Balieiro, Mauro C., Manoel A. dos Santos, José Ernesto dos Santos, and William W. Dressler. (2011)...

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Mauro C. Balieiro, Manoel Antônio dos Santos, José Ernesto dos Santos and William W.depression?

Does perceived stress mediate the effect of cultural consonance on

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DOI: 10.1177/1363461511418873 tps.sagepub.com

Does perceived stress mediatethe effect of cultural consonanceon depression?

Mauro C. BalieiroPaulista University

Manoel Antonio dos Santos and Jose Ernesto dos SantosUniversity of Sao Paulo-Ribeirao Preto

William W. DresslerThe University of Alabama

Abstract

The importance of appraisal in the stress process is unquestioned. Experience in the

social environment that impacts outcomes such as depression are thought to have these

effects because they are appraised as a threat to the individual and overwhelm the indi-

vidual’s capacity to cope. In terms of the nature of social experience that is associated

with depression, several recent studies have examined the impact of cultural conso-

nance. Cultural consonance is the degree to which individuals, in their own beliefs and

behaviors, approximate the prototypes for belief and behavior encoded in shared cultural

models. Low cultural consonance is associated with more depressive symptoms both

cross-sectionally and longitudinally. In this paper we ask the question: does perceived

stress mediate the effects of cultural consonance on depression? Data are drawn from a

longitudinal study of depressive symptoms in the urban community of Ribeirao Preto,

Brazil. A sample of 210 individuals was followed for 2 years. Cultural consonance was

assessed in four cultural domains, using a mixed-methods research design that integrated

techniques of cultural domain analysis with social survey research. Perceived stress was

measured with Cohen’s Perceived Stress Scale. When cultural consonance was examined

separately for each domain, perceived stress partially mediated the impact of cultural

consonance in family life and cultural consonance in lifestyle on depressive symptoms.

When generalized cultural consonance (combining consonance in all four domains) was

examined, there was no evidence of mediation. These results raise questions about how

culturally salient experience rises to the level of conscious reflection.

Corresponding author:

William W. Dressler, Department of Anthropology, The University of Alabama, PO Box 870210, Tuscaloosa,

AL 35487-0210, USA.

Email: [email protected]




Keywords

cultural consonance, perceived stress, depression, Brazil, mediation

There is general agreement on the outlines of a model of psychosocial stress. In thismodel, both chronic and acute difficulties in life create threats to an individual’ssense of well-being. Individual appraisal of threat is a central cognitive mechanismmediating the impact of events and circumstances. Drawing on both social andpsychological resources, individuals adjust to these difficulties in order to reducethis sense of threat. If the psychological and social resources for adjusting to diffi-culties are deemed adequate, secondary appraisal leads to a reduced sense of threatand long-term complications can be avoided. If the threat continues, however, long-term complications, such as depression, can ensue (Monroe, 2008).

The role of culture in this stress process has been examined in several ways. It hasbeen shown that in situations of social change and modernization, certain kinds ofspecialized stressors arise as a function of political-economic processes. Also, themeasurement of specific elements of the stress process has been modified to makethose measurements culturally appropriate (Dressler, 1996).

More recently, the role of cultural consonance has been examined as a predictorof depressive symptoms. Cultural consonance is the degree to which individualsapproximate, in their own beliefs and behaviors, the prototypes for those beliefsand behaviors encoded in cultural models. This concept helps to resolve an oldproblem in social theory, namely the relationship of culture, conceived of as collec-tive representation, and individual belief and behavior. Low cultural consonance (ingeneral) is a chronically stressful circumstance and is associated with worse healthoutcomes (Dressler, 2007).

Our aim in this paper is to examine the effects of cultural consonance on depres-sive symptoms, relative to a measure of individual appraisal. At one level, this is astraightforward comparison of the predictive effects of variables shown to influencedepression. At another level, this comparison addresses fundamental questions bothabout culture and the stress process.

Appraisal and the stress process

Through the life course, individuals are faced with problems that must be resolvedif they are to realize central life goals. These problems can be chronic and longterm, or they can be acute and short term. If these difficulties are meaningful tothe individual, he or she will attempt to adjust in some way. These adjustments maytake the form of behavioral or psychological strategies to alter the meaning of thedifficulty, or they may take the form of seeking the advice and counsel of others.In either case, if these social or psychological resources are helpful, then the diffi-culty can be addressed in some way, with its impact being consequently reduced(Monroe, 2008).

2 Transcultural Psychiatry 48(5)




In the stress model, chronic and acute difficulties are referred to as ‘‘stressors.’’The social and psychological resources that individuals bring to bear on thesestressors are referred to alternatively as ‘‘coping strategies,’’ ‘‘protective strategies’’and ‘‘social support.’’ At times these variables are treated as independent influenceson outcomes (i.e., main effects), and at other times their interdependence (in theform of the buffering model) is emphasized. Outcomes that have been studied rangefrom the purely psychological (such as depressive symptoms) to the purely physio-logical (such as blood pressure). The terms ‘‘the stress model’’ or ‘‘the stress pro-cess’’ are then used to describe the entire process (Dressler, 2011).

