, Department of
Hospitals, and Department of Mental Health,
County of Los Angeles, in the early develop-
ment of the Hubert Humphrey Health Center
in South Los Angeles.
xv
He was a lecturer in Public Health at
the University of California, Los Angeles
School of Public Health and lecturer in Public
Administration at the University of Southern
California, School of Public Administration.
He also was the director of public health
education at the Orange County (California)
Department of Public Health. He received his
MPH degree in public health education and
behavioral sciences from the University of
California, Berkeley, School of Public Health.
He received his DrPH degree in medical care
organization and health administration from
the University of California, Los Angeles,
School of Public Health.
Darleen V. Peterson is associate professor of
community and global health at Claremont
Graduate University (CGU). She also serves as
the school’s associate dean of academic affairs
and is the founding director of the Master
of Public Health (MPH) Program. Prior to
joining the faculty at CGU, she served as
an assistant professor of Clinical Preventive
Medicine at the University of Southern
California (USC), where she was the assistant
director of the MPH program. She has taught
graduate courses in health behavior theory,
health communications, and supervised field
training in public health. Her research interests
include health communication, specifically
the evaluation of statewide tobacco control
campaigns and the assessment of protobacco
marketing activities on youth smoking. She
currently provides consultation on public
health program accreditation to new and
existing MPH programs. She received an MA
in communications management from USC’s
Annenberg School for Communication, an
MPH in Community Health Education from
California State University, Northridge, and a
PhD in preventive medicine (health behavior
research) from the Keck School of Medicine
of USC. She is a masters-level certified health
education specialist (MCHES).
About the Contributors
Sawssan R. Ahmed, PhD, is an assistant
professor in the Department of Psychology
at California State University, Fullerton.
She received her doctoral degree in
clinical psychology with specializations in
community psychology and quantitative
methods where her work focused on the
relationship between sociocultural factors
(including perceived racism, religiousness,
and ethnic identity) and the physical and
mental health of adolescents of color.
She has completed postdoctoral work in
health disparities and children’s services
research at the University of California, Los
Angeles’ Center for Culture, Trauma, and
Mental Health Disparities and at San Diego
State University where she was the Oscar
Kaplan Fellow in developmental issues. Her
research interests include understanding
the link between sociocultural risk and
protective factors and health disparities in
adolescents of color with specific interests
in Arab-American and refugee youth.
Shayma Alzubi, MPH, received her master’s
degree in urban public health from the
Charles Drew University (CDU) of Medicine
and Science. While pursuing her degree, she
volunteered as an HIV testing counselor with
the CDU HIV Education and Community
Outreach projects on their mobile testing
unit. She also has a BS degree in biochemistry
from the University of California, Riverside.
As a public health professional, she hopes to
work with the Arab-American communities
xvi
to educate, empower, and mobilize them to
improve their well-being.
Lourdes A. Baezconde-Garbanati, PhD,
MPH, is an associate professor in preventive
medicine at the Keck School of Medicine of
USC. She also holds a joint appointment in
sociology from the Dornsife School of Letters,
Arts, and Sciences and a courtesy appointment
at the Annenberg School for Communication
and Journalism. She has devoted her career to
increasing the understanding of the important
role of culture in health behaviors with the
goal of correcting health inequities. She works
with various population groups though the
emphasis is on Hispanic health. She conducts
community-based participatory research in
cancer control in the areas of women’s cancers,
tobacco prevention, and youth empowerment
to eliminate obesity at the community level.
She has received multiple awards from the
National Institutes of Health (NIH) and is a
nationally and internationally known expert
on health disparities.
Patricia Chalela, DrPH, is an assistant
professor at the Institute for Health Promotion
Research at the University of Texas Health
Science Center at San Antonio, Texas. Her
areas of expertise include social and behavioral
sciences, health communications and
promotion, and health disparities research.
Her main research interests are in chronic
disease prevention and control, particularly
the role of epidemiological, environmental
About the Contributors
and individual psychosocial factors on health
and disease, and on racial/ethnic disparities
with emphasis on Latino populations. Her
research studies involve applied research
methods with multidimensional strategies
comprised of theory-driven hypothesis
development and testing, and the design,
implementation, and evaluation of theory-
based interventions to promote healthy
behaviors, improve health outcomes, and
reduce health disparities among underserved
populations.
Michael R. Cousineau, DrPH, is an associate
professor of research in the Department
of Family Medicine and director of the
Center for Community Health Studies at the
University of Southern California (USC), Keck
School of Medicine. His primary research
interests are health policy and health services
evaluation research, access to care for low-
income and uninsured families, governance
and operation of safety-net providers, and
health needs of vulnerable populations
including the homeless.
N. Tess Boley Cruz, PhD, MPH, CHES, is
an assistant professor of clinical preventive
medicine in the Department of Preventive
Medicine and the Institute for Prevention
Research at the University of Southern
California, Keck School of Medicine. She
teaches in academic programs at USC,
conducted evaluations of community-based
programs, and trained health professionals
in materials development for low-income
populations. Her primary research interests
are health disparities, health literacy, public
health communication, tobacco marketing,
and tobacco control.
Diane Viscencio Dobbins, MPH, RN, has
40 years of experience working in public
health and community health nursing. She
has advocated on behalf of maternal child
health programs and populations for the
State of California and the March of Dimes.
xvii
She has been instrumental in the development
of community collaboratives focused on teen
pregnancy, breastfeeding, and family violence
prevention. Her graduate work culminated
in a thesis exploring the cultural competency
of law enforcement agencies in three rural
communities experiencing demographic
changes. She is a lecturer at California State
University, Northridge where she teaches
both undergraduate and graduate MPH
students in cultural competency, community
organization, and current issues in public
health.
C. James Frankish, PhD, is the director of
the Centre for Population Health Promotion
Research and is a professor in health care and
epidemiology (medicine) and the College for
Interdisciplinary Studies at the University of
British Columbia. He has authored numerous
papers on community participation, mental
health and population health, health impact
assessment, and participatory research. His
prior work includes research on regional
health boards and national studies of
measures of health communities, health
goals, and health promotion in primary
care. His current projects focus on health
promotion and homelessness, health literacy,
and poverty and nutrition. He is on the board
of the Lookout Homeless Shelter Society and
is chair of the Impact of the Olympics on
Communities Coalition.
Kipling J. Gallion, MA, is deputy director of
the Institute for Health Promotion Research
(IHPR) at the University of Texas Health
Science Center at San Antonio, Texas, and
is an accomplished health communications
producer and researcher who has vast
experience in program development
and analysis. He has helped to develop
different culturally tailored media strategies,
technologies, and messages to promote
positive health behavior changes, such as
new public health service ads to promote
Latino cancer screenings and new avenues
xviii HEALTH PROMOTION IN MULTICULTURAL POPULATIONS
to spread positive messages, like the social
media realm of Facebook and Twitter. He is
also involved in helping coordinate several
IHPR research projects funded by National
Cancer Institute (NCI), NIH, the Susan G.
Komen for the Cure, and the Robert Wood
Johnson Foundation.
Patti (Rosa Patricia) Herring, RN, MA, PhD,
is an associate professor in the Department
of Health Promotion and Education at Loma
Linda University, Loma Linda, California.
She is a codirector and coinvestigator for the
Adventist Health Study-2 and consults in a
variety of roles, including the San Bernardino
County Head Start Program, The Inter-
American Improvement Association, and
the Moreno Valley Unified School District
grant to serve underserved, minority, and
disadvantaged children’s academic and social
development—a service learning project.
Christopher Elliott Hodge, MA, has worked
in the area of cultural competency in American
Indian populations. His research interests
include childhood trauma, posttraumatic
stress disorder (PTSD) and maladaptive
behaviors in American Indian groups.
Felicia Schanche Hodge, DrPH, is a professor
in the School of Nursing and School of
Public Health at the University of California,
Los Angeles. She has over 30 years of
experience working in American Indian
communities and has developed the Talking
Circle intervention as a data collection
measure as well as a method of delivering
educational interventions. Her work includes
health behavior research in chronic disease
prevention and intervention in the areas
of cancer, diabetes, smoking cessation, and
adverse childhood events.
Joyce W. Hopp, PhD, MPH, CHES, RN, is a
distinguished professor of Health Education
at Loma Linda University, Loma Linda,
California. She has taught in the Department
of Health Promotion and Education in the
School of Public Health since 1968. For 16
years, she served as dean of the School of
Allied Health Professions at the university.
