Cult Med Psychiatry. 1997. v. 21, N. 3. P. 303-35. (22956)

WILLIAM W.
DRESSLER, MAURO CAMPOS BALIEIRO AND

JOSE ERNESTO DOS SANTOS
THE CULTURAL CONSTRUCTION OF SOCIAL SUPPORT IN

BRAZIL: ASSOCIATIONS WITH HEALTH OUTCOMES
ABSTRACT. The association of social support and health outcomes has received consider-
able attention in recent years, but the cultural dimension of social support has not been
extensively investigated. In this paper, using data collected in a Brazilian city, we present
results indicating that those individuals whose reported access to social support more
closely approximates an ideal cultural model of access to social support have lower blood
pressure and report fewer depressive symptoms and lower levels of perceived stress. The
cultural model of social support is derived using a combination of participant observa-
tion, semi-structured interviews, and the systematic ethnographic technique of cultural
consensus modelling. These results are then used to develop a measure of an individual’s
approximation to that model of social support in a survey of four diverse neighborhoods in
the city (n = 250). We call this approximation to the ideal cultural model of social support
“cultural consonance” in social support. The association of health outcomes with cultural
consonance in social support is independent of individual differences in the reporting of
social support, and of standard covariates. In the case of blood pressure and perceived stress,
it is independent of diet, and other socioeconomic and psychosocial variables. The asso-
ciation with depressive symptoms is not independent of other psychosocial variables. The
implications of these results are discussed with respect to research on cultural dimensions
of the distribution of disease.
INTRODUCTION
There is a general recognition of the importance of social relationships

in the distribution of disease within a population. Generally speaking,
persons who have more social contacts live longer and in better health
than persons with fewer social contacts. This observation has generated
considerable research under the rubric “social support.” Surprisingly little
of that research, however, has taken into account the way in which social
interaction, and hence access to social support, is culturally constructed.
In this research, the cultural construction of access to social support
was investigated directly in relation to blood pressure and psychological
distress in a Brazilian city. Combining culture theory and ethnographic
methods, especially the cultural consensus model developed by Romney,
Weller, and Batchelder (1986), it was possible to construct a measure of
Culture, Medicine and Psychiatry 21: 303–335, 1997.

c 1997 Kluwer Academic Publishers. Printed in the Netherlands.
VICTORY PIPS: 125141 HUMNKAP

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304 WILLIAM W. DRESSLER ET AL.
social support access that reflected the extent to which an individual’s

reported access to social support corresponded to an ideal cultural model
of support, and to distinguish this measure from individual differences in
the reporting of perceived social support. This technique was integrated
both with more conventional ethnographic methods, and with traditional
survey techniques. The aim of this paper is to present these results in detail,
following a discussion of theory and method underlying the cultural study
of social relationships and health.
SOCIAL SUPPORT AND HEALTH STATUS
A considerable amount of research effort in the sociomedical sciences

has been, and continues to be, expended on research in social support and
health (Cohen and Syme 1985; Shumaker and Czajkowski 1994). This area
of research grew out of basic descriptive epidemiologic observations that,
for example, married persons die at lower rates from all causes of mortality
than do single persons (Somers 1979). Berkman and Syme (1979) system-
atized these observations in a prospective study in which they developed a
measure that they termed “social networks,” but which most workers in the
area would now call “social integration.” This measure combined data on
marital status, reported patterns of friendship, and membership in volun-
tary associations; it was found that less socially integrated individuals were
3–5 times more likely to die during an 8-year follow-up period than persons
more socially integrated. This prospective association between measures
of social integration and overall mortality has been found to be remarkably
robust and widely replicated. In general, the association between social
integration and overall mortality is independent of socioeconomic status,
health status at the beginning of the study, access to medical care, and a
variety of health habits and health indicators (see Orth-Gomer and Johnson
1987; Hirdes and Forbes 1992).
While the association of social integration and mortality is intriguing,
by itself it offers little insight into the mechanisms by which social rela-
tionships may be associated with health status or morbidity. Because of the
persistence of the association of social integration and mortality despite the
use of a variety of control variables, interest has turned to behavioral and
psychosocial mechanisms that might connect social relationships to health
status. With respect to behavioral mechanisms, it has been suggested that
persons with more social contacts are more likely to exercise and to follow
beneficial dietary recommendations, as well as to avoid excessive alcohol
intake and tobacco use. Aside from a few studies showing that persons
with more social contacts are more likely to be successful in tobacco absti-
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ASSOCIATIONS WITH HEALTH OUTCOMES 305
nence, there is not much evidence to support this behavioral interpretation

(Cohen 1988).
As a result, much more effort has been invested in the study of psycho-
social mechanisms relating social integration and health status. Guiding
most of this work is the social support hypothesis, as formulated by Cassel
(1976) and Cobb (1976) in their influential review papers. Both of these
theorists introduced the idea that there is a psychological component to
social relationships, which is a belief held by individuals that they are
integrated into a system of mutual support and that they are valued and
esteemed within this system. Along with purely practical issues of access to
information and material resources within a support group, it was hypothe-
sized that this sense of social security provides the beneficial health effects
of social integration.
Much of the evidence for the psychosocial effects of social support
comes from research guided by the “buffering” hypothesis of social
support. This hypothesis suggests that social support per se does not neces-
sarily have any effect on health status, but rather that individuals who are
exposed to psychosocial stressors and who simultaneously are higher in
social support are protected from the deleterious effects of those stressors.
Therefore, the statistical effects of stressors and social support are not
additive, but rather interactive (Kessler and McLeod 1985). Presumably,
the emotionally threatening aspects of psychosocial stressors are either
dampened or short-circuited by the emotionally positive aspects of social
support. By the same token, where social support is absent, the emotionally
threatening aspects of psychosocial stressors may be enhanced. Available
evidence indicates that whether or not the individual actually receives
support is less important in the process than whether or not the individual
believes that support is available to him or her (Wethington and Kessler
1986).
The buffering hypothesis has received considerable support in research
on mental health (Cohen and Wills 1985). There is also growing evidence
that the buffering model of stressors and social support can be extended
to health conditions such as cardiovascular disease (Blumenthal, Burg,
Barefoot et al. 1987; Gerin, Milner, Chawla, and Pickering 1995) and
diabetes (Griffith, Field, and Lustman 1990). Virtually left out of discus-
sions of social support and health, however, are considerations of the
cultural dimension of social support.
medi997.tex; 23/09/1997; 1:57; v.6; p.3

CULTURE, SOCIAL SUPPORT, AND HEALTH STATUS
In much of the literature in behavioral medicine and epidemiology, the

association of social support and health status is treated nearly as if the
dimension of social support in social relationships was somehow given
in nature. Put differently, there is little consideration given to the ways
in which appropriate social relationships, and the transactions that occur
in them, are socially and culturally constructed. This means that much of
the research literature relies on social-psychological, individual-difference
models of social support and health. Two basic assumptions underlie such
models. First, just as Young (1980) argues for the stress model, there is a
view of human beings as individualistic and voluntaristic in social relation-
ships; that is, individuals make choices with respect to social interaction in
terms of personal volition. There is little consideration given to the ways in
which sociocultural systems may construct choice in social relationships
for individuals, nor to the implications such a cultural construction of social
relationships may have for health. Second, the only differences that need
to be understood are the differences between individuals in the amount
and quality of social support that they perceive;1 no other dimension is
relevant. The most important implication of these assumptions for social
support research is that the investigator can ignore who the source of social
support is. It does not matter, so long as the individual defines someone
as a source of social support, and so long as the investigator can quantify
that definition in such a way as to distinguish between individuals. Support
from anyone is seen as equally effective.
The social-psychological, individual-difference model of social support
is at the least incomplete (Dressler 1994). What is missing from current
formulations regarding social support is the recognition that within specific
societies the sorts of emotional and instrumental transactions that make up
social support are not appropriate for just any category of social relation-
ship. Rather, different kinds of relationships are culturally defined as having
different kinds of reciprocal rights and obligations. To seek supportive
transactions outside of the relationships within which they are appropriate
is to transgress cultural norms, which in turn may interfere with the social
and physiologic processes that are conducive to better health.
Of course, these issues are basic to anthropology; the ways in which
social interaction is conditioned by culturally-defined social position is
central to much ethnography. And some researchers have used culture
theory to derive testable hypotheses regarding the effects of social
support in culturally diverse groups, as reviewed in Dressler (ibid.). Two
approaches have been taken. First, in some settings there are specific kinds
of relationships that are defined as supportive. For example, Janes (1990)
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examined blood pressure, psychological distress, and social support among