Since the publication of Richard S. Lazarus’s landmark work (1966), the appraisalof stress has been a central theoretical construct in research, if not always a measuredvariable. Appraisal refers to how stressors are cognitively evaluated, especiallywhether or not individuals define them as a threat to their well-being, or believethemselves to have a sense of control over the stressors. Psychological threat usuallyrefers to the risk of loss of an individual’s self-esteem or social status, and control canalso refer to a psychological more than a physical influence. The degree of threat andlack of control in turn determines the impact of the stressor. Additionally, appraisalprocesses are thought to guide recourse to resources for adjusting to stressors and theevaluation of the adequacy of those resources (Herbert & Cohen, 1996, p. 317).Monroe (2008) points out that the above described model is based on NorthAmerican and European middle-class normative understanding of the importanceof the individual and his or her thoughts. This model of the person is agentic, volun-taristic, and individualistic. As Young (1980) put it, stress research reproduces aWestern, middle-class understanding of what it means to be a person.

Making the individual and his or her construal of the world central to the stressprocess has been criticized by others, notably George W. Brown. Beginning with aseminal paper in 1974, Brown criticized the notion that individual appraisal is ofcentral importance in defining the threat associated with a stressor; rather, heargued, threat is a social construction (Brown, 1974). Brown pointed out anumber of reasons why an individual’s definition of threat might be problematic,not the least of which is that consciously reported stress may in itself be an attemptto cope with the stressor (e.g., ‘‘controlling‘‘the threat by minimizing it). Brownargued that a better evaluation of threat is to be found in the social environment.That is, given the occurrence of a stressor, and given the social and personalcontext within which it occurs, would a reasonable person regard that stressor asthreatening? Brown’s work has had a major influence on research in the area,especially with respect to the measurement of stressful life events (Brown &Harris, 1978). At the same time, in Brown’s work the collective understanding ofthe impact of stressors is not examined within the community within which theyoccur, but rather by a set of ‘‘experts’’ in the form of a panel of researchers. Therelationship of these evaluations to the cultural construction of meaning within thecommunity is unclear.

These critiques notwithstanding, appraisal processes are still appropriatelyregarded as central to the stress process, and many have tried to measure stress

Balieiro et al. 3




appraisal. Two approaches have been used. In the measurement of acute stressors,some researchers ask respondents to rate the stressfulness of specific events that theyhave experienced. Stress appraisal is then measured as the sum of these ratings. Withrespect to chronic stressors, measurement has essentially defaulted to subjectiveratings, since the scales measuring chronic social role stressors depend on theself-report of respondents (Herbert & Cohen, 1996; Monroe & Kelley, 1995).

There is also a general measure of appraisal in the form of Cohen’s PerceivedStress Scale (PSS) (Cohen, Karmack, & Mermelstein, 1983). The PSS is explicitlyconsidered to be a measure of the appraisal of stress, but in a global sense. As Cohennotes:

PSS items were designed to tap the degree to which respondents find their lives unpre-

dictable, uncontrollable, and overloading: three issues central to the appraisal of

stress . . . the scale attempts to represent situations where persons perceive that their

demands exceed their ability to cope. (Cohen, 1986, p. 325)

Cohen argues that an advantage of the scale is that it is not tied to the occurrence ofa particular event or circumstance. Rather, it is intended to allow the individual toassess all events and circumstances meaningful to him or her, and to assess whetheror not these demands exceed his or her ability to respond (Cohen, 1986). Monroe(2008) notes that the PSS is probably the most widely used measure of perceivedstress, conceived of as global appraisal, in research today.

There is thus a synthesis in literature on stress that identifies environmentalevents and circumstances that are appraised as threatening as potential risks fornegative health outcomes. It is recognized that the true degree of threat at times maybe best estimated by the social construction of the impact of those events and cir-cumstances. However the individual’s appraisal of the impact of events and circum-stances, including the global appraisal of threat as assessed by the PSS, is regardedas central in the stress process.

Cultural dimensions of the stress process

Discussions of cultural dimensions of the stress process parallel the development ofthe stress model in other fields, although the literature is not nearly so large. Forexample, the anthropologist William Caudill (1958) developed a theoretical modelof stress incorporating ‘‘cultural stressors’’ early in the growth of this literature. Butthe enduring contributions of anthropology to the stress literature took the form ofempirical studies of rapid social change, modernization, and migration, and howthese sociocultural processes influence health outcomes (Dressler, 1999).

Based on that literature, Dressler (1982) argued for the importance of statusinconsistency for psychological distress. He argued that the principal impact ofmodernity was a shift in systems of social status from local systems based on tra-ditional criteria to global systems based primarily on the ability of households toachieve North American lifestyles (in the sense of the accumulation of material





consumer goods and the adoption of related leisure activities). Aspirations for novellifestyles occurred in the context of a limited capacity for the economic support ofthese lifestyles as a result of uneven income growth within developing communities.This could lead to situations of individuals attempting to maintain higher statuslifestyles in the context of meager incomes, and this was hypothesized to be chron-ically stressful. This form of status incongruence—referred to accurately, if some-what infelicitously, as ‘‘lifestyle incongruity’’—was associated with higher bloodpressure, compromised immune status, and depression in diverse settings(Dressler, 1982, 1990; McDade, 2001, 2002).

In studies of lifestyle incongruity it was argued that individual motives did notrevolve around consumption per se, but consumption that satisfied the achievementof what Veblen termed a ‘‘basic standard of decency’’ (Veblen, 1912). This referredto a basic lifestyle profile that corresponded to what a ‘‘decent’’ person would ownor do, or a kind of middle-class propriety. Furthermore, even though the advance ofmodernity continues to have a standardizing influence regarding notions of ‘‘thegood life,’’ local variations from one setting (or culture) to another would undoubt-edly remain. This led Dressler to argue that the essential part of the process was thelocal cultural definition of a lifestyle consistent with leading such a ‘‘good life,’’ andin turn individuals’ variable successes in achieving this culturally defined target.Seeing oneself, and being seen by others, as not achieving local, culturally definedstandards was hypothesized to be stressful (Dressler, 1990).