She has served on the editorial board of the
Journal of School Health and as a reviewer
for numerous peer-reviewed journals in the
field of health education. She has received
awards for educating minority young people
and for fostering cultural pluralism through
40 years of international health professions
education.
Sondos M. S. Islam, PhD, MPH, MS, is an
associate professor and director of the Urban
Public Health Program in the College of Science
and Health at Charles R. Drew University of
Medicine and Science. She teaches graduate
courses in program planning and evaluation,
social and behavioral theories in public health,
epidemiology, and biostatistics, and she chairs
numerous MPH theses. Her expertise is in
curriculum development and health program
evaluation, and she is currently a Council on
Education for Public Health (CEPH) certified
site visitor. Her research is focused on the
influence of cultural factors on Arabs’ and
Arab-American health behaviors.
Aimie F. Kachingwe, PT, DPT, EdD, OCS,
F.A.A.O.M.P.T., is an associate professor
in the Department of Physical Therapy at
California State University, Northridge.
She is an American Physical Therapy
Association Board certified clinical specialist
in orthopedics and a fellow of the American
Academy of Orthopaedic Manual Physical
Therapists. Her research interests include the
promotion of ethnic diversity in the profession
of physical therapy and the incorporation of
multiculturalism into health care educational
curriculum.
Marjorie Kagawa-Singer, PhD, MA, MN, RN,
is a professor in the Department of Asian
American Studies at the University of California,
Los Angeles (UCLA) School of Public Health
in Los Angeles, California. Her clinical work
About the Contributors
has been in oncology and on the etiology
and elimination of disparities in physical and
mental health care outcomes for communities
of color, with a primary focus on Asian-
American and Pacific Islander communities.
She serves on multiple local, state, and national
committees addressing the impact of ethnicity
on health care and health outcomes and is
the principal investigator of the Los Angeles
site for the National Cancer Institute–funded
national Asian American Network on Cancer
Awareness Research and Training.
Christine Kho is a second-year medical student
at the David Geffin School of Medicine. She
is president of the UCLA chapter of the
national Asian Pacific American Medical
Student Association. This chapter advocates
for reducing health disparities and improving
health access in Asian Pacific Islander
communities in the Greater Los Angeles area.
She is committed to focusing her medical
career on issues of social justice, especially
as they pertain to the quality of health care
for Asian-American, Native Hawaiian, and
Pacific Islander communities.
Chris Y. Lovato, PhD, is an associate
professor in the Department of Health
Care and Epidemiology at the University of
British Columbia (UBC) where she teaches
program evaluation to graduate students.
She is also director of the Evaluation Studies
Unit for the Faculty of Medicine at UBC. Her
primary areas of expertise are population
health and program evaluation. Much of
Dr. Lovato’s research has focused on youth
tobacco control including the evaluation of
smoking cessation interventions. She has
extensive experience in program evaluation
and has provided consultation to numerous
government and nongovernment agencies
evaluating health-related programs.
Omar M. Mahmood, PhD, is a clinical
psychologist specializing in neuropsychological
assessment of children and adults. He has
xix
extensive experience conducting cognitive
evaluations bilingually (English and Arabic)
with patient populations in the United States
and throughout the Middle East. He is also a
research scientist at the University of California,
San Diego, and the VA San Diego Healthcare
System.
Alfred L. McAlister, PhD, is a professor at
the University of Texas, Houston School of
Public Health. He was the lead member of the
research teams of the Stanford 3-Community
Study in California and the North Karelia
Project in Finland. He has been involved in the
Centers for Disease Control and Prevention
(CDC) AIDS Community Demonstration
Projects, led several international research
studies in Europe and Latin America, and
participated in teaching and research in a
variety of countries in Europe and Central
and South America.
Janelle F. Palacios, PhD, CNM, RN, is a
faculty researcher at the Native American
Research and Training Center in the
Department of Family and Community
Medicine at the College of Medicine at the
University of Arizona. She is a postdoctoral
fellow in the School of Nursing at the
University of California, Los Angeles, and
is a practicing certified nurse midwife in
Northern California. With over 11 years
of experience working collaboratively with
American Indian Communities, she has
focused on the use of storytelling to elicit
young parenting experiences. Her research
interests include maternal/child health,
parenting, adverse childhood experiences,
reproductive health, substance abuse, and
mental health.
Paula Healani Palmer, PhD, is associate
professor and director of Global Programs
at the Claremont Graduate University
School of Community and Global Health.
Her research focuses on the reduction of
health disparities among ethnically diverse
xx HEALTH PROMOTION IN MULTICULTURAL POPULATIONS
and underrepresented population in the
United States and abroad. Recent research
projects funded through the National
Institutes of Health include community-
based participatory research (CBPR) study
that investigates how culture, social, and
environmental cues, and neurocognitive
characteristics impact cigarette smoking and
quitting among Pacific Islanders and a study
of mental health outcomes among China’s
internal migrants. Other funded projects
include a CBPR project that studies the
influences impacting smoked and smokeless
tobacco use among immigrant Pakistanis,
Indians, Nepalis, and Sri Lankans as well as
a longitudinal study on mental health and
social readjustment of tsunami victims in
India and Sri Lanka. She has developed and
teaches graduate courses on global health,
disaster management, maternal and child
health, ethics and culture, and leadership and
management of global health organizations.
She and her team utilize various types of
technology to facilitate both virtual global
learning environments and innovative
methods of health promotion interventions.
Iraj Poureslami, PhD, is a senior research
associate at the Human Early Learning
Partnership and Centre for Population
Health Promotion Research at the University
of British Columbia. He is a WHO EMRO
(World Health Organization Regional Office
for the Eastern Mediterranean) mentor of
health promotion, WHO Early Childhood
Development Knowledge Network consult-
ant, and member of the Canadian Council
on Learning’s health literacy expert panel.
His research interests are in the sociocultural
determinants of health and quality of life
within ethnocultural communities in Canada.
He has extensive knowledge and expertise on
developing community-based health literacy
information, audio-visual materials, and
working with newcomer communities and
their families in British Columbia.
Amelie G. Ramirez, MPH, DrPH, is a
professor of epidemiology and biostatistics at
the University of Texas Health Science Center
at San Antonio, where she is also a founding
director of the Institute for Health Promotion
Research. Over the past 30 years, she has
directed many research programs focused on
human and organizational communication
to reduce chronic disease and cancer health
disparities affecting Latinos. She directs two
national research networks, one funded by
the National Cancer Institute and one funded
by the Robert Wood Johnson Foundation.
She has been recognized for her work to
improve Latino health and advance Latinos
in medicine, public health, and behavioral
sciences and was the 2011 White House
Champion of Change. She has served on
many boards and advisory committees both
nationally and locally in her community
including the Institute of Medicine of the
National Academies and the Susan G. Komen
for the Cure Scientific Advisory Board.
Gregory D. Stevens, PhD, is an assistant
professor of research in the Department of
Family Medicine and Center for Community
Health Studies at the University of Southern
California, Keck School of Medicine. His
research has focused on primary health
care quality for vulnerable children, racial/
ethnic and socioeconomic disparities in care,
and patient-provider relationship issues
involved in the delivery of well-child care
and developmental services.
Ian M. Thompson Jr., MD, is an
internationally renowned expert in prostate,
bladder, kidney, and testicular cancer. He
received his undergraduate degree from
West Point and his MD degree from Tulane
University. He retired as a colonel from
the U.S. Army, having served as chairman
of the Department of Surgery at Brooke
Army Medical Center as well as commander
of the 41st Combat Support Hospital. He
About the Contributors
served in Saudi Arabia and Iraq as a general
surgeon in a combat support hospital during
Operation Desert Storm/Shield. He is the
current director of the Cancer Therapy &
Research Center at the University of Texas
Health Science Center at San Antonio that
is the only NCI-designated cancer center in
South Texas. He is known as an international
groundbreaker in the advancement of care
and treatment for prostate cancer through his
clinical trial experience and multiple large-
scale cancer research studies.
Christina Vane, MPH, completed her master’s
at the University of Southern California with
an emphasis in child and family health.
She is currently a project manager in the
Department of Family Medicine at the Keck
xxi
School of Medicine at USC, focused on
primary care and diabetes, and she has
worked in health policy specifically focused
on implementing health care reform in
California. Her primary research interests
lie in uninsured, underinsured, and
undocumented populations.
Soheila Yasharpour, MPH, is project
coordinator of the Infoshare Project at the
David Geffen School of Medicine at the
University of California, Los Angeles. She has
been involved in a variety of health education
projects addressing the needs of underserved
communities and is currently working on a
project focusing on information technology
and bioinformatics in local hospitals and
clinics in Los Angeles.
PART I