Samoan migrants to Northern California. Based on ethnographic research,
he argued that there was a core group of kin, mainly siblings, who main-
tained affectively close relationships throughout life. He hypothesized that
individual variation in the amount of those relationships would be related
to health outcomes, a hypothesis that was supported. Similarly, Dressler,
Mata et al. (1986) suggested that the so-called fictive kinship created in a
Mexican town through the system of ritual co-parenthood (compadrazgo)
would have particular relevance to health. They found that the perception
of support from compadres was a stronger correlate of lower blood pressure
than support from relatives, friends, or neighbors, especially among males,
for whom these compadrazgo relationships are particularly important.
Second, in some settings cultural meaning systems may alter the effec-
tiveness of different kinds of support. This is illustrated most clearly by
Dressler’s (1991a, b) research on social support within an African Amer-
ican community in the rural southern USA. There is ample evidence
to indicate that the extended family is a primary support system with-
in the black community. During the long period prior to the civil rights
movement, during which the effective conditions of slavery persisted, kin
were the people who could really be counted on for help in times of distress.
Throughout the four decades since the movement began, however, younger
members of the community have been thrust into educational and occu-
pational settings in which coping with everyday problems is more likely
to be facilitated by support from peers who are dealing with those same
problems, as opposed to kin who may or may not be. This is not to say that
younger people do not define kin as support, nor that older people do not
define nonkin as support; rather, the support provided by nonkin to younger
people, and by kin to older people, is more culturally salient or meaningful,
and hence likely to have beneficial effects. In two separate studies exam-
ining depressive symptoms and blood pressure, kin support was found to
moderate the effects of stressors on outcomes for older respondents, while
nonkin support was found to moderate the effects of stressors on outcomes
for younger respondents.
This research (along with other studies reviewed in Dressler 1994)
strongly suggests that cultural dimensions of social support are an impor-
tant component of the social production of disease, and that these dimen-
sions are in need of further exploration. The question then becomes how
to do this. In the research briefly reviewed above, general ethnography
(participant-observation and key informant interviewing) was used to
examine the cultural context of social relationships; this general quali-
tative information was then used to create measurements consistent with
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that context. This process can often remain mysterious; going from general
cultural patterns to specific measurements can require considerable inter-
pretation, and hence can be easily contested. For example, in the case of the
African American community, the generational differences in the effects
of social support could be attributed to lifespan developmental processes
in the formation of social relationships, as opposed to the sociocultural-
processual model proposed by Dressler (1991a). Or, rather than having
identified a cultural dimension of social support, it might be argued that
kin and nonkin are merely providing special resources relevant to the
specific stressors faced by the young and old.
It would be useful, in other words, to systematize the inferential steps
leading to the derivation of measures of social support in such a way as
to clearly specify the cultural dimension of social support, and to contrast
this dimension of social support with other ways of looking at the process
(e.g., an individual difference model). Our aim in this paper is to do just
that, employing culture theory and related methods.
THEORY AND METHOD IN EXAMINING THE CULTURAL

DIMENSION OF SOCIAL SUPPORT
D’Andrade’s (1984) model of cultural meaning systems is a useful one

for our purposes here. In this model, D’Andrade outlines four ways in
which cultural meaning systems work. The first is along a constructive
dimension by which culturally meaningful phenomena are defined. The
constructive dimension of cultural meaning systems functions to define
what constitutes, for example, the very notion of social support within a
society. The second dimension of cultural meaning systems consists of
various ways in which that information is represented cognitively, or how
the mind stores the information in readily retrievable form. Third, cultural
meaning systems serve a directive function, in that they guide the behavior
of individuals. Finally, there is an affective dimension to cultural meaning
systems, along which ways of feeling about various cultural domains are
organized. One need only add the caveat that cultural meaning systems are
socially transmitted and shared to complete this theory (D’Andrade 1987).
D’Andrade’s (1984) work, rather than being simply another definition of
culture, represents a theory of culture that is useful in the kind of empirical
investigation pursued in this paper.
Ideas about and behaviors relevant to social support will be embedded
in and generated out of such a system of meaning. Elsewhere, an essentially
Firthian rendering of social support has been suggested that is consistent
with this theory of cultural meaning systems (Dressler 1994). In this orien-
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tation, the most abstract organizing scheme for social support systems is
the set of definitions, expectations, and strategies for social interaction that
can be referred to as social structure. Social structure defines with whom
interaction is permitted, prohibited or preferred, and what sorts of trans-
actions within interactions can be expected. These rules and expectations
will only be incompletely realized, however, due to various sorts of social
environmental constraints. The observable realization of social structural
ideals then is referred to as social organization. Stepping down another
level of abstraction, the kinds of social relationships centered on the indi-
vidual can be described as the ego-centered social network. It is to this
network that the individual will turn for help during times of felt need; the
belief or perception that such help is (or would be) forthcoming in such
times is what will be referred to as social support.
The question then becomes, how can the cultural construction of social
support within a particular setting be examined in such a way that this
information can in turn be used to study the influence of cultural defini-
tions of support on the distribution of health status? What is required is
some means of defining a shared model of social support, and in turn deter-
mining to what extent individuals in a sample adhere to or approximate this
shared model. The way in which health status is distributed relative to indi-
vidual approximation to this cultural model of social support can then be
examined. In the remainder of this paper, these issues will be examined in
the context of research in a Brazilian city, applying the cultural consensus
model of Romney, Batchelder and Weller (1986) to the study of cultural
models of social support, and integrating the use of that model with more
conventional ethnographic methods and traditional survey techniques.
THE RESEARCH SITE
The research on which this study is based was carried out in the city of
Ribeirão Preto, a city of approximately 500,000 population in the state
of São Paulo. Ribeirão Preto sits in the middle of the richest agricultural
region in Brazil. Much of the land surrounding the city is devoted to
the cultivation of sugar cane, which is refined into sugar and used in the
production of alcohol fuel for automobiles. Significant amounts of land
are also devoted to the cultivation of coffee and citrus. The city was
founded in the late nineteenth century as a market center for the large
farms (fazendas) in the region. Later, it became important as a rail center,
and for light manufacturing such as the brewing of beer. The city grew
dramatically in the years following the second world war as a financial
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service center and a regional center for health care. Today it is among the
most affluent cities in Brazil.
One of the challenges of this research was to adequately sample the full
range of socioeconomic variation in the city. To do so, we first identified
four neighborhoods in the city that spanned that range. Households were
then sampled within those neighborhoods for more intensive study. The
poorest neighborhood was a favela on the edge of the city. Favelas are semi-
legal squatter settlements made up both of migrants seeking to partake of
the affluence of the region, and of the socially marginal who have not been
able to attain economic stability. They are semi-legal in the sense that the
building of houses on the site has not been approved by the municipality,
but the residents nevertheless pay rent on the house sites to the owner of
the land. In fact, upon leaving the favela, residents will even sell their
houses to new arrivals. Houses in a favela vary enormously, ranging from
ragtag affairs hammered together from castoff lumber and corrugated tin,
to concrete block and multi-roomed houses with electricity siphoned from
a passing power line. People in the favela tend to be unstably employed as
unskilled laborers and domestics.
The second neighborhood sampled was a conjunto habitacional. A
conjunto is a kind of public housing project. In partnership with the local
city government, a builder will develop houses on a tract of land on the edge
of the city; the conjunto studied here was begun in about 1988 and consisted
of several hundred 3–4 room concrete houses. The houses are then sold
to buyers who qualify for low-cost loans on the basis of being stably
employed. Persons in the conjunto tend to be employed in semi-skilled
jobs such as driving a bus or in construction or low-status service jobs. The
key, however, is the stability of the employment. A conjunto passes from
nondescript sameness to variation in housing styles very quickly, as people
add rooms (sometimes stories), garden walls, garages, and architectural
details to their basic houses. As the conjunto evolves, more basic services
are added, such as small grocery stores, drug stores, and other shops. In this
way, the conjunto takes on the feeling of a small independent community
attached to the larger city.
The third neighborhood sampled was a traditionally lower middle class
area of the city. Early in the century this was a new neighborhood created
by the influx of Italian and Spanish immigrants to Ribeirão Preto; now it
is an old neighborhood completely engulfed by the city proper. The streets
are cobbled (rather than paved) and the houses present seamless walls to
the street. There is a large praça or square with a church in the center
of the neighborhood, and many shops, bars, and restaurants. In short, this
neighborhood has a much more urban feel to it, although it is not in the city
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center proper. Houses here are substantially larger than in a conjunto, and
although the economic participation of residents tends to be quite varied,
incomes and occupational statuses are substantially higher. People tend to
be in business, or to work as lower level managers in factories or the public
sector.
The fourth and last neighborhood studied is an upper middle class
area made up primarily of recently constructed houses. The residents are
upper level managers, prosperous businesspersons, and professionals. This
happens to be an attractive neighborhood for physicians and related profes-
sionals, some of whom have studied and taken graduate and postgraduate
degrees in the United States and Europe. The houses verge on being enor-
mous with extensive and well-tended gardens. Although we did not trace
such connections precisely, it would not be unlikely for favelados to be
serving as domestics or tending the gardens in this neighborhood.
SOCIAL ORGANIZATION AND SOCIAL SUPPORT IN BRAZIL
Discussions of social organization in Brazil typically begin with the family.