This led Dressler to propose a broader concept of ‘‘cultural consonance.’’Cultural consonance is the degree to which individuals approximate, in their ownbeliefs and behaviors, the prototypes for those beliefs and behaviors encoded inshared cultural models (Dressler, dos Santos, & Balieiro, 1996). The concept ofcultural consonance is embedded in a larger cognitive theory of culture, in whichculture is defined as the knowledge one must possess to function effectively in agiven social setting (Goodenough, 1996). This knowledge is encoded in the form ofshared (or cultural) mental models of specific cultural domains. Cultural modelsdefine the elements of the domain, how those elements are linked in a semanticnetwork, and prototypical processes defining functional relationships among ele-ments. The degree to which salient dimensions of cultural models in specificdomains are shared and distributed can then be assessed using the cultural consen-sus model (Romney, Weller, & Batchelder, 1986). Finally, the cultural consensusmodel can be used to estimate how a reasonably culturally competent respondent ina given social setting would evaluate the elements of the cultural model along thesedimensions.

Cultural consonance is then measured by comparing the behaviors and beliefs ofindividuals to consensus models regarding those beliefs and behaviors. Using thisapproach, Dressler and colleagues have measured cultural consonance in diversecultural domains in research in the African American community in the USA andurban Brazil. Low cultural consonance in the domains of lifestyle and social supportwas associated with higher blood pressure and body composition (Dressler,Balieiro, & dos Santos, 1998; Dressler, Balieiro, Ribeiro, & dos Santos, 2005;

Balieiro et al. 5




Dressler & Bindon, 2000; Dressler, Oths, Ribeiro, Balieiro, & dos Santos, 2008).Low cultural consonance in a wider variety of domains, including family life,national identity and food, was associated with generalized psychological distressand depressive symptoms, independently of stressful life events. This was foundboth in cross-sectional and longitudinal studies (Dressler, Balieiro, Ribeiro, & dosSantos, 2007a, 2007b). The inability to put into practice widely shared models ofhow life is to be lived appears to be a stressful experience.

It is important to emphasize here that when cultural consonance is measured, weare assessing how well an individual matches in belief or behavior the shared modelfor that domain; we are not assessing whether or not they are matching some sub-jective or idiosyncratic representation of the domain. In other words, an individual’sappraisal of their success in achieving personally defined life goals is ignored in favorof their success in achieving shared culturally defined life goals.

The question presents itself: is cultural consonance associated with stress out-comes (such as depressive symptoms) independently of the appraisal of stress, ordoes individual appraisal mediate the effect of cultural consonance on depression?This question propels the current paper.

The research site

This research was carried out in the city of Ribeirao Preto (pop¼ 500,000), an urbancommunity in the north of the state of Sao Paulo in Brazil. The city is a center forlight manufacturing and finance serving the agro-industries of the area, as well as aregional center for education and health care. The data on which this paper is basedwere collected between 2001 and 2005.

Four neighborhoods differing in socioeconomic status were used as samplingstrata. A stratified sampling strategy was employed in order to compensate forthe wide economic disparities in Brazilian society. The first neighborhood hadbegun as a favela or squatter settlement. After over 10 years of existence, the munic-ipality built a small housing project of simple, concrete-block houses and moved thepopulation of the favela there. Average incomes are significantly lower than otherneighborhoods, and it retains an unsavory reputation for crime and drug trafficking.Residents tend to be employed as unskilled laborers or domestics.

The second neighborhood began life some 20 years ago as a conjunto habitacional.Another kind of municipal initiative, this involves a partnership between the cityand a developer to provide housing for what could roughly be termed the lowermiddle class. This conjunto has developed rapidly, and now boasts a wide range ofservices, including a supermarket, pharmacies, and other commercial outlets.Residents include schoolteachers, technicians, and sales clerks.

The third neighborhood is a traditional middle-class neighborhood that datesback to the founding of the city at the turn of the 20th century. The neighborhoodis renowned as representing a kind of Old World gentility The neighborhood has itsown central business district with all commercial amenities. Houses present a





seamless wall to the cobbled streets. Neighborhood residents work at variedoccupations and include small business owners and lower level professionals.

The fourth neighborhood is a gated subdivision that caters to the upper middleclass. It consists of large houses owned by physicians, attorneys, and executives inlarge companies and financial institutions.

Methods

Data are derived from a 2-year longitudinal study, enabling causal sequences to bemore reliably evaluated. Research on cultural consonance requires a multistage,mixed-methods research design. The first stage is a cultural domain analysis(Borgatti, 1999) to identify emically, in the words of the respondents themselves,the important elements of the domain and their meaning. This stage of researchculminates in a test for cultural consensus along relevant dimensions of the domain.The results of the cultural consensus analysis can then be used to develop measuresof cultural consonance. The second stage consists of an epidemiologic survey tocollect data for the testing of hypotheses regarding the effects of cultural conso-nance. The research protocol was reviewed and approved by both the InstitutionalReview Board for the Protection of Human Subjects of The University of Alabama,and the Ethics Committee of the Faculty of Medicine of Ribeirao Preto, theUniversity of Sao Paulo. All research participants provided informed consent.Research methods have been described in detail in a number of papers, so a briefoverview will be provided here (Dressler, Borges, Balieiro, & dos Santos, 2005).