Foundations
1. Culture, Health Promotion, and Cultural Competence 3

2. Cross-Cultural Concepts of Health and Disease 24

3. The Ethics of Health Promotion Intervention in Culturally Diverse Populations 43

4. Models, Theories, and Principles of Health Promotion and Their Use

With Multicultural Populations 64

5. Health Disparities in Multicultural Populations: An Overview 101

6. The Cultural Assessment Framework 127

7. Planning Health Promotion and Disease Prevention Programs

in Multicultural Populations 150

8. Cross-Cultural Communication and Health Literacy in Multicultural Populations 181

1
Culture, Health Promotion, and Cultural
Competence
R O B E R T M . H U F F, M I C H A E L V. K L I N E ,
A N D D A R L E E N V. P E T E R S O N

Chapter Objectives
On completion of this chapter, the health promotion student and practitioner will
be able to
• Define and discuss the concepts of health education, health promotion, and disease
prevention as these relate to working with multicultural population groups
• Define and discuss at least five common terms associated with working with
diverse population groups, including the terms culture, ethnicity, acculturation
and assimilation, ethnocentrism, and cultural competence
• Identify and discuss at least five potential barriers to multicultural health
promotion and disease prevention activities designed for diverse cultural groups

A ctivities for promoting health and pre-

venting disease in any population,
whether directed at individuals, groups, or
communities, are a formidable task. Such
endeavors require an organized effort charac-
terized by an understanding that culture and
cultural forces, among other social forces,
are powerful determinants of health-related
behaviors. Culture, in any group or subpopu-
lation, can exist as a total or partial system of
interrelationships of human behavior guided
and influenced by the organization and the
products of that behavior. Indeed, the beliefs,
ideologies, knowledge, institutions, religion,