Continuity is traced from the large, extended patrifocal families that orga-
nized colonial plantations (oftentimes referred to as “patriarchal” families
in older literature) to the contemporary Brazilian family (Azevedo 1963).
While a large, bilateral extended family is often identified as the Brazilian
ideal, ethnographic work has shown that the formation of social relation-
ships under the rubric of kinship varies considerably by class (Kottak 1967;
Sarti 1995). For example, Miller (1979) demonstrates the density of social
relationships among members of a middle class extended family in the
south of Brazil. An important function of these dense relationships is the
provision of mutual support in the form of help with child care, direct
monetary assistance, information leading to mutual economic benefit, and
leisure time social interaction. Individuals value their extended family
relationships for these functions, especially because kinship relationships
help to insure the quality of those relationships.
Within the lower class, however, kinship relationships are viewed more
ambivalently (Sarti 1995). In part this ambivalence reflects a larger conflict
between the personalism of social relationships in Brazil, and the individu-
alism that is also valued and enables equally valued upward social mobility
(Hess 1995). The concept of personalism refers to the definition of social
being not primarily through status characteristics such as education or
occupation, but rather through membership in a network of social (espe-
cially kin) relationships. Roberto da Matta (1991) in particular has drawn
attention to the tension within Brazilian society between the impersonal,
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bureaucratic definition of social beings as individuals, versus the definition

of social beings as persons, characterized by the intimate bonds of kinship
relationships. For da Matta, this is a central feature of Brazilian culture,
and he has written extensively regarding rituals of social interaction that
mediate the tension between individualism and personalism. Within the
lower class, personalism is valued as it is in the middle class, however,
personalism also complicates upward mobility (the individualistic pole of
the continuum) because the meager economic resources that can be accu-
mulated in the lower class can be easily dissipated by the obligations and
responsibilities entailed by the kin network (Kottak 1967).
In addition to the importance of these extended family relationships,
patterns of friendship within the local neighborhood and beyond are impor-
tant. For those in the lower class, relationships within the neighborhood
can be essential in maintaining the quality of life that they seek in their
quest for upward mobility (Sarti 1995). For those in the middle class,
social clubs and other sorts of voluntary associations are extremely impor-
tant in terms of the investment of leisure time activity, as well as in terms
of maintaining the social contacts outside the family that could prove to
be important future resources. Finally, the system of compadresco, or co-
parenthood, still exists in Brazil, although without the importance it holds
in other parts of South America (Kottak 1967). In the south of Brazil at
the present time, compadres are present usually only at baptism, and the
selection of a compadre is often simply a recognition of a close affective
bond between friends or relatives at that time.
In prior research on social support in relation to health in Brazil, we
found social support in both kin and nonkin relationships to be associ-
ated with better health status (as measured by blood pressure and serum
lipids) in interaction with social stressors (Dressler, Santos, Viteri, and
Gallagher 1991; Santos, Dressler, and Viteri 1994). While general ethno-
graphic observations were used in the development of those measures of
social support, the measures and analytic model examined only individual
differences in the amount of support perceived. In the current research, we
examine more closely the cultural construction of access to social support.
DATA COLLECTION: AN OVERVIEW
Three sets of data were collected in the four neighborhoods that were
sampled. First, there was a survey of a representative sample of households.
In the favela, a complete enumeration of households was obtained from
a community association; forty households were chosen at random from
that listing. For the other three neighborhoods, detailed maps of occupied
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house sites were obtained from the city government, and forty households
were chosen at random from each of the neighborhoods. Households were
contacted and invited to participate in the research. We asked the head of
household, spouse (if present), and one child over the age of 18 (if present)
to participate in the research. If a household refused to participate (rarely
did only one individual refuse), another was substituted at random. Overall,
68.5% of the households originally contacted agreed to participate. This
resulted in a final sample of 304 individuals. Because of sampling by
households, there is a potential problem of a lack of independence among
cases when data are analyzed by individual; also, many of the variables
in which we are interested are more important for older and economically
established persons. Therefore, in subsequent analyses we delete dependent
children, resulting in a sample of 250 male and female household heads.
Data collection in the survey required four separate interviews with
each respondent. In the first interview, social and psychological data were
collected by a trained psychologist. The second and third interviews were
24-hour dietary recalls, conducted by trained nutritionists. One 24-hour
recall was always conducted on a Monday, in order to sample dietary
habits conventionally restricted to weekends. The second 24-hour recall
was conducted on any other weekday indifferently. The fourth interview
was conducted by a nurse who collected blood pressures, serum samples
for blood chemistry, bioelectric impedance measures of body composition,
and a brief health history. When data are analyzed that require only the
information obtained in the initial interview, the sample size is 250. There
were of course dropouts who did not complete the more extensive round of
data collection that included diet and biological measures; when analyses
are carried out that require the biological measurements, the sample size
drops to 208.
Second, intensive structured ethnographic interviews were conducted
with a set of 20 informants, 5 from each neighborhood. To be described
more fully below, these interviews generated data on social support that
were then analyzed using the cultural consensus model of Romney, Weller,
and Batchelder (1986). The key informants for these interviews were
selected by the interviewer (MCB) from the survey component of the
research on the basis of the “typical” household in that neighborhood. The
selection of key informants was guided by a knowledge of the range of
variation of a subcommunity and effort was made to arrive at representa-
tiveness.
Third, unstructured ethnographic interviews were conducted with eight
households, two from each of the neighborhoods. Again, these households
were selected in part as being typical of these areas, but of course in part
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because of the willingness of the respondents to participate. An unstruc-

tured interview guide was used in these interviews that covered topics of
lifestyles, social support, health, and related issues germane to the research.
Usually a husband and wife were interviewed together, and all interviews
were tape recorded and transcribed. Each interview was between one and
one-half and two hours in length.
Finally, all of these data were collected in the context of ongoing,
informal participant observation.
GENERATING A CULTURAL MODEL OF SOCIAL SUPPORT
Anthropology has been hampered by the lack of a quantitative measure-