Cultural domain analysis

The cultural domains selected for investigation include lifestyle, social support,family life, and national identity. A key to identifying cultural domains is theiruse in everyday conversation. All of these domains are likely to be the topic ofspontaneous discussion in many settings. Lifestyle (estilo da vida in Portuguese)refers to the material goods and leisure time activities that define ‘‘having a goodlife.’’ Social support (suporte social) refers to the kinds of persons who can beapproached for help and assistance in times of felt need. Family life (a vida familiar)may be one of the most frequently encountered subjects (along with politics andfootball) in everyday conversation. And national identity (sometimes referred to as‘‘Brazilian-ness’’ or Brasililidade) is a topic of endless discussions.

Several types of interviews were employed to investigate these domains. Witheach type of interview, respondents were purposively selected to have equal numbersof people under and over age 45; equal numbers of men and women; and, equalnumbers of people with primary, secondary, and university educations (a proxy forsocial class). In the cultural domain analysis sample sizes ranged from 30 to 45,depending on the aim of the interview, and some respondents participated ineach step.

Balieiro et al. 7




The investigation of each domain began with a free-list exercise, in which respon-dents were asked to list elements of the domain (e.g., ‘‘What things are important tohave to live a good life?’’). Terms from the free lists were then selected based on theirsalience, which combines the number of people listing the item and the average rankat which it appears in the free lists. Care was also taken to sample the full range ofmeaning in each cultural domain. Twenty to 30 terms were selected for each domain.

Then, respondents were asked to perform unconstrained pile sorts for eachdomain. Pile sorting is useful for determining the similarity and differences in mean-ing among terms within a domain, and especially for identifying distinctive featuresthat persons use to distinguish among the terms. In each domain the ‘‘importance’’or value of an item was a salient dimension. For example, items in the lifestyledomain were judged to be differentially important for having a good life. Certainkinds of potential social supporters were deemed to be more or less important inrelation to specific kinds of problems. In the domain of family life this dimensionwas phrased even more bluntly: certain family characteristics were deemedmore important ‘‘para ter uma familia’’ (to have a family). And finally, character-istics of national identity were more or less important in distinguishing Brazilians.

Another sample rated or ranked domain elements along the dimension of impor-tance within each domain. For the domains of lifestyle and national identity, ele-ments were rated along a 4-point scale (from ‘‘not at all important’’ to ‘‘veryimportant’’). For the domains of family life and social support, rankings wereused. In family life, respondents did a complete ranking of the items from mostto least important for ‘‘having a family.’’ For social support, respondents ranked theimportance of seven different kinds of supporters in response to eight different kindsof problems. These data were obtained from 66 respondents and served as input forcultural consensus analyses. It should be noted that in asking respondents to rate orrank elements, they were not asked to supply their personal, subjective rankings, butrather were asked to rate or rank items ‘‘in terms of the community’’ or for ‘‘peoplearound here.’’

Cultural consensus analyses

Cultural consensus analysis was used to test for agreement along the dimension ofimportance for each of the cultural domains. The ‘‘informal data model’’ (Weller,2007) was employed, which essentially is a principal components analysis of arespondent-by-respondent matrix for each domain. If the ratio of the first tosecond eigenvalues is greater than 3.0, this indicates sharing in the ratings/rankingssufficient to make reasonable the inference that all respondents are using variants ofa single cultural model in making their evaluations. The loadings of respondents onthe first principal component estimate their cultural competence, or how well theirindividual responses estimate the responses of the group as a whole. The followingeigenvalue ratios and mean cultural competences were obtained for each domain:lifestyle (eigenvalue ratio¼ 6.59, mean competence¼ .71� .12); social support(eigenvalue ratio¼ 6.53, mean competence¼ .67� .14); family life (eigenvalue





ratio¼ 7.42, mean competence¼ .82� .09); and, Brazilian national identity(eigenvalue ratio¼ 3.97, mean competence¼ .57� .19). While the degree of sharingor consensus varies from one domain to another, these data are consistent withshared cultural models in each domain.

In a society as large and diverse as Brazil, there is likely to be diversity in theunderstanding of these domains. In cultural consensus analysis, this diversity can beevaluated by examining the distribution of cultural competence across social cate-gories, and by the analysis of residual agreement beyond the overall consensus(Ross & Medin, 2005). In the presence of overall cultural consensus (as exists inall four domains studied here), differences between social categories in culturalcompetence indicate that shared knowledge tends to be concentrated among certainkinds of people. In the presence of overall cultural consensus, differences in residualagreement between social categories indicates, in the case of our study, that certainelements of a domain are valued somewhat more or less by certain kinds of people.For example, while there is overall sharing in the domain of lifestyle, lower classrespondents have higher cultural competence in the model ( p< .01), and they tendto value lifestyle items associated with leisure more than upper class respondents( p< .05). In the domain of family life, women tend to have higher competence thanmen ( p< .01), and lower class respondents put greater emphasis on family structureand organization than do upper class respondents ( p< .01). However, this variationdoes not alter the overall consensus in each domain. Furthermore, adjusting themeasures of cultural consonance (see below) in these domains to take into accountthis variation does not change the associations of cultural consonance and psycho-logical outcomes. This is due to the high overall cultural consensus in each domain(Dressler, 2009).

Given that there is cultural consensus in each domain, the use of these results todevelop measures of cultural consonance was justified.