3
4 FOUNDATIONS
and governance, as well as nearly all activi-
ties (including efforts to achieve health-related
behavior change), are affected by the forces of
culture.
Culture is a dynamic, fluid, ever-changing,
and complex force in the lives of individu-
als, groups, and communities. And it is this
complexity that has made it difficult to for-
mulate a universally accepted definition of cul-
ture. Kreuter, Lukwago, Bucholtz, Clark, and
Sanders-Thompson (2003) note that no single
definition of culture is universally accepted.
But there is “general agreement that culture
is learned, shared, and transmitted from one
generation to the next, and it can be seen in
a group’s values, norms, practices, systems
of meaning, ways of life, and other social
regularities” (p. 133). The definition of culture
will be dealt with in greater depth later in the
chapter. It is also important, where possible, to
be aware that ethnic and cultural factors may
be connected with a target group’s vulnerabil-
ity to certain communicable and chronic dis-
eases and other health-related problems. Such
knowledge can provide the planner with many
clues during the assessment process. Students
and practitioners should be aware that many
of a target group’s health risk factors are ame-
nable to behavior change, thus reducing risk.
Efforts to promote health and prevent disease
within culturally different ethnic subgroups,
as in any target group, will entail influencing
the health behavior of individuals, families,
groups, or communities. This will require
identifying and changing those factors that
are associated with accomplishing the desired
health-related behavior. Also, these efforts
probably will require some type of sustained
collaboration between the public, private, and
voluntary sectors and the people most directly
affected by a defined health concern or prob-
lem. Cultural considerations ultimately may
determine whether a particular population
or target group will choose to participate
in health promotion and disease prevention
(HPDP) programs. There will be the need for
a continuing communication between these
stakeholders that establishes and maintains
working relationships characterized by mutual
understanding, trust, and respect (see Hodge,
Hodge, & Palacios, Chapter 16, this volume,
for a discussion reflecting this process).
There are many settings in the community
where activities are conducted for promoting
health and preventing disease in a population.
These include a myriad of work sites, schools,
health care program sites, and the commu-
nity itself. Comprehensive health promotion
activities at a work site consisting of a large,
culturally diverse employee population may, for
example, carry out employee-risk assessments
(including screenings and appraisals) as well as
establish and maintain an appropriate variety
of educational programs, services, and activities
to reduce or eliminate identified areas of health
risk. In this setting, a work site must carry out
culturally sensitive and effective interventions
that meet the needs of their employees. This
sensitivity must be carried over in the group
as well as in one-to-one counseling or educa-
tional encounters. Awareness and sensitivity to
cultural diversity, then, must be reflected in the
planning, design, implementation, and evalua-
tion phases of such a complex undertaking.
This chapter will distinguish between the
concepts of health promotion and health
education and briefly examine the implica-
tions and impact of culture at these two
overlapping levels. We will also provide an
overview of culture, particularly as cultural
differences affect HPDP efforts, and discuss
current paradigms that have been proposed
to improve practitioner skills in working in
multicultural health care settings. Finally, we
will describe potential barriers to effective
multicultural HPDP efforts.
HEALTH PROMOTION AND
DISEASE PREVENTION
The terms health promotion and disease pre-
vention, when used in this text, encompass
Culture, Health Promotion, and Cultural Competence
a similar range of interests and concerns as
expressed long ago in the Joint Committee on
Health Education Terminology (1991) report.
The committee defined HPDP as “the aggregate
of all purposeful activities designed to improve
personal and public health through a combi-
nation of strategies, including the competent
implementation of behavior change strategies,
health education, health protection measures,
risk factor detection, health enhancement, and
health maintenance” (p. 102). Central to this
conceptualization, it should be noted, is the
need to achieve different levels of outcomes
(e.g., individual, family, group, organization,
community) through a combination of health
promotion and health education strategies and
intervention activities.
Another ageless definition of health promo-
tion is “any planned combination of educa-
tional, political, regulatory, and organizational
supports for actions and conditions of living
conducive to the health of individuals, groups,
or communities” (Green & Kreuter, 1991,
p. 432). Explicit in this definition is the need
for interventions that respond to a broad level
of community concern relating to stimulating,
establishing, and sustaining an appropriate
combination of educational, organizational,
and political support needed to facilitate
actions aimed at achieving desired community
health outcomes. These definitions of health
promotion provided above serve the pur-
pose of this text well because they are valid
in today’s context; they are succinct, readily
understandable, multidimensional; and they
focus on the reality and need for several dif-
ferent levels of specific and needed program
activities and outcomes (e.g., individual, fam-
ily, group, organization, community) in HPDP
program planning.
Health education has been defined as “any
planned combination of learning experiences
designed to predispose, enable, and reinforce
voluntary behavior conductive to heath in
individuals, groups, or communities” (Green
& Kreuter, 1991, p. 432). Intervention efforts
5
from this particular vantage point concentrate
on facilitating the voluntary acquisition of
specific health-related knowledge, attitudes,
and practices associated with achieving spe-
cific health-related behavior changes. Health
education is mentioned here because health
promotion emerged out of health education
and designates a broader level of outcome
than does health education. However, health
education is considered a primary instru-
mentality for achieving health promotion
outcomes. For example, the focus of health
education interventions in a cervical cancer
education and screening program targeting
African-American women living in a specific
geographical area may be concerned with
making educational programs more available
and accessible to this group. Such programs
can enable the target group to develop skills
for carrying out defined voluntary screening
behaviors related to reducing the risk of this
life-threatening disease. However, the plan-
ning of interventions and related activities
at this level, then, usually focus on reaching
only one target group among the many pos-