ment model by which shared cultural knowledge could be operational-
ized; however, with the development of the cultural consensus model by
Romney, Weller, and Batchelder (1986), there is reason to hope that this
lacuna has been filled. Romney et al. start with the assumption that culture
is most usefully studied in terms of knowledge (consistent with D’Andrade
1984), and that the most important characteristic of a cultural knowledge is
that it is shared. Theirs is a statistical model that first examines the degree
of sharing of knowledge among a set of informants. If there is evidence of
a sufficient level of sharing among informants, then it can be inferred that
all informants are drawing on a single underlying cultural model of that
domain.
The next step in the model involves determining informants’ differ-
ing command of knowledge within a particular domain. Different infor-
mants will of course have some idiosyncratic notions regarding a particular
domain. Also, some informants will simply know more about a particular
domain than other informants. The model of Romney et al. provides a way
of estimating how much information each informant shares with every
other informant (or, conversely, how much of their knowledge is idiosyn-
cratic). This they refer to as the informant’s “cultural competence.”
The final step in the model involves estimating the “best” set of cultural
answers regarding the domain in question. In the sense of this theory
and method, the best set of cultural answers would be produced by the
most “knowledgeable” or “competent” informants. Since the differences
in cultural competence have already been determined, a set of answers to
a task can be estimated giving more weight to the responses of the most
competent informants. The Romney-Weller-Batchelder model will be used
here to examine the sharing and distribution of cultural models of social
support in this Brazilian community.
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The interview used to generate data for the cultural consensus model
was actually first suggested by observing respondents replying to questions
about social support in the survey component of the research. Questions
about social support consisted of a series of probes regarding common
problems, such as needing to borrow money, or needing help with a
personal problem. Then, respondents were asked, in turn, about relatives,
friends, neighbors, and compadres as potential sources of support in
response to those problems. In observing survey respondents, it seemed that
they replied to these questions with a clear sense of hierarchy of resort to
different sources of social support. It seemed as if, for most people in most
instances, the sequence of “relative ! friend ! neighbor ! compadre”
was precisely the pattern adopted in response to most questions.
Cultural consensus analysis was chosen to test this observation. The
hypothesis guiding this test was that this pattern of responses would be
shared by a set of key informants at levels consistent with what Romney et
al. refer to as the “one culture” hypothesis. In cultural consensus modelling
the one culture hypothesis refers in this instance to a shared and culturally
constructed way of thinking and talking about seeking access in a social
support system among this set of informants. In the cultural consensus
interview, respondents were again presented with the same series of five
problems as were used in the survey component of the research. They
were then presented with the four potential sources of social support, plus
a fifth alternative of “some other person.” They were asked who the most
important person in that set would be to ask for help for that particular
problem. They were then asked who the next most important person would
be, the next, and so on, until all alternatives were exhausted. This provided
a ranking of alternative sources of social support, from first through fifth,
for all five of the potential problems. It should also be pointed out here that
the order of the problems, and the order in which the potential supporters
were asked about, were varied from the order used in the survey component
of the research.
As noted above, 20 key informants, five from each of the sampled neigh-
borhoods, participated in this task; none had any difficulty with it. This
resulted in a 20 informants-by-25 problem/supporter matrix of ratings2
that were analyzed using cultural consensus analysis as programmed in
ANTHROPAC 4.7 (Borgatti 1992). In essence, the first step in conducting
a consensus analysis is to examine common factors in a matrix (as in factor
analysis) taking the informants as the variables. If there is a single initial
factor that accounts for most of the variation relative to the other factors
(i.e., if all informants cluster on a single factor), then it is reasonable to
assume that all of the informants are drawing on a single, underlying,
medi997.tex; 23/09/1997; 1:57; v.6; p.13

Table 1. Cultural consensus analysis of rankings of social support
Consensus level 3.11
Mean cultural competence coefficients

Total sample 0.61
Favela 0.52
Conjunto habitacional 0.56
Lower middle class area 0.73
Upper middle class area 0.61
See text for definitions.
shared cultural model regarding social support in making their (partially

idiosyncratic) rankings.
Table 1 summarizes various indices derived from a cultural consensus
analysis of the informants’ responses to the rating task. “Consensus level”
refers to the ratio of the amount of variation accounted for by the first
factor to the second factor. Romney et al. (1986) recommend that this ratio
be 3.0 or larger to accept the hypothesis that informants’ responses are
similar enough to be indicative of their sharing a single cultural model
of social support. “Cultural competence coefficients” indicate the degree
to which the responses of each individual informant match the consensus
model. Since individual cultural competence is not of interest here, average
competence is shown for all twenty informants, and for informants broken
down by neighborhood. For cultural consensus to be meaningful, these
competence coefficients should generally be large and positive. Overall,
this is the case. The somewhat lower mean competence in the first two
neighborhoods stems from two informants (one in each group) having
very low (< 0.30) competence coefficients. In general, however, these
results indicate that there is a single model of the cultural construction of
social support that is shared overall and within each neighborhood.
Next, it is possible to calculate summary ratings of social supports in
response to different problems by averaging over individual responses,
but giving more weight to those individuals who have higher competence
coefficients. Table 2 shows the consensus rankings of sources of social
support in response to each problem. In each cell of the table, the consensus
rating is given; in parentheses, the integer ranking of the source of social
support in response to each problem is also given.
In four of the five potential problems, the consensus responses conform
to the hierarchy of resort that was hypothesized. In the fifth problem,
however, the rank of relatives and friends is reversed, with friends assuming
prominence as the first chosen source of social support.
medi997.tex; 23/09/1997; 1:57; v.6; p.14

Table 2. Consensus ratings of seeking social support
Problems Relative Friend Neighbor Compadre Other
Wanting a loan 1.69(1) 2.46(2) 3.42(3) 3.44(4) 3.99(5)

Illness 1.65(1) 2.50(2) 2.65(3) 3.75(4) 4.44(5)
Distress 1.68(1) 1.79(2) 2.26(3) 3.57(4) 4.71(5)
Being in debt 1.72(1) 2.07(2) 3.28(3) 3.63(4) 4.30(5)
Problems at work 2.50(2) 1.32(1) 3.45(3) 3.46(4) 4.27(5)
Numbers are consensus rankings of who would be sought as a source of support

first, second, etc., derived from the consensus analysis shown in Table 1. Numbers
in parentheses are integer ranks of the corresponding consensus ranks.
Several things are worth noting here about this consensus model. First,
the model clearly has substantive meaning. It conforms to what would be
anticipated on the basis of ethnographic analyses of social relationships in
Brazil, as well as bearing out the observation made in the survey component
of the current study. Second, the danger existed that what was observed
in the survey component of the research was merely a function of the
order of presentation of items. However, the fact that the informants in
the consensus analysis went against the ordering of the items on the fifth
problem, ranking friends over relatives as the preferred source of support,
is clear evidence that these responses are substantively meaningful, and
not a function of how the questions were asked. Third, beyond friends
and relatives as sources of support, it is clear that there is considerable
flexibility in who would be chosen next, since the consensus scores for
these other sources of support are quite close in magnitude.
Romney et al. (1986) are quite clear in their derivation of consensus
theory regarding the generalizability of findings such as these. Given a
reasonable sampling of key informants, and the failure to reject the one
culture hypothesis, it can be assumed that the information provided by
the consensus ranking of the items generalizes to the social context being
studied. In other words, Table 2 contains a best estimate of a shared cultural
model of how to access social support in response to a variety of common
problems in this Brazilian city, one that generalizes across diverse socioe-
conomic groupings. In this model, kin are the preferred source of social
support for most problems, followed by friends, neighbors, compadres,
and other persons. Only in response to job-related problems are nonkin
(friends) rated as the preferred source of support.3
medi997.tex; 23/09/1997; 1:57; v.6; p.15

THE DISCOURSE ON SOCIAL SUPPORT
The quantitative evidence provided above for the hierarchy of resort with
respect to social support can be compared to the third set of data collected,
the open-ended interviews. A middle-aged, married woman from the favela
discussed social support in the following terms.
I think that people have to first turn to God for everything, and afterwards I think that I
would go to the side of my husband. Then I go to the side of my sister. I always seek her
because we are the closest in the family. We always look to each other for help. If I see
something that is beyond us, I try to get the help of some other person. I always ask my
sister first, and I think that everybody must do this, if it is mother, father, husband, wife.
The following discussion was provided by an older man living in the

conjunto.
Interviewer (I): Do you believe that other persons can help during times of stress?
Respondent (R): They can help. I think they can. A friendship, the family, the coming
together of the family, friends, all this.
I: Who is the person most important when we are feeling stress or have problems?
R: I don’t know who the most important person is, but in my case it would be her, my wife,
because she is my companion day to day. She knows my life as no one else knows. If I
were to have my parents here today, they would not know as well as she. I really think so.
It is she and the children, the family, because if I become ill today who is it who is going
to look after me? My family. It is true that I have my brothers and sister, that she has her
brothers and sisters. They would provide help, some assistance, but later and more modest.
There are many united families like this.
The following exchange between interviewer and respondent was typical

of other interviews. Here the respondent is a middle aged, married male
from the upper middle class site.
I: And can other persons help someone confronting stress?
R: Of course, including professionals. In the beginning friends can help and other persons.
I: These are the first persons you would ask?
R: No, first the family, of course. Afterwards the professional.
Another respondent from the upper middle class neighborhood, a success-

ful businessman, emphasized the family (his wife) as first resort, but also
cited the importance of friends.
I: Can other persons help if you are suffering stress while confronting a problem?
R: Yes, friends. They can help right at first. They come to the house, make a visit, talk it
over. They are basic.
While this pattern was reported in most interviews, there was one
interview in which the helpfulness of the family was explicitly rejected.
This interview was conducted with a husband and wife in the traditionally
middle class neighborhood.
medi997.tex; 23/09/1997; 1:57; v.6; p.16