Measuring cultural consonance

The answer keys from each cultural consensus analysis were used to develop mea-sures of individual belief and behavior in each domain. Each measure was designedso that the similarity or difference in an individual’s belief or behavior to the culturalprototype revealed by cultural consensus analysis could be assessed (see Dressleret al., 2005, for more detail).

. Cultural consonance in lifestyle: Out of the 33 items that were rated in terms oflifestyle, 19 were rated as important or ‘‘very important’’ in having a good life.The measure of cultural consonance in this domain consisted of counting thoseitems affirmed by the respondent (ownership in the case of material goods, doingfrequently in the case of behaviors) and dividing that total by 19.

. Cultural consonance in social support: Respondents were asked to rank theimportance of sources of social support in response to each problem (in thiscase importance referred to availability of that supporter to the respondent

Balieiro et al. 9




for help). These individual responses were then correlated with the consensusresponses from the cultural consensus analysis. For each respondent, this corre-lation assesses cultural consonance in the domain of social support.

. Cultural consonance in family life: A set of 18 Likert-response items was devel-oped. Each item was phrased around an element generated in the free list andexplored in the pile sort. Respondents were asked to assess, on a 4-point agree–disagree scale, if their families could be characterized by that element from thecultural domain analysis. Also, items were weighted by the importance of theelement as assessed by the consensus analysis (weights were used in this scale tomaximize the information used from the cultural consensus analysis). This scalehas acceptable reliability (Cronbach’s alpha¼ .88).

. Cultural cynicism: The cultural domain of national identity was complex, in thatit encompassed both positive and negative characteristics of Brazilians. As in thedomain of family life, Likert-response items were constructed to determinerespondents’ perceptions of their peers in terms of those characteristics. In scalinganalyses of survey data, only the items that described Brazilians negativelyformed an internally consistent scale. These characteristics included a view ofothers as untrustworthy and quick to resort to the Brazilian practice of o jeitinho,a culturally constructed means of violating social norms. We have labeled thissubscale ‘‘cultural cynicism.’’ Higher cultural consonance in the other threedomains is associated with lower cultural cynicism (see Dressler et al., 2007a,for a longer discussion). This subscale has acceptable reliability (Cronbach’salpha¼ .69).

In addition to cultural consonance in each specific domain, exploratory analysesdemonstrated that all four measures of cultural consonance loaded on a singleprincipal component (which accounted for about 50% of the variance among theitems). There is thus a tendency for individuals who are culturally consonant inone domain to be consonant in others as well, and a principal-component scorecombining levels of cultural consonance across the four domains is termed ‘‘gener-alized cultural consonance’’ (see Dressler et al., 2007a, for a more completediscussion).

Survey sampling

Simple random samples of households were selected from each of the neighbor-hoods using complete enumerations of occupied dwellings, based on municipalservice records. Within each household, the head of household, spouse, and onechild over the age of 18 were invited to participate in the research. This resulted in asample of 271 persons, which is a response rate of 72.3%. For the 2-year follow-up,210 members of the original sample agreed to be reinterviewed (77.5% of theoriginal sample). The Time 1 and Time 2 samples were compared on all vari-ables included in this analysis using goodness-of-fit tests, and there were nodifferences.





Measurement of depressive symptoms, perceived stress, and covariates

The outcome variable in the research reported here is depressive symptoms, asmeasured by a Brazilian Portuguese version of the Center for EpidemiologicStudies Depression Scale (CES-D), translated and validated by da Silveira andJorge (2000). The CES-D has acceptable reliability in this sample (Cronbach’salpha¼ .88).

The exposure variable (in addition to cultural consonance previously described)is perceived stress, as measured by Cohen’s Perceived Stress Scale (PSS) (Cohenet al., 1983), translated into Portuguese and then back-translated by our researchgroup in a previous study (Dressler et al., 1998). In that study and in the currentstudy, the PSS was found to have satisfactory internal consistency (Cronbach’salpha> .78) and to be highly correlated with depressive symptoms (r> .60 forboth studies).

For the purposes of this paper, three covariates are employed: age (assessed asreported age in years); gender (coded as women¼ 0 and men¼ 1); and, socioeco-nomic status (SES). SES was assessed as a composite scale of household income(reported in numbers of minimum salaries per month), education (reported as yearsof education completed), and occupational status. The latter was coded using thescale reported in Pastore (1982), which was developed in Brazil in research onoccupational mobility. A single principal component accounts for 60.7% of theshared variance in these three variables, and the principal component score isused as the measure of SES.

Data analysis and modeling strategies

To test the mediation hypothesis, data analytic procedures proposed by Baron andKenny (1986) were employed. The essential features of this approach are first todetermine that the exposure variable of interest (cultural consonance in this case)has an independent effect (net of covariates) on the outcome variable (depressivesymptoms), using ordinary least squares regression analysis. It should also be asso-ciated with the mediating variable (perceived stress), which should itself have aneffect on the outcome variable. Then, when controlling for perceived stress, theeffect of cultural consonance should be substantially reduced, perhaps even tozero in the case of a very strong mediating effect. Finally, the indirect effect ofcultural consonance on depressive symptoms can be estimated as the product ofits effect on perceived stress and the effect of perceived stress on depression, and thestatistical significance of this mediating effect can be tested.