sible groups of women at risk and in need
of specified educational programs. On the
other hand, the planning of strategies and
interventions at the health promotion level
goes beyond a single cervical cancer education
program focus. For example, interventions
may focus on the need to establish and sustain
a more accessible and equitably distributed
system of women’s health screening and edu-
cation programs for enhancing the overall
health of all poor and underserved women in
that particular community. The complexity of
health promotion program efforts requires a
greater scope of coordination, participation,
commitment, and expense than does the cer-
vical cancer education and screening aimed
at a single target group. Indeed, many com-
munity participants representing a diversity
of public, private, and voluntary agencies,
organizations, and institutions will need to be
involved in this endeavor.
6 FOUNDATIONS
Health promotion efforts also may be
conducted at a broader community level and
may seek health and health-related behavior
changes or social outcomes through ecologi-
cal or environmental approaches intended to
result in permanent structural changes or sup-
ports in the form of policies, regulations, and
expanded access to resources affecting people
where they work and live (Green & Kreuter,
1991, 2005; Green, Richard, & Potvin, 1996;
McLeroy, Bibeau, Steckler, & Glanz, 1988;
Richard, Potvin, Kischuk, Prlic, & Green,
1996).
It is seen, then, at one level, health educa-
tion programs, for example, might concen-
trate on facilitating the voluntary acquisition
of specific health-related knowledge, atti-
tudes, and practices for reducing the specific
target group’s health risk for certain chronic
or communicable diseases. It is important
to recognize that interventions designed to
achieve change on only the individual level
will not be as effective as those that can
achieve broader change on the community
level. Thus, program efforts at other levels
(i.e., the health promotion level) may seek
social or environmental changes (supportive
structures) for reducing population health
risk. These changes are in the form of new
risk-reducing policies, laws, and regulations
and new or increased organizational or
structural arrangements that encourage,
enable, and reinforce the acquisition and
practice of certain health-related behaviors
(Green & Kreuter, 1991, 2005).
HPDP programs, through their assess-
ment and diagnosis processes of community
needs (discussed in Chapters 6 and 7 of this
volume), must be able to identify at-risk
target groups in the community and specifi-
cally the kinds of disease prevention efforts
(by particular target group) that need to be
included in their health promotion activities.
The following identifies the specific focus and
types of activities generally conducted under
the different levels of disease prevention:
(1) the primary prevention level (providing
specific protection that prevents the onset
of the disease itself or reduces exposure
or risk levels to the disease processes, e.g.,
immunizations against a variety of child-
hood diseases, disease screening, smoking
prevention and cessation programs, HIV/
AIDS education and screening programs);
(2) the secondary prevention level (provid-
ing activities related to early diagnosis and
prompt treatment of a disease that is already
present, (e.g., syphilis, HIV/AIDS, gonorrhea,
diabetes, cervical cancer); and (3) the tertiary
level of prevention (activities implemented
through treatment and rehabilitation efforts
to minimize disability after the damage has
been done from existing illness (e.g., alcohol-
ism, diabetes, cirrhosis of the liver, chronic
obstructive pulmonary disorder, emphysema,
high blood pressure) (Turnock, 2001).
Finally, the focus of all HPDP efforts must
of necessity include an awareness and sensitiv-
ity to culture and the many cultural differences
reflected in the population to be targeted. And
within their own cultural milieu, all plan-
ning participants (e.g., planners and com-
munity participants) need to recognize that
any HPDP interventions contemplated must
consider the personal experiences, knowl-
edge, health practices, and problem-solving
methodologies that are acceptable within the
framework of the individual, group, or com-
munity to be targeted.
HEALTH PROMOTION AND CULTURE
Promoting health and preventing disease is a
challenging goal that, to many, might seem
straightforward, logical, and highly scientific.
After all, we know about germ theory, diseases
of lifestyle, medications, radiation, surgery,
and other Western approaches to preventing
and/or diagnosing and treating health prob-
lems in the general population. However, this
process is not always what it seems. Indeed,
there are many different ways of perceiving,
Culture, Health Promotion, and Cultural Competence
understanding, and approaching health and
disease processes across cultural and ethnic
groups with which health practitioners need
to become better acquainted.
Cultural differences can and do present
major barriers to effective health care inter-
vention. This is especially true when health
practitioners overlook, misinterpret, stereo-
type, or otherwise mishandle their encounters
with those who might be viewed as different
from them in their assessment, intervention,
and evaluation-planning processes.
There is not a day that goes by that we are
not exposed to a variety of sights, sounds,
and tastes reflecting influences coming at us
from a multitude of sources including the
news media, our work settings and contacts
in the community, and the foods we choose
to eat. From these, we form opinions, make
judgments, and take actions perceived to be
appropriate to the situation and setting in
which we find ourselves. When these choices
involve our efforts to improve the health
of the many “publics” we encounter in our
health care roles, our perceptions of how
these publics relate to and respond to our
efforts may be colored by our own ethnocen-
tric views of the world. In turn, our publics
may view us in a similar manner. That is,
whereas we might view a client as delusional
if the individual comes to us for help and tells
us he or she has been seeing a traditional folk
healer because they believe someone has put
a “hex” on him or her, that client might view
us as ignorant and inexperienced when we
offer him or her counseling and medication
as the treatment for the problem. In both
cases, cultural beliefs and practices born out
of years of enculturation and socialization
in divergent worldviews have gotten in the
way of the communication and treatment
possibilities.
Brislin and Yoshida (1994) note that health
care professionals’ lack of knowledge about
health beliefs and practices of culturally
diverse groups and problems in intercultural
7
communication has lead to significant chal-
lenges in the provision of health care services
to multicultural population groups. They
also observed that the cultural diversity of
the health care workforce itself could present
problems that can disrupt the provision of
services because of competing cultural values,