I: Who would be the most important person to ask for help when someone is confronting a
stressful situation?
R (husband): A good friend. At times they can be much more helpful than family.
R (wife): Family have too many opinions. At times you can count on many more things
from a person from outside than you can with the family. At times your family is the cause
of stress. Then, a friend is better.
These data from open-ended interviews provide two additional bits of

information. First, within the limits of idiosyncratic expression in nondi-
rected interviews, most of the informants talk about social support in a
way consistent with the model of a hierarchy of access, moving from the
most intimate relationships within the family to less intimate relationships
beyond the family (which echoes da Matta’s (1987) ideas of the distinction
between “a casa e a rua” or “the house and the street”). Second, there are
people who, for whatever reason, talk about social support in a way that is
distinct from the cultural model (i.e., the middle-class couple above), just
as there are informants in the cultural consensus model who do not share
much in their responses with others (i.e., who have low cultural compe-
tence). Put differently, there appears to be a shared cultural model of social
support, along with some individual deviation from that model. The ques-
tion then becomes: what are the health consequences of approximating –
or not – that cultural model of social support?
CULTURAL CONSONANCE IN SOCIAL SUPPORT: A MEASURE
In order to examine this question we need some measure of an individual’s

approximation to the ideal cultural model, a measure we will refer to as
“cultural consonance in social support.” Derivation of such a measure
(unlike a corresponding measure of cultural consonance in lifestyle, see
Dressler 1996) was complicated by the fact that questions about social
support were asked differently in the consensus model interview than in
the survey, i.e., asked as rankings in the consensus interview and as simple
“yes-no” questions in the survey. In order to increase the comparability of
the two sets of data and to derive a measure of cultural consonance, we first
applied weights to the survey responses that were the mirror-image of the
rankings; that is, if the person responded that he/she would ask a relative
for a loan, that response received a weight of 4.0; if he/she responded in
terms of asking a friend, that response received a weight of 3.0; and so on,
keeping in mind that none of these responses in the survey are mutually
exclusive. The respondents were free to name as many potential sources
of support as they cared to. Also, it must be kept in mind that in four of the
five questions, weights were used that reflected the “family ! friend !
medi997.tex; 23/09/1997; 1:57; v.6; p.17

neighbor ! compadre” pattern; for the fifth question, weights were used
that reflected the “friend ! family ! neighbor ! compadre” pattern.
Applying these weights to the survey sample enabled us to compare
individual patterns of response to the consensus model. For example, if the
person responded that he/she would request support from a relative, then
any or all of the remaining responses would also be valid in terms of the
hierarchy of resort. If he/she did not name a relative, however, the hierarchy
would be maintained only if he/she did name a friend. If he/she did not
name a friend, then the hierarchy would be maintained only if he/she
named a neighbor. If the respondent named only a compadre, however,
then there would be as little evidence of use of the hierarchical model as
if he/she had named no one. Therefore, the individual actually has three
opportunities to respond in accordance with the hierarchy of resort on each
question. The respondent also has a number of different ways of deviating
from that hierarchy of resort. If only a compadre is named, as noted above,
that would be a deviation. If, however, the respondent named a relative
and a neighbor, the hierarchy of resort would be less well maintained than
if he/she had also named a friend. While this solution is not perfect, it does
enable us to compare individual patterns of responses with the consensus
model, and it does not require that the respondent always name the most
highly ranked source of support in order to maintain adherence to the
hierarchy. Finally, in that these patterns are being examined across five
different questions, we can detect a consistency of response on the part of
the individual.
Each respondent has three chances to answer each question in a way
consistent with the consensus model. We required that they use at least one
of those chances in order for the responses to that question to be regarded as
consistent with the shared cultural model derived from consensus analysis.
When this was done, fully half of the respondents, 54.4%, answered all
five questions in a way that was consistent with the consensus model.
Another 19.6% of the respondents answered four of the five questions in
a way consistent with the consensus model. The remaining 26.0% of the
respondents answered three or fewer of the questions in a way consistent
with the consensus model. We will refer to these groups as “consensus
group 1 (or CG1); consensus group 2 (or CG2); and, consensus group 3
(or CG3)” respectively. CG1 is highest in its consonance with the cultural
consensus model, and CG3 is lowest in its consonance with the cultural
consensus model.4
medi997.tex; 23/09/1997; 1:57; v.6; p.18

CULTURAL CONSONANCE IN SOCIAL SUPPORT AND

HEALTH OUTCOMES
The next step in the analysis is to determine what, if any, association there
is between an individual’s approximation to the cultural ideal of social
support and that individual’s health status as measured by blood pressure,
depressive symptoms, and perceived stress. Blood pressure measurements
were made using a DINAMAP Vital Signs Monitor Model 845XT. This
is an automated system for the monitoring of blood pressure that virtually
insures no inter-observer bias. Five blood pressure measurements were
taken, and the results reported here employ the mean of all five of those
readings. In addition to systolic and diastolic blood pressure, pulse pressure
will be used as a dependent variable; this is the difference between systolic
and diastolic blood pressure. (Descriptive statistics for all variables used
in the analyses are reported in Appendix Table A1.)
Depressive symptoms are measured with a 10-item scale, adapted from
one used in research in the USA (Dressler 1991a). Respondents were asked
to report how often during the past month they had experienced common
symptoms of depression, such as sadness, hopelessness, helplessness, and
fatigue. They reported the frequency of experience of the symptoms on a
four-point scale. The scale has acceptable internal consistency reliability
in this sample (Cronbach’s alpha = 0.79). Perceived stress is measured
with a shortened form of the scale developed by Cohen and associates
(Cohen, Kamarck, and Mermelstein 1983). This scale assesses the extent
to which individuals perceive themselves to be burdened and under strain
from forces outside of their control. Additional items concern their self-
perceived abilities to make and to manage changes in their lives. Four of
the original fourteen items in this scale proved to be unreliable, in the sense
that the item-remainder correlations for those items were small; the remain-
ing ten items have acceptable internal consistency reliability (Cronbach’s
alpha = 0.80). All of the scales were translated from English by bilin-
gual members of the research team working in a group, and nuances of
meaning were resolved through discussion. These scales are very similar
to ones widely employed in research in Brazil (Almeida-Filho 1987);
furthermore, general ethnographic work indicated that persons from a
variety of socioeconomic settings talked regularly about stress and depres-
sion in just these terms.
The association of cultural consonance in social support with systolic
and diastolic blood pressure, pulse pressure, depressive symptoms, and
perceived stress, is shown in Table 3. In each of these analyses, statistical
effects and adjusted health outcome values were derived using a general
linear model with age, sex, and body mass index as control variables in
medi997.tex; 23/09/1997; 1:57; v.6; p.19

Table 3. Health outcomes in relation to consensus groups

Consensus Systolic blood Diastolic blood Pulse Depressive Perceived
group pressure pressure pressure symptoms stress
CG1 119.6 79.1 40.7 19.5 19.8