Two tests of the mediation hypothesis are presented. In the first, the four separatemeasures of cultural consonance are entered simultaneously. In the second, the com-posite measure of generalized cultural consonance is entered. It should be empha-sized that the data employed here are from a prospective follow-up, so thatdepressive symptoms measured at Time 1 (as well as Time 1 values of all othervariables) can be used as covariates, along with age, sex, and socioeconomic

Balieiro et al. 11




status. These data thus provide a stronger foundation for causal inference.Throughout the analysis, standardized regression coefficients are reported.

Results

Descriptive statistics for all variables included in the analyses are shown in Table 1.The first analysis, in which the four measures of cultural consonance are consideredas separate variables, is shown in Table 2. When the four Time 2 measures of cul-tural consonance are entered as a block, cultural consonance in family life andcultural consonance in lifestyle both have significant effects ( b¼�.26 andb¼�.21 respectively). When PSS at Time 2 is entered, the effect of cultural conso-nance in family life is reduced substantially, but remains statistically significant( b¼�.17, p< .05), and the effect of PSS at Time 2 is substantially larger( b¼ .35). The effect of cultural consonance in lifestyle is reduced to statistical non-significance ( p< .10) when PSS is controlled.

In the second analysis, the measure of generalized cultural consonance (whichcombines all four measures of cultural consonance as a single principal-componentscore) was used. This analysis is shown in Table 3. When the measure of generalizedcultural consonance is entered into the analysis, it has a significant effect on

Table 1. Descriptive statistics, Time 1 (N¼ 271) and Time 2 (N¼ 210)

Mean Standard deviation

DepressionTime 1 12.46 10.16

DepressionTime 2 11.94 9.70

Age* 40.95 11.65

Socioeconomic status (SES)* 0.00 1.00

Sex (% male)* 0.39 0.00

Perceived stress (PSS)Time 1 9.31 5.74

Perceived stress (PSS)Time 2 9.77 5.78

Cultural consonance in family lifeTime 1 106.91 24.59

Cultural consonance in family lifeTime 2 102.74 21.77

Cultural consonance in lifestyleTime 1 0.67 0.15

Cultural consonance in lifestyleTime 2 0.69 0.16

Cultural consonance in social supportTime 1 0.48 0.19

Cultural consonance in social supportTime 2 0.51 0.16

Cultural cynicismTime 1 11.75 3.81

Cultural cynicismTime 2 11.20 3.38

Generalized cultural consonanceTime 1 0.00 1.00

Generalized cultural consonanceTime 2 0.00 1.03

Note: *Values from Time 1 only used in the analysis.





Table 2. Regression of depressive symptoms on measures of cultural consonance and

perceived stress

Variables Model 1 Model 2 Model 3

Age -.02 -0.03 -.01

Sex -.11 -.11* -.07

SES .02 .07 .02

DepressionTime 1 .48** .47** .40**

CCFLTime 1 .01 .18** .12

CCLSTime 1 -.05 .10 .09

CCSSTime 1 .01 .02 .02

CCTime 1 .04 -.01 -.02

PSSTime 1 .15* .15* .02

CCFLTime 2 – -.26** -.17*

CCLSTime 2 – -.21* -.15+

CCSSTime 2 – .05 .01

CCTime 2 – .08 .09

PSSTime 2 – – .35**

Multiple R .64** .69** .74**

Multiple R2 .41 .48 .55

Note: SES¼ Socioeconomic status.+p< 10; *p< 05; **p< 01.

CCFL¼Cultural consonance in family life.

CCLS¼Cultural consonance in lifestyle.

CCSS¼Cultural consonance in social support.

CC¼Cultural cynicism.

PSS¼ Perceived Stress Scale.

Table 3. Regression of depressive symptoms on generalized cultural consonance and per-

ceived stress

Variables Model 1 Model 2 Model 3

Age -.03 -.04 -.02

Sex -.10 -.11* -.07

SES .00 .05 .02

DepressionTime 1 .48** .45** .38**

GCCTime 1 -.04 .18 .14

PSSTime 1 .15* .16* .01

GCCTime 2 – -.32** -.26**

PSSTime 2 – – .38**

Multiple R .64** .66** .73**

Multiple R2 .41 .45 .54

Note: SES¼ Socioeconomic status.

*p< 05; **p< 01.

GCC¼Generalized cultural consonance.

PSS¼ Perceived Stress Scale.




depressive symptoms ( b¼�.32, p< .01). When the effect of PSS is controlled for,this effect is reduced ( b¼�.26), but again remains statistically significant ( p< .01).The effect of PSS is substantial at Time 2 ( b¼ .38, p< .01).

In studies of mediation, it is possible to test the statistical significance of themediated effect of the exposure variable, operating through the mediating variable(referred to as the Sobel test; Baron & Kenny, 1986, p. 1177). The first analysis wasrepeated, but including cultural consonance in family life and cultural consonancein lifestyle in separate analyses. The effect of cultural consonance in family life ondepressive symptoms that is mediated by the PSS is statistically significant (z¼ 2.75,p< .01). The effect of cultural consonance in lifestyle on depressive symptoms that ismediated by the PSS is statistically nonsignificant (z¼ 1.71, p< .10). There is nosignificant mediation of the effect of generalized cultural consonance on depressivesymptoms (z¼ 1.55, ns).

Discussion

We began this paper with a relatively straightforward question: does stress apprai-sal, as measured by the PSS, mediate the effect of cultural consonance on depressivesymptoms? The answer appears to be: partially. When the PSS is controlled for, thelongitudinal effects of cultural consonance on depressive symptoms are reduced, butdo not disappear entirely. When individual measures of cultural consonance areused, the effects are reduced more. When the measure of generalized cultural con-sonance is used, the effects are reduced less.