beliefs, norms, and health practices in conflict
with the traditional Western medical model.
For example, Putsch (1985) describes a situa-
tion in which an elderly Navaho patient with
a mild senile dementia has returned for an
outpatient visit after several long hospital-
izations. He greets his physician in Navaho,
shakes hands, and embraces him. He then
turns to greet the nurse’s aide, who will act
as an interpreter, and extends his hand to her.
She flees from the room visibly frightened.
When later questioned about her behavior,
she relates that she had been warned by her
mother never to shake hands with gray-haired
people because they might “witch you.” She
also noted that she knew about this man
through her husband’s family and that he was
“no good” (p. 3346). In exploring cultural
differences in more detail, a discussion of
what we mean by culture, ethnicity, accultura-
tion, and other related terms will help set the
scene for how these may affect our ability to
assess, plan, implement, and evaluate HPDP
programs for a variety of multicultural popu-
lation groups.
CULTURE
The term culture has been defined in many
ways over the years and continues to be a
concept that is hotly debated among anthro-
pologists even today. In 1871, E. B. Tylor
defined culture as “that complex whole which
includes knowledge, belief, art, morals, law,
custom and any other capabilities and habits
acquired by man as a member of society”
(quoted in Bock, 1969, p. 17). Stein and Rowe
(1989) define culture as “learned, nonrandom,
systematic behavior that is transmitted from
8 FOUNDATIONS
person to person and from generation to
generation” (p. 4). Kagawa-Singer and Chung
(1994) describe culture as “a tool which
defines reality for its members” (p. 198) and
note that within this perception of reality, the
individual’s purpose in life emerges through
a process of socialization in which he or she
learns the appropriate beliefs, values, and
behaviors shared by society. Thus, culture is
seen as both integrative and functional in that
the beliefs and values transmitted to the indi-
vidual provide a sense of identity as well as the
rules the individual must follow to enable his
or her culture to survive over time (Kagawa-
Singer & Kho, Chapter 12, this volume; Tseng
& Streltzer, 2008). Kagawa-Singer (2012)
also notes that it is unclear what the actual
contribution of culture is to health outcomes
and that “culture is rarely defined or appro-
priately measured” (p. 356). She suggests
that, for researchers working with diverse
population groups, better operationalizing
what they mean by the term will lead to more
scientifically relevant and better results for the
communities they are studying.
Slonim (1991) identifies five basic crite-
ria for defining a culture: having a common
pattern of communication, sound system, or
language unique to the group; similarities in
dietary preferences and preparation methods;
common patterns of dress; predictable rela-
tionship and socialization patterns between
members of the culture; and a common set
of shared values and beliefs. No matter how
it may be defined, culture can be seen as a
dynamic template or framework a society uses
to view, understand, behave, and pass on its
culture to each succeeding generation. Culture
helps specify what behaviors are acceptable in
any given society, when they are acceptable,
and what is not acceptable. It also provides
some guidance for dealing with the basic
problems of life (Rani, 2007). Anderson and
Fenichel (1989) caution, however, that this
cultural framework is only a set of tendencies
or possibilities for behavior, and individuals
within any given society are essentially free
to choose from all the available possibilities
within this frame.
What do the above issues have to do with
HPDP? Consider, if you will, what possible
barriers one might encounter if he or she
were designing a health program for a com-
munity primarily composed of first-generation
Hmong who were recent immigrants to the
United States. Certainly, language could be a
problem, but so too could the many cultural
differences at nearly every level, from the basic
nuances of communication to the significant
differences in their worldview of what con-
stitutes health and disease, from cause and
prevention to treatment and cure. In fact,
the Hmong health belief system is primarily
based on the supernatural, and much of their
traditional treatment is based on spiritual
appeasement (Brainard & Zaharlick, 1989;
Fadiman, 1997; Kalantari, 2012). A failure
to understand and appreciate these “differ-
ences” would have serious implications for
the success of any HPDP effort. Even with this
caveat, we must also recognize that culture
groups are fluid, dynamic, and change over
time in response to the environments they
exist in. Thus, first generation peoples will
differ from second, and second from third and
so forth. This makes it imperative that health
promoters/health care practitioners carefully
assess before designing interventions or treat-
ments in order to ensure that what they do is
effective, relevant, and appropriate to those
they are working with.
ETHNICITY
Ethnicity relates to the sense of identity an
individual has based on common ancestry,
national, religious, tribal, linguistic, or cul-
tural origins. It generally implies that there are
shared values, lifestyles, beliefs, and norms
among those claiming affiliation to a specific
ethnic group (Henderson, Spigner-Littles, &
Milhouse, 2006; Nunnally & Moy, 1989;
Culture, Health Promotion, and Cultural Competence
Office of Minority Health, 2001; Paniagua,
1994; Spector, 2013). Ethnic identity provides
a sense of social belonging and loyalty for
the individual and often is used by others
outside the ethnic group to identify or label
“difference” (Kagawa-Singer & Chung, 1994;
Kagawa-Singer & Kho, Chapter 12, this vol-
ume). Unfortunately, ethnicity also is used to
stereotype diversity in human populations and
frequently leads to misunderstanding and/or
distrust in all sorts of human interactions. In
fact, the use of an ethnic label by someone
outside the ethnic group may lead to a partial
or complete shutdown of the learning curve
for both parties in this process. For example, it
can be seen that once the stereotype has been
identified, one or both parties often cease to
look beyond the stereotype to find out who
each really is.
Slonim (1991) distinguishes between cul-
ture and ethnicity but notes that they tend
to overlap with respect to how they are
defined and used. She notes that culture
is concerned with symbolic generalities and
universals about social and family groups,
whereas ethnicity is concerned with one’s
sense of identification and belonging to a spe-
cific reference group within any given society.
Ethnicity, then, helps shape the way we think,
relate, feel, and behave within and outside
our reference group and defines the patterns
of behavior that provide an individual with a
sense of belonging and continuity with his or
her ethnic group over time.
Ethnicity is a word that often is used in
the same breath as the term race. It is impor-
tant, however, not to confuse ethnicity with