CG2 123.3 78.9 44.6 20.0 21.8
CG3 129.0 82.2 46.9 22.0 23.3
F = 6.67 F = 1.73 F = 8.73 F = 3.03 F = 6.18
df = 2,204 df = 2,204 df = 2,204 df = 2,245 df = 2,245
p = 0.002 n.s. p = 0.0002 p = 0.049 p = 0.002
Numbers in the cells of the table are adjusted values. For blood pressure, values are
adjusted for age, sex, and the body mass index. For reported symptoms, values are
adjusted for age and sex.
relation to blood pressure, and age and sex as control variables in relation
to depressive symptoms and perceived stress. In each case, the highest (and
hence least favorable) health outcome values are observed among persons
in CG3, that is, among those persons who least approximate the ideal
cultural model of social support. Health outcome values are also higher
among the intermediate group, but not as high. The overall statistical
effects of cultural consonance in social support are significant for all of the
variables, except for diastolic blood pressure.5
These analyses demonstrate that, net of control variables, individuals
who most closely approximate the cultural ideal of social support in their
responses to questions about social support also have relatively better
health status.
CULTURAL CONSONANCE VERSUS INDIVIDUAL DIFFERENCES
Not surprisingly, the three groups that differ in their approximation to

the ideal cultural model of social support also differ in the total number
of potential supporters named in response to the social support ques-
tions. Since there were four possible responses to each of five questions,
respondents in the survey could have named a total of 20 potential
supporters. Respondents in CG1, the largest group, named an average of
6.26 supporters; respondents in CG2 named an average of 5.48 supporters;
and, respondents in CG3 named 3.18 supporters. These differences are
highly significant (F = 41.06; df = 2, 247; p < 0.001). Given these differ-
ences, it is possible that the groups formed as approximating the ideal
cultural model of support are in fact simply recapitulating individual differ-
medi997.tex; 23/09/1997; 1:57; v.6; p.20

ences in the perception of social support, and that the results reported above
are an artifact of these individual differences.
A new variable, “perceived support,” was formed by counting the total
number of potential sources of social support named by the respondent.
Then, the relationship of this variable to each of the outcomes, controlling
for the covariates named above, was examined using multiple regression
analysis. In the case of systolic blood pressure ( = 0.15, p < 0.02),
diastolic blood pressure ( = 0.13, p < 0.03), and perceived stress (
= 0.14, p < 0.03), perceived support was associated with lower (and
hence more favorable) levels of the outcome variables. For pulse pressure
and depression, these effects were also inverse but of borderline statistical
significance (p 0.10). Therefore, total perceived support is associated
with better health status, consistent with an individual difference model.
Table 4 shows these same multiple regression analyses, but with cultural
consonance in social support added to the equation. In this case, what is
referred to as “dummy variable” regression is being used. Cultural conso-
nance is converted to two dichotomous variables: one indicates whether
or not an individual falls into CG2 (= 1 in dummy variable coding) versus
either CG3 or CG1 (= 0 in dummy variable coding); the other indicates
whether or not an individual falls into CG3 (= 1 in dummy variable cod-
ing) versus CG2 or CG1 (= 0 in dummy variable coding). No code is
introduced for falling into CG1, since including both of the other dum-
my variables completely accounts for all cases. These two variables can
be interpreted as any other independent variables. The results in Table 4
indicate that there is virtually no change in the statistical effects of cultur-
al consonance in social support when perceived support is controlled for.
This can be seen directly in Table 4, since metric regression coefficients are
reported. These can be interpreted as the adjusted category deviations from
CG1 for CG2 and CG3, and hence can be compared directly to category
differences in Table 3. When cultural consonance is introduced into the
equation, the statistical effects of perceived support drop to nonsignifi-
cance. Given that there is a rather large correlation between perceived
social support and cultural consonance in social support, several parame-
ters of the regression models in Table 4 were scrutinized rather closely,
including the tolerances associated with each variable, the variance
inflation factor for each variable, and the condition index for each model.
Each of these can be used to detect the problem of multicollinearity; there
was no indication from any of these parameters that collinearity influenced
the results presented here.
The substantive implications of the results in Table 4 are that the results
of the analyses relating cultural consonance in social support and health
medi997.tex; 23/09/1997; 1:57; v.6; p.21

Table 4. Regression of health outcomes on control variables, consensus groups, and

perceived social supporta
Variables Systolic blood Diastolic blood Pulse Depressive Perceived

entered pressure pressure pressure symptoms stress
Age 6.28 4.07 2.21 0.014 1.33

Sex 9.68 5.48 4.18 4.58 3.95
BMI 3.49 3.66 0.16 – –
Perceived
support 1.19 1.30 0.11 0.23 0.37
CG2 3.34 0.55 3.90 0.53 1.88+
CG3 8.09 1.67 6.41 2.16 2.98
Multiple R 0.576
0.563 0.421 0.354 0.377
+ p < 0.10 p < 0.05 p < 0.01 p < 0.001.
a
Values given in this table are metric regression coefficients. All continuous variables
have been standardized, so that these coefficients can be read as the amount of deviation
in the dependent variable associated with a one standard deviation difference in the inde-
pendent variable. For categorical variables (i.e., the consensus groups) these coefficients
represent the amount of difference in the dependent variable between that category and
the reference category.
outcomes are not an artifact of individual differences in the perception of

social support.
The final step in this analysis was to determine if any competing
explanatory variables might account for the relationship between cultural
consonance in social support and the health outcomes examined here. For
blood pressure, the following variables were examined: household income,
skin color, tobacco use, alcohol intake, sodium intake, total fat intake, and
a measure of social integration. The latter measure was constructed by
combining information on membership in voluntary associations, reported
friendships within the neighborhood, and number of relatives living in
the city. For depression and perceived stress, the following variables were
examined: household income, alcohol intake, locus of control, and social
integration. For blood pressure and perceived stress, the inclusion of other
variables made no difference in the results. For depression, the association
of cultural consonance and social support was reduced to nonsignificance
when locus of control was controlled for.6
medi997.tex; 23/09/1997; 1:57; v.6; p.22

DISCUSSION
The aim of this paper has been to examine the cultural dimension of
social support in Brazil and to determine if this cultural dimension of
social support is associated with health outcomes. The approach has been
to compare the association of the cultural dimension of social support
with health outcomes to the association of a measure assessing purely
individual differences in perceived support, as well as other competing
explanatory variables. Overall, the results suggest that the extent to which
an individual’s reported access to social support approximates the cultural
ideal of social support, or what we have referred to as cultural consonance
in social support, is a much stronger correlate of health outcomes than
perceived social support conceived of as an individual difference variable.
Furthermore, cultural consonance in social support retains its association
with these health outcomes after competing explanatory variables have
been controlled for.
The orientation guiding this research is novel, or at least somewhat
unusual, for research in biocultural medical anthropology. As others have
noted, especially Ware and Kleinman (1992), efforts to link culture with
psychophysiologic outcome variables have not been particularly produc-
tive. All too often “the cultural,” to borrow Borofsky’s (1994) term, has
been reduced to ethnic or racial categories, linguistic affiliations, or values
and attitudes that end up being indistinguishable from inventories of
personality traits. Despite the rich and fertile ground provided by culture
theory, there has been little progress in using that theory to examine the
psychophysiologic differences between individuals. Instead, researchers
have been forced into a kind of methodological solipsism (Sabini and
Schulkin 1994), examining only those social and psychological factors
that are consistent with what we have referred to as an individual differ-
ence model of social support.
What is limiting about such an approach is that it virtually forces the
researcher to regard as important only that which can be regarded as
consistent with individual psychological processes. In the case of research
involving social support, it reduces down to an examination of the varying
kinds and amounts of support that the individual believes or perceives are
available to him or her. Yet, culture theory and other kinds of social and
cultural constructivism (Gaines 1992; Sabini and Schulkin 1994) suggest
that the mind must be seen in a context larger than the individual. And
to be fair, researchers in behavioral and psychosomatic medicine have
also felt this need. No doubt, it is this comprehension that has provided
much of the energy for research on social support. Including the social
along with the individual-perceptual has proven valuable in extending
medi997.tex; 23/09/1997; 1:57; v.6; p.23

social scientific perspectives on the etiology of disease (Dimsdale 1995).

But this approach has been limited by the difficulty of translating insights
from culture theory into testable propositions using operational constructs.
In lieu of actual measurements, culturally oriented researchers are forced
to rely on interpretive analyses, which cannot be used to demonstrate
the empirical efficacy of cultural constructs relative to more conventional
social-psychological constructs.
Evaluating social support research in light of culture theory suggests that
the way in which social support is construed and the way in which social
support can be accessed in any group is culturally constructed (Dressler
1994). Testing such a notion requires that the cultural construction of social
support can be unambiguously defined, that an individual’s approximation
to that model of social support can be measured, and that this approx-
imation to a cultural model of social support can be evaluated relative
to more conventional notions of social support. The particular variant of
culture theory employed in this research was D’Andrade’s (1984) theory
of cultural meaning systems. This specific theory proved to be valuable
because it entails the view that culture is fundamentally a system of shared
knowledge that imbues social acts with meaning, and that portions, at
least, of that shared knowledge and meaning reside in representations in
individual minds. At the same time, it is not a reductionist theory in the
sense that all of culture consists of individual cognitive representations and
processing. Rather, the theory of cultural meaning systems encompasses
both the perspective that if culture is to be found anywhere, it must be
found in individuals’ minds (at least to some extent), and that a compre-
hensive understanding of a cultural system requires a level of abstraction
beyond what individuals know and can consciously articulate.
In this research, a cultural model of social support in a Brazilian commu-
nity was derived using previous ethnography, participant-observation,
key-informant interviewing, and the cultural consensus model of Romney,
Weller, and Batchelder (1986). The combination of these techniques
enabled us to identify a hierarchical model of access to social support. In
this model, in most cases members of one’s nuclear and extended family
are the preferred source of support, followed by friends, neighbors, and
other persons. In some instances, this hierarchy is modified with nonkin
sources of support being preferred.
When examined in a representative survey sample, it was found that
50–74% of respondents reported access to social support in a way that was
highly consistent with this model. The remaining 26%, however, reported
patterns of access that were much less consistent with this model. These
individuals had higher blood pressure, and reported more depressive symp-
medi997.tex; 23/09/1997; 1:57; v.6; p.24