In the case of cultural consonance in family life, controlling for perceived stressaccounts for approximately half of its total effect on depressive symptoms. It hasbeen noted repeatedly that the cultural domain of the family is of particular saliencein Brazilian society (DaMatta, 1985; Wagley, 1971). The family is the center aroundwhich all social life in Brazil revolves. Brazilians invest a great deal of time andenergy in thinking about and talking about their families. Therefore, given thesalience of the family in Brazilian society, it is likely that individuals who seetheir families as not corresponding to the prototype of the family shared in Brazilare also likely to experience conscious distress over that lack of consonance, result-ing in depressed affect (Dressler, Balieiro, Ribeiro, & dos Santos, 2007b).

The question then becomes, why is only half of the effect of cultural consonancein family life, a modest portion of the effect of cultural consonance in lifestyle, and anonstatistically significant portion of the effect of generalized cultural consonance,mediated by perceived stress? What else might be mediating the effects of culturalconsonance? At the outset, it must be noted that this could be a methodologicalartifact. That is, the correlations of perceived stress with both depressive symptomsand cultural consonance are limited by the reliability with which these variables aremeasured, and the reliability with which the mediator is measured in particular cancompromise the estimation of the mediating effect (Baron & Kenny, 1986, p. 1177).It must therefore be recognized that, while the PSS shows acceptable internal con-sistency reliability in our research, the reliability with which it has been measured is





not perfect. Therefore, any other interpretation of the effect must include the caveatthat it could be a methodological artifact.

That being said, however, half of the effects of cultural consonance in family life,cultural consonance in lifestyle, and in essence all of the effect of generalized culturalconsonance are not mediated by perceived stress. One possible substantive interpre-tation is that the felt distress that mediates cultural consonance and depression is notexhausted by the measurement of perceived stress. A short list of candidate variablesthat have been suggested as stress mediators include coping styles, locus of control,perceived self-efficacy, and self-esteem, and this does not exhaust the potential medi-ators (Lin & Ensel, 1989). Therefore, future research should explore a wider range offactors that might mediate these effects.

At the same time, these results may offer some insight into cultural processes andhow they shape psychological processes, including how some culturally salientdomains rise to a level of conscious reflection and others do not. The question ofconsciousness is of particular importance here, because at one level the appraisal ofstress depends on the conscious processing of information. This is not to say thatappraisal processes do not occur outside of conscious awareness, because they cer-tainly do. But to measure appraisal, whether by the PSS or by some event- orcircumstance-specific scale, requires that the respondent has thought about whetheror not he or she feels sufficient distress to report it in response to a set of directquestions. The fact that respondents who experience low cultural consonance infamily life have a part of that overall effect on depression mediated by the phenom-enal experience of being distressed (as measured by the PSS) may indicate that thedomain of the family is of sufficient cultural salience that it comes to the forefront ofconscious thought.

In the analysis presented here, when cultural consonance was examined in alldomains as separate variables, there appeared not to be any effects; however, whenthese variables are combined into a composite variable of generalized cultural con-sonance, the prospective effect of cultural consonance on depressive symptoms isstronger than the effect of any single domain measure of cultural consonance, indi-cating that all of these measures of cultural consonance do indeed contribute todepression. And, the effect of generalized cultural consonance is completely unme-diated by consciously expressed perceived stress. How does this effect work? Wehave hypothesized that cultural consonance is an important component in mundanesocial interaction (Dressler, Balieiro, Ribeiro, & Dos Santos, 2005; Dressler et al.,2007a). Many of our interactions in mass society are either anonymous (i.e., weinteract with someone in a limited context for a limited time period, such as checkingin for a flight at the airport), or they are carried out among people with whom wehave ‘‘weak ties’’ (i.e., people with whom we are not involved in dense, multilayeredrelationships). Nevertheless, we are being socially evaluated in these interactionsand we hope to be accepted and our social status recognized. We do not mean thatwe necessarily expect others to respond with deference, but rather with the basicrecognition that we are fully members of society and hence deserving of a modicumof respect. Cultural consonance in various domains helps to mediate these

Balieiro et al. 15




interactions, since our dress, our body habitus, and our cultural capital all serve tolocate us in social space, as Bourdieu (1984) has so ably demonstrated. For theindividual low in cultural consonance, the small slights experienced in interactionsin which they may have withheld from them an acknowledgment of their culturalidentity, may not rise to the level of conscious awareness, but its impact is demon-strable. In experimental social psychology, it has been demonstrated that a threat tosocial status in an experimental situation may not be conscious in the sense ofreporting distress in association with that threat, but that physiological effectssuch as cardiovascular reactivity are substantial (Christian & Stoney, 2006;Scheepers, Ellemers, & Sintemaartensdijk, 2009). It may be, then, that over a longperiod failure to receive confirmation as a member of society on equal footing withothers does not rise to a level of conscious reflection, but that these small slights inmundane interaction nevertheless build up as a kind of negative existential load, theend result being depressed affect.