race, the latter of which is a biological term
used to describe ethnic groups on the basis of
physical characteristics such as skin color or
shape of the eyes, nose, and mouth (Helman,
2007; Montague, 1964; Rani, 2007; Tseng &
Streltzer, 2008). Nelson and Jurmain (1988)
note that race is an ancient concept that in
more recent times has been used by scientists
to place human populations into “racial”
9
categories for purposes of classification. This
form of classification, although convenient,
ignores the issue of genetics, which is con-
cerned with heredity and biological variation
in all living things. Nelson and Jurmain regard
the term race as a sociocultural concept rather
than a biological one. Thus, people often are
classified along racial lines regardless of their
genetic traits, and these racial categories have
long been used as a basis for promoting dis-
crimination, hatred, and divisiveness among
human groups all around the world. Disreali
(1849) commented that “The difference of
race is one of the reasons why I fear war may
always exist; because race implies difference,
difference implies superiority, and superior-
ity leads to predominance” (The Quotations
Page, 2013). In this book, the term race is
not used to describe the various multicultural
groups discussed. The exceptions are where
contributors are reporting epidemiological
data presented by federal, state, or local health
agencies that gather and report health statis-
tics using race as a variable. The editors prefer
the terms ethnic, multicultural, and culturally
diverse. They believe that these terms reflect a
more accurate description of human popula-
tions. For the health practitioner, reframing
the term race to multicultural, ethnic, or cul-
turally diverse may serve to promote a greater
sensitivity to the challenges, potentialities,
and rewards of working with diverse cultural
groups in HPDP activities.
ACCULTURATION AND ASSIMILATION
Acculturation is a term used to describe the
degree to which an individual from one cul-
ture has given up the traits of that culture and
adopted the traits of the dominant culture
in which he or she now resides (Celenk &
Van de Vijver, 2011; LaFromboise, Albright,
& Harris, 2010; Lazarevic, Pleck, & Wiley,
2012; Wallace, Pomery, Latimer, Martinez,
& Salovey, 2009). Locke (1992) identifies
four levels of acculturation: the “bicultural”
10
individual, who can function equally well in
his or her own culture and the dominant cul-
ture; the “traditional” individual, who holds
on to most, if not all, of his or her traits from
his culture of origin; the “marginal” indi-
vidual, who seems not to have any real contact
with traits from either culture; and the “accul-
turated” individual, who has given up most
of his or her traits of origin for those of the
dominant culture. Locke notes the importance
of assessing the degree of acculturation when
working in a multicultural setting, as there is
a natural tendency on the part of many cultur-
ally diverse individuals to resist acculturation.
This resistance can lead to significant mis-
understandings and the inability to establish
meaningful and mutually beneficial working
relationships between the health care practi-
tioner and those he or she may be seeking to
help or influence. An example might be the
practitioner who encounters a Latina mother
with a newborn who feels that the child is ill
because of the mal de ojo (evil eye), that is, the
belief that a sudden change in the emotional
or physical health of an infant or young child
is caused by the jealousy (or admiration) of a
person with powerful eyes (de Paula, Lagana,
& Gonzales-Ramirez, 1996). A failure to rec-
ognize the significance of this problem for the
patient, and the prescribing of a treatment that
seems out of order in the mind of the mother,
might result in her not following through or
even engaging in an active way in the clinical
encounter.
Enculturation is a similar process as accul-
turation yet is also different. While accul-
turation is concerned with taking on the
traits of a new culture one has moved into,
enculturation has to do with learning and
practicing the culture one is born into. That
is, the language, behaviors, food practices,
religion, dress, social and gender roles, and
other values, beliefs, and mores of the fam-
ily and society in which they are reared. Of
importance here also, is that a child undergo-
ing enculturation within his or her family will
FOUNDATIONS
also be undergoing acculturative forces from
outside the family. This can, and often does,
lead to a culture clash between the child and
his or her parents and other relatives.
Assimilation is a closely related process to
acculturation and is viewed as the social, eco-
nomic, and political integration of a cultural
group into a mainstream society to which
it may have emigrated or otherwise been
drawn (Casas & Casas, 1994). Generally, for
assimilation to occur, there must be at least
some minimal acculturation with respect to
the language, values, laws, customs, and other
major features of the dominant society. As
Locke (1992) notes, however, there may be
a genuine resistance and rejection of many
of the values of the dominant culture with
only a minimal level of cultural assimilation
into mainstream society. Like acculturation,
then, the level of an ethnically diverse client’s
assimilation into mainstream society might
need to be assessed by the health practitioner
to better understand and perhaps predict how
well that person will accept and/or participate
in HPDP recommendations and behaviors.
One has only to pay a visit to areas of his or
her city where recent immigrants have settled
or where there is a long-established but insular
population characterized by the maintenance
of the culture-of-origin behaviors, including
language, customs, food practices, and other
social conventions that keeps its members iso-
lated from mainstream society.
ASSESSMENT OF ACCULTURATION
The measurement of acculturation levels in
the clinical setting has been the focus of a
number of investigators studying a diversity
of multicultural groups (Celenk & Van de
Vijver, 2011; Cuellar, Harris, & Jasso, 1980;
Hoffman, Dana, & Bolton, 1985; Lazarevic
et al., 2012; Mendoza, 1989; Milliones, 1980;
M. Ramirez, 1984; Smither & Rodriguez-
Giegling, 1982; Suinn, Rickard-Figueroa, Lew,
& Vigil, 1987). Paniagua (1994) comments
Culture, Health Promotion, and Cultural Competence
on the variety of acculturation scales that can
be used, depending on the ethnic group in
which one is interested, and describes the Brief
Acculturation Scale suggested by Burnam,
Hough, Karno, Escobar, and Telles (1987).
This scale uses three variables: generation in
the United States, preferred language, and
preferences for whom the individual most
often socializes with. The assumptions under-
lying these variables hold that (a) the longer
the individual is exposed to the dominant
culture or the younger the individual is at the
time he or she enters this culture, the more
the individual communicates in the language
of the dominant culture and (b) the more the
individual socializes outside his or her primary
cultural group, the more acculturated the indi-