toms and more perceived stress, than those persons whose responses were
more consistent with cultural constructions of access to social support. This
was not a function of the overall support perceived by individuals, nor was
it a function of other social, psychological, dietary, or anthropometric vari-
ables (except in one instance). In short, the ways in which individuals
approximate the ideal cultural model of social support is strongly related
to their mental and physical well-being. Put this way, this seems almost
a trivial statement. Yet being able to demonstrate this relationship empir-
ically, and in a way in which the cultural can be disaggregated from the
social-psychological, is not trivial.
The only instance in which another explanatory variable compromised
the association of cultural consonance in social support with an outcome
variable was when depressive symptoms were examined. In that case,
the inclusion of locus of control in the analysis reduced the association
of cultural consonance and depressive symptoms to nonsignificance. Not
surprisingly, cultural consonance in social support is associated with locus
of control. Individuals less consonant with the cultural model of social
support score significantly in the direction of an external locus of control
(F = 5.2; df = 2,247; p = 0.006); that is, individuals less consonant with
the cultural model of social support express a view of themselves as under
the control of forces external to themselves. Conventional discussions of
resources for coping with stressors often oppose social resources, such
as social support, and “personal” resources, such as the beliefs regarding
self-efficacy described by the construct of locus of control (Dressler 1991a:
18–22). The results regarding depressive symptoms could be interpreted
as demonstrating the superior empirical efficacy of locus of control with
respect to depression; this interpretation, however, may require too much
faith in the power of statistical techniques to disentangle causal relation-
ships. It is equally plausible that a particular view of oneself as embedded
in a culturally appropriate nexus of supportive relationships is conducive
to a view of oneself as able to influence events and circumstances. In this
sense, constructs describing the self may mediate the association between
cultural constructs and symptoms of distress.
The empirical demonstration of the importance of cultural consonance
here is not without its shortcomings. It should be clear from this presen-
tation that these data were collected using what might be thought of as an
emergent research design. That is, over a period of three years insights were
generated and research operations to examine those insights were devel-
oped. This resulted, for example, in a lack of functional correspondence
between the phrasing of questions to develop the consensus model of social
support and the phrasing of questions regarding access to social support in
medi997.tex; 23/09/1997; 1:57; v.6; p.25

the survey component of the research. This led to a somewhat ungainly, and
not entirely satisfactory, process of assessing individual approximation to
the cultural model of social support. Nevertheless, the pattern, consistency,
and robustness of the results lend credence to the research operations. Some
of these continuing methodological problems can be addressed in future
research.
These results pose additional interesting questions, one of which
concerns the influences on cultural consonance in social support. That
is, why do some people not report access to social support in a way that is
consistent with their culture? First, do they not know their own culture? It is
important to emphasize here that phrasing this question in this way is based
on a chain of inference combining ethnography and survey research. We
are assuming that what we learn from key informants can be generalized
to represent the knowledge generally shared within a community. And of
course, this has always been the rationale behind the use of key informants
in anthropological research; namely, that intensive interviewing with a few
well-chosen key informants can provide some kinds of cultural informa-
tion that holds true for a community. The consensus model systematizes
this general idea by, in essence, measuring the reliability of key infor-
mants. If informants are measurably consistent with one another, then it
can be assumed that the information they provide can be generalized to the
community. Furthermore, taking into account potential intracultural diver-
sity, as we did, contributes to our confidence that, in this case, the cultural
model of social support generalizes across diverse contexts. Therefore,
the likely answer to this question is that the divergence of individuals’
reporting of their preferences in social support is not the result of their
not knowing the model, because ethnographic operations indicate that the
model is generally shared.
Second, are there obstacles preventing them from accessing social
support in a culturally preferred way? One way of approaching this issue is
to examine the correlates of cultural consonance. The association of other
variables with cultural consonance in social support is neither extensive
nor strong. For example, the percentage of persons who fall into CG3,
the group that least well approximates the cultural ideal, is highest in the
favela (41.8%), and progressively declines in the conjunto (24.6%), the
traditionally middle class neighborhood (19.3%), and the upper middle
class neighborhood (16.4%). This difference is statistically significant
(2 = 16.12, df = 6, p = 0.013). Beyond what appear to be these obvi-
ous wealth differences, there are few correlates of cultural consonance in
social support. This association needs to be understood in relation to the
fact that key informants in the favela show no difference in their cultural
medi997.tex; 23/09/1997; 1:57; v.6; p.26

competence with respect to the model of social support in the cultural con-
sensus analysis. This would suggest that the favelados share the cultural
model, but that they do not use it, which is consistent with other obser-
vations of lower class social organization in Brazil. As others have noted
(Kottak 1967; Sarti 1995), the demands of maintaining the cultural ideal of
the dense social network for the Brazilian poor may be more than the sys-
tem can handle. At the same time, however, the deviation from that ideal
shows up in higher blood pressure and more expressed distress. This may
then be a part of the way in which the poor suffer the insults to their health
so widely observed in epidemiologic studies, by not having the resources
sufficient to live life in accordance with prevailing cultural standards.
These points lead also to a consideration of the psychophysiologic
processes by which a lack of cultural consonance produces its effects.
Research on mechanisms mediating social and psychological processes
has progressed considerably, and in most such models individual percep-
tion or appraisal sits squarely in the middle of the process (McEwen and
Stellar 1993). In research on social support, it is generally assumed that the
perception that social support is available in turn reduces the likelihood that
events or circumstances will be perceived as stressful, thus reducing the
probability of disease (Cohen, Kaplan, and Manuck 1994: 204). The results
presented here can be interpreted as at least complicating this perspective.
As noted earlier in the analysis, persons in the cultural consonance group
that least approximates the ideal model report less overall support, but it
is not that lower reported support that is most strongly associated with
poorer health outcomes; rather, it is the lack of consonance with the cultur-
ally shared pattern of reporting social support that is associated with poorer
health outcomes. The individuals may or may not perceive themselves to
have little support. This presents a challenge to the standard model of
stress appraisal. Either appraisal is not all that important, or the concept
of appraisal must be modified to take into account the central role of the
cultural construction of those appraisals.
A slightly different view of the process, one that explicitly takes culture
into account, was suggested by Cassel and his colleagues (Cassel, Patrick,
and Jenkins 1960; Henry and Cassel 1969) some years ago. In this view,
under certain conditions, there may develop a kind of cultural incongru-
ence, or a discrepancy between the cultural meaning system of a community
and the perceptions of individuals. Such a discrepancy could be generated
by social change, or by the movement of migrants into a host community.
By either pathway, the conflict between prevailing systems of meaning and
the ideas or behaviors of individuals could lead to confusion and uncer-
tainty in social interaction, which in turn could be stressful and lead to
medi997.tex; 23/09/1997; 1:57; v.6; p.27

poor health status. Such a process might involve conscious appraisal of the
discrepancy. Or, it might be more akin to a cognitive dissonance process,
in which individual behaviors are subject to competing demands. In either
event, these results suggest that individual appraisals must be explicitly
viewed in the context of cultural meaning systems, and not as purely
individual perceptions. For our purposes here, however, it is probably
most important to emphasize that these results, if they stand up to further
empirical scrutiny, may contribute to a revision of prevailing theories of
psychosomatic processes.
Needless to say, it is precisely that further empirical scrutiny that is now
needed. These results provide an interesting and potentially fruitful avenue
for examining the overlap of human biological processes and cultural
processes, something that has long intrigued students of culture, but which
has proven difficult to realize.
ACKNOWLEDGEMENTS
The research on which this study is based was funded by a grant from
the National Science Foundation (BNS-9020786) and with research funds
provided by The University of Alabama. Dr Kathryn S. Oths has provided
guidance, assistance and critique throughout the entire project.
NOTES
1. The point we are making here is relevant regardless of whether or not one accepts the
hypothesis that perception of support is the only important aspect of support. The same
argument would apply if one were to insist on studying received support.
2. Cultural consensus modelling was originally developed for use with dichotomous
items, although its use has been extended to rankings and interval data (Romney and
Batchelder 1987; Weller 1987). As a way of checking the results obtained here, the
highly ranked responses were treated as the “correct” answers in the task, and the lower
ranked responses were treated as “incorrect” responses, generating a matrix of yes-no
reposes. When this was used as input, essentially the same results were obtained in the
consensus analysis, lending support to our use of the rankings as scores.
3. As a way of assessing the reasonableness of this conclusion, and as a way of determining
the association of this cultural model with reported behaviors, the data given in Table 2
were examined in relation to aggregate reported social support behaviors in the survey
sample. Two columns of numbers were generated. The first was simply the ratings from
the cultural consensus model given in Table 2, only ordered as a column in which each
row was a problem/supporter combination. The second column of numbers was the
percentage of respondents in the survey research who reported selecting a relative in
response to needing a loan, followed by the percentage who reported selecting a friend
medi997.tex; 23/09/1997; 1:57; v.6; p.28

in response to needing a loan, and so on for all of the problem/supporter combinations.

Then, a standard Pearson correlation coefficient was calculated between these two sets
of figures, which is a measure of how well the key informant consensus ratings describe
what 250 survey respondents reported. This correlation is r = 0.92. In other words, the
consensus model of social support describes almost perfectly the aggregate behavior of
a survey sample of 250 persons who were responding to questions about social support.
Put differently, it is not unreasonable to conclude that, at least in the aggregate, survey
respondents’ reported preferences regarding social support are patterned in terms of
how the domain of social support is culturally constructed.
4. We can evaluate the validity of these groupings in the same way that the profile
similarity of the consensus ratings and the reported access to social support for the
entire survey sample was examined. The percentage of respondents selecting different
sources of support within each of these groups can be correlated with consensus model
ratings. When this is done, the correlation for CG1 is r = 0.93. The correlation for CG2
is r = 0.83. And, the correlation for CG3 is r = 0.74. In the aggregate, persons in CG1
have the highest profile similarity with the consensus model; persons in CG2 have the
next highest; and, persons in CG3 have the lowest profile similarity with the consensus
model. This is confirming evidence that, in the aggregate, these three groupings order
persons in the survey sample in terms of their approximation to the cultural model of
social support. In the aggregate, persons in CG3 show the least relative approximation
to the cultural model of social support in their individual responses.
5. More precise category differences were also examined. CG3 is statistically different
<
from CG1 for both systolic blood pressure (p 0.001) and for pulse pressure (p <
<
0.001), and CG2 is statistically different from CG1 for pulse pressure (p 0.05). For
<
diastolic blood pressure, CG3 shows a marginal (p 0.08) difference from CG1. For
depressive symptoms, the significance of the effect of cultural consonance is produced
entirely by the difference between CG3 and CG1 (p < 0.02). For perceived stress,
<
the difference between CG3 and CG1 is significant (p 0.001), while the difference
between CG2 and CG1 achieves borderline significance (p 0.08).<
6. The form of each of these analyses was the same. The standard covariates and the
dummy variables measuring cultural consonance in social support were forced into the
equation; competing explanatory variables were then allowed to enter on a stepwise
basis.
medi997.tex; 23/09/1997; 1:57; v.6; p.29

Appendix Table A1. Descriptive statistics
Descriptive statistics
Systolic blood pressure 124.3 ( 18.4)

Diastolic blood pressure 80.7 ( 12.8)
Pulse pressure 43.6 ( 9.9)
Depressive symptoms 20.2 ( 6.8)
Globally perceived stress 20.9 ( 6.9)
Age 40.8 ( 11.3)
Sex (% male) 40.8
Body mass index 24.9 ( 4.9)
Skin color (% preto/pardo) 19.6
Cultural consonance in social support
% Consensus group 1 54.4
Locus of control 7.5 ( 3.3)
Perceived social support 5.3 ( 2.5)
Social integration 0.8 ( 0.8)
Sodium intake (mg) 3751.6 ( 1805.1)
Alcohol intake (g) 52.1 ( 136.4)
Total fat intake (% of total calories) 34.6 ( 8.3)
Household income (minimum salaries) 6.6 ( 3.7)
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medi997.tex; 23/09/1997; 1:57; v.6; p.33

WILLIAM W. DRESSLER, MAURO CAMPOS BALIEIRO AND JOSE ERNESTO DOS SANTOS
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WILLIAM W.

DRESSLER, MAURO CAMPOS BALIEIRO AND

THE CULTURAL CONSTRUCTION OF SOCIAL SUPPORT IN

There is a general recognition of the importance of social relationships

Culture, Medicine and Psychiatry 21: 303–335, 1997.

VICTORY PIPS: 125141 HUMNKAP

social support access that reflected the extent to which an individual’s

SOCIAL SUPPORT AND HEALTH STATUS

A considerable amount of research effort in the sociomedical sciences

medi997.tex; 23/09/1997; 1:57; v.6; p.2

nence, there is not much evidence to support this behavioral interpretation

medi997.tex; 23/09/1997; 1:57; v.6; p.3

CULTURE, SOCIAL SUPPORT, AND HEALTH STATUS

In much of the literature in behavioral medicine and epidemiology, the

medi997.tex; 23/09/1997; 1:57; v.6; p.4

examined blood pressure, psychological distress, and social support among

medi997.tex; 23/09/1997; 1:57; v.6; p.5

THEORY AND METHOD IN EXAMINING THE CULTURAL

D’Andrade’s (1984) model of cultural meaning systems is a useful one

medi997.tex; 23/09/1997; 1:57; v.6; p.6

THE RESEARCH SITE

medi997.tex; 23/09/1997; 1:57; v.6; p.7

medi997.tex; 23/09/1997; 1:57; v.6; p.8

SOCIAL ORGANIZATION AND SOCIAL SUPPORT IN BRAZIL

Discussions of social organization in Brazil typically begin with the family.

medi997.tex; 23/09/1997; 1:57; v.6; p.9

bureaucratic definition of social beings as individuals, versus the definition

DATA COLLECTION: AN OVERVIEW

medi997.tex; 23/09/1997; 1:57; v.6; p.10

medi997.tex; 23/09/1997; 1:57; v.6; p.11

because of the willingness of the respondents to participate. An unstruc-

GENERATING A CULTURAL MODEL OF SOCIAL SUPPORT

Anthropology has been hampered by the lack of a quantitative measure-

medi997.tex; 23/09/1997; 1:57; v.6; p.12

medi997.tex; 23/09/1997; 1:57; v.6; p.13

Table 1. Cultural consensus analysis of rankings of social support

Consensus level 3.11

Mean cultural competence coefficients

See text for definitions.

shared cultural model regarding social support in making their (partially

medi997.tex; 23/09/1997; 1:57; v.6; p.14

Wanting a loan 1.69(1) 2.46(2) 3.42(3) 3.44(4) 3.99(5)

Numbers are consensus rankings of who would be sought as a source of support

medi997.tex; 23/09/1997; 1:57; v.6; p.15

THE DISCOURSE ON SOCIAL SUPPORT

The following discussion was provided by an older man living in the

The following exchange between interviewer and respondent was typical

Another respondent from the upper middle class neighborhood, a success-

medi997.tex; 23/09/1997; 1:57; v.6; p.16

These data from open-ended interviews provide two additional bits of

CULTURAL CONSONANCE IN SOCIAL SUPPORT: A MEASURE

In order to examine this question we need some measure of an individual’s

medi997.tex; 23/09/1997; 1:57; v.6; p.17

medi997.tex; 23/09/1997; 1:57; v.6; p.18

CULTURAL CONSONANCE IN SOCIAL SUPPORT AND

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Table 3. Health outcomes in relation to consensus groups

CG1 119.6 79.1 40.7 19.5 19.8

CULTURAL CONSONANCE VERSUS INDIVIDUAL DIFFERENCES

Not surprisingly, the three groups that differ in their approximation to

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medi997.tex; 23/09/1997; 1:57; v.6; p.21

Systolic blood pressure 124.3 ( 18.4)