This interpretation is of course speculative, although it is supported by a linkedset of research findings. It is also consistent with the recent formulation of thecomponent process model of emotion, as outlined by Grandjen, Sander, andScherer (2008). These authors argue that the conscious experience of emotion resultsfrom a linked set of components, based in a neurological substrate, that includeconscious and unconscious appraisal processes, modified by memory, attention,motivation, self-concept, and ultimately schema and scripts that add meaning tosensation and feeling. As they note:

What is available to interpersonal sharing of emotion through communication (and to

research based on declarative reports) is only the tip of the iceberg—the individual’s

verbal account of a consciously experienced feeling . . . (Grandjean et al. 2008, p. 487)

Put differently, consciously expressed distress in association with some experience inthe social environment is a manifestation of distress, not the manifestation of dis-tress. From an anthropological point of view, one area of interest here is what kindsof cultural influences are associated with this felt and verbally expressed distress,versus cultural influences that are not mediated in this way. We are suggesting thatwhen cultural consonance is low in a domain with high cultural salience in a society,the effect of cultural consonance on depression is likely to be mediated by perceivedstress. Overall, however, low generalized cultural consonance can have effects thatare not manifest in consciously perceived distress.

One term in this theoretical outline that is in need of much greater elaboration (anelaboration that is unfortunately beyond the scope of this paper) is ‘‘cultural sal-ience.’’ This phrase is encountered with some frequency in the anthropological lit-erature, but it is not well defined. Generally, it seems just to refer to ‘‘importance,’’but an importance that is collectively bestowed. This is the meaning attached to ithere, although we have distinguished a kind of salience that is so great that it causesa domain to be elevated to a level of conscious reflection, versus other domains thatare sufficiently salient for there to be cultural consensus within those domains, yet





they hold some kind of lesser salience. Future work in this area should examine thehypotheses offered here in more detail, as well as examine critically the concept ofcultural salience.

There are some limitations to this study that need to be considered. First amongthese is the selection of cultural domains within which to investigate cultural con-sonance. More attention in research should be devoted to systematically identifyingcultural domains within which cultural consonance can be measured, particularlywith respect to this issue of cultural salience, but also with respect to the specificsocial contexts studied. Traditional ethnography is the basis for the selection ofdomains at this point, and procedures for verifying the salience of those domains(over other potential domains) would be useful. With respect to the measurement ofcultural consonance, systematic steps for integrating the results of a narrative anal-ysis (as in focus groups) of cultural domains with the results of cultural consensusanalysis would likely lead to more sensitive and nuanced measures. These issuescould usefully be explored in future studies.

In concluding, it is useful to return to the basic questions of subjectively perceiveddistress versus ‘‘objective’’ events and circumstances in the environment as influ-ences on depression. An individual who is low in cultural consonance certainly, inan objective sense, lacks certain kinds of things (e.g., material goods or elements offamily life). But this objective situation is itself dependent on a collective subjectiv-ity, that is, the consensus definition that a particular element is a valued componentof a specific cultural domain. As Searle (2006) has argued, this objectivity of col-lective subjectivity is a defining feature of human social life. A cognitive theory ofculture, the related concept of cultural consonance, and the research and analyticmethods of cultural domain analysis and cultural consensus analysis, provide thetools for the investigation of this seemingly paradoxical situation in a way that, tothis point in anthropological research, has been difficult.

Acknowledgements

Jason DeCaro offered helpful comments on an earlier draft of this paper. The authors areresponsible for any errors.

Funding

Data on which this paper is based were collected with the support of the U.S. NationalScience Foundation (BCS-0090193) and the University of Alabama College of Arts &Sciences Leadership Board.

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Mauro C. Balieiro, PhD, is Professor of Psychology at Paulista University-RibeiraoPreto, where he is Director of the Center for Applied Psychology. His researchinterests center on the relationship of culture and the individual, and culturalmodels of psychological distress. Current projects include an investigation of thedistribution of cultural models of major life goals in Brazilian society, and therelationship of cultural consonance and classic psychodynamic defense mecha-nisms. Address: Paulista University, Rua Mariana Junqueira, 1346 CPA – Centerfor Applied Psychology, 14015-010, Ribeirao Preto, SP, Brazil. [Email:[email protected]]

Manoel Antonio dos Santos, PhD, is Associate Professor of Psychology at theUniversity of Sao Paulo-Ribeirao Preto, where he is Director of PostgraduateStudies and heads the Center for Research and Teaching in Health Psychology.His research interests are in the area of health psychology with a principal emphasison chronic disease and eating disorders. Recent projects include a study of howcancer patients cope emotionally during bone marrow transplantation. Address:University of Sao Paulo, Department of Psychology and Education, MonteAlegre, 14040-901, Ribeirao Preto, SP, Brazil. [Email: [email protected]]

Jose Ernesto dos Santos, MD, is Associate Professor of Medicine at the University ofSao Paulo-Ribeirao Preto, where he is Director of the Laboratory of Nutrition.He has broad research interests in eating disorders, ranging from lipid metabolismto anorexia nervosa and bulimia. Recent research projects include studies of the roleof depression in eating disorders. Address: University of Sao Paulo, Faculty ofMedicine, Department of Clinical Medicine, Av. Bandeirantes, 3900, MonteAlegre, 14039-900, Ribeirao Preto, SP, Brazil. [Email: [email protected]]

William W. Dressler, PhD, is Professor of Anthropology at the University ofAlabama. His research interests focus on cognitive theories of culture, culturalconsonance, and health. His most recent research examined the interaction betweencultural consonance and a genetic polymorphism for a serotonin receptor in thebrain in relation to depression. Address: Department of Anthropology, TheUniversity of Alabama, PO Box 870210, Tuscaloosa, AL, USA 35486-0210.[Email: [email protected]]




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