vidual is likely to become within the dominant
society.
In general, assessment of acculturation has
been used in clinical research settings rather
than in HPDP programs, but this has been
changing in recent years as researchers and
interventionists look more closely at the effects
of acculturation on other variables influencing
HPDP activities (Abraido-Lanza, Armbrister,
Florez, & Aguirre, 2006; Clark & Hofsess,
1998; Dolhun, Munoz, & Grumbach, 2003;
LaFromboise et al., 2010; Rojas-Guyler,
Ellis, & Sanders, 2005; Wallace et al., 2010).
Incorporating assessment of acculturation in
the formative stages of HPDP program plan-
ning could prove quite valuable to the practi-
tioner. For example, A. G. Ramirez, Cousins,
Santos, and Supic (1986) devised and tested a
four-item Media Acculturation Scale (MAS)
for use with Mexican Americans that focused
on media and language preferences and were
able to demonstrate that the instrument could
identify subsets of their study group by their
distinct media usage patterns and demographic
characteristics. The ability to identify specific
target group media preferences and sources is
a much more efficacious way to reach one’s
audience than guessing at them and expending
resources that might have little payoff. Marin
11
and Gamba (1996) developed and validated a
Bidimensional Acculturation Scale (BAS) for
use with Hispanics that they note works very
well with Mexican Americans and Central
Americans. They argue that acculturation is
bidirectional in that as the individual is learn-
ing and taking on characteristics of the new
culture (acculturation), the individual is simul-
taneously doing the same within his or her
culture of origin (enculturation). Marin and
Gamba note that understanding this process
can help the practitioner be more aware of
what Hispanics go through as they accultur-
ate. It also would seem that the practitioner
who is aware of where his or her target group
is with respect to acculturation might be bet-
ter able to tailor interventions that integrate
health-promoting strategies into the learning
that is occurring in both the culture of origin
and the new culture as that acculturation pro-
cess proceeds.
Although acculturation scales have been
primarily used in research and clinical settings,
what seems clear is that these scales have the
potential to be included within needs assess-
ment instruments used in the early stages of
program plan development. For example,
Castro, Cota, and Vega (1999) present a
scale that they have found quite useful in a
variety of settings working with Hispanics
in health-promoting efforts. Thus, the use of
acculturation scales for HPDP activities repre-
sents a relatively new and innovative tool the
practitioner can employ to better understand
the culturally diverse population groups with
which he or she may be working.
ETHNOCENTRISM
Ethnocentrism is a concept that often plays
a part in confusing an already difficult situ-
ation when working with ethnically diverse
individuals or cultural groups. Ferguson and
Browne (1991) describe ethnocentrism as the
assumption an individual makes that his or
her way of believing and behaving is the
12
most preferable and correct one. She notes
that often the health practitioner is unaware
of his or her own ethnocentric behavior and
that this can lead to dysfunctional treatment
encounters. Leddy (2003) terms this behavior
medicocentrism, that is, “the bias produced by
viewing health through the lens of medicine
as it is currently found in modern society”
(p. 100). Rani (2007) notes that cultural bias
in combination with ethnocentrism can lead
us to not being able to see alternative view-
points. For example, the practitioner/health
promoter may directly or indirectly discount
or ignore the client’s cultural orientation and
belief system, considering them unimport-
ant, incorrect, or in conflict with their own
perceptions or worldview of how best to treat
the clients health problem or issue. This can
leave the client feeling angry, frustrated, and
uncooperative. Of equal importance is the
awareness that whereas health care practi-
tioners/health promoters may be caught in
their own ethnocentric dance, so too may be
the culturally diverse client they are serving.
That is, the culturally diverse client may view
the health professional as foreign, ignorant
of illness or disease causality, or uneducated
to proper social customs, forms of address,
and nonverbal behaviors deemed appropriate
by the client for dealing directly or indirectly
with his or her health problem or concern.
For example, Kramer (1992) notes that Native
American elders find such behaviors as getting
right down to business; speaking to strang-
ers in loud, confident tones; and frequently
interrupting the speaker as intolerably rude.
This, in turn, may lead to the withholding of
important information the health professional
needs for an accurate assessment and interven-
tion plan.
One can argue, then, that there is a need for
both the health professional/health promoter
and the culturally diverse client to develop a
modicum of cultural sensitivity and cultural
competence with respect to each other’s val-
ues, beliefs, and health practices. This would
FOUNDATIONS
be a major step forward in achieving a more
balanced and respectful partnership in any
health-related encounter.
CULTURAL COMPETENCE AND
ETHNOSENSITIVITY
There is a large body of literature emerg-
ing from the social, behavioral, and health
sciences promoting a philosophy of cross-
cultural competence to which all persons
working with multicultural groups should
subscribe. Cross, Bazron, Dennis, and Isaacs
(1989), examining how health care agencies
serve culturally diverse clients, view the pro-
cess of cultural competence among these agen-
cies on a continuum ranging from “culturally
destructive” to “culturally competent.” On
this continuum, agencies that provide health
care services may be seen as moving through a
number of phases as they become increasingly
more aware of how it is that they serve cultur-
ally diverse groups. Agencies that do not con-
sider that culture is an important factor when
delivering services can be seen as “culture
blind,” whereas agencies that accept, respect,
and work with cultural differences can be seen
as being “culturally competent.”
Campinha-Bacote (1994) defines cultural
competence as “a process for effectively
working within the cultural context of an
individual or community from a diverse cul-
tural or ethnic background” (pp. 1–2). She
proposed a Culturally Competent Model of
Health Care, which encompassed four lev-
els: Cultural Awareness, Cultural Knowledge,
Cultural Skill, and Cultural Encounter.
Cultural Awareness is concerned with the
process of becoming more sensitive to differ-
ences manifest in culturally diverse clients and
of the health professional’s own biases and
prejudices toward different cultural groups.
Cultural Knowledge is the process of gaining
an understanding of different cultural groups,
including their beliefs, values, lifestyle prac-
tices, and ways of solving problems in their
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN