The term “wellness” has gained prominence, conceptual value, and acceptance in a variety of health- and medical-related areas, only in relatively recent times. For decades before the twentieth century it was mostly used in family-based transactions or as an expression of formal socialization exchanges among community members (Kirkland, Reference Kirkland2014). During the nineteenth century, wellness became a sort of symbolic, ultimate purpose of diverse modalities of what was later called alternative medicine, at times difficult to distinguish from what official medicine considered “pseudoscientific” health interventions (Upchurch & Rainisch, Reference Upchurch and Rainisch2015; Zimmer, Reference Zimmer2010).
As the world and its growing number of health implications rounded up notions of “comprehensiveness” and “thoroughness” as the main objectives of total and integral care, it was gradually considered a broader expression of “well-being,” present in the World Health Organization’s 1948 historical definition of health. The main emphasis of wellness was, then, provided by notions of full development and accomplishment of an individual’s potential physical, mental, emotional, and social capabilities. When considered a nuclear component of specific programs, wellness is said to have nine dimensions: physical, environmental, financial, occupational, social, emotional, spiritual, intellectual, and sexual (Stoewen, Reference Stoewen2017). Some authors (and countries like the USA) would add a distinctive legal connotation (Elliott, Bernstein, & Bowman, Reference Elliott, Bernstein and Bowman2014).
Although not free of critical objections coming from traditional health-related quarters and professions, wellness is now accepted as a sought-for objective and culminating product of efficient care practices dispensed in a fair, adaptable set of procedures entailing “different types of justice” (i.e., distributive, procedural, relational, retributive, informational, and developmental) (Prilleltensky, Reference Prilleltensky2012, p. 6). In fact, wellness entails, for many, an effective overall state of psychological stability surrounded by a variety of biosocial reflections (Beadling et al., Reference Beadling, Maza and Nakano2012). For the purposes of this chapter, the role and relevance of culture and cultural factors will be systematically focused upon, culminating in the presentation of crucial distinctions in the definition, processing, and characteristics of wellness among the main societies and cultures across the world.
5.2 Basic Conceptual Implications
The variety of implications that the concept of wellness contains complicate its definition beyond what an initial approach may suggest. In addition to the concept of well-being and its implied overall description of pleasantness and stability, wellness is also closely associated with the now fashionable label quality of life (QoL), research about which is still scarce (Crocker, Smith, & Skevington, Reference Crocker, Smith and Skevington2015). While wellness represents a general, almost overinclusive perspective, QoL strongly suggests a more specific appraisal in need of both subjective estimations and objective, measurable (therefore, also quantitative) data. QoL may have a multitude of smaller components and, in fact, has become a powerful indicator of integral health. It is important to clearly delineate these two fields of knowledge and research to avoid misleading synonymities and, rather, to reinforce useful complementarities.
Furthermore, and in a more traditional way, wellness implies the convergence of both physical and emotional health. Needless to say, the former may be considered by many as an essential component of the definition and content of wellness, perhaps its most obvious, visible, and provable evidence (Boller & Barba, Reference Boller, Barba, Jeste and Friedman2006; Lieberman & Ogas, Reference Lieberman and Ogas2015). The numerous features or areas involved in descriptions of good physical health lead to clear, conclusive connections with wellness, but such connections would still be characterized as partial or compartmental.
Emotional health (also commonly called psychological, behavioral, or mental health), on the other hand, emerged later as a component of wellness, coming from a subjective, profoundly personal, unique, and almost unexchangeable perspective. In fact, the definition of emotional health and the assessment of its constituent experiences differ between individuals, communities, societies, and other sociocultural entities. For these reasons, the evaluation of wellness has in its emotional or psychological components the most individualized as well as the most varied and even heterogenous perspective of what it means to have a stable and positive way of life (Freeman, Reference Freeman1999; Golden, Berquist, & Coleman, Reference Golden, Berquist and Coleman1978).
Last but not least, wellness also implies social harmony at both micro and macro levels. The former has to do with life in the family circle, the daily or frequent contact and interactions between the members of a family group facing and handling common experiences with either successful or painful outcomes. Such interactions encompass diverse mechanisms (analyses, reflections, explanations, consolations, ethical considerations, etc.) and, ultimately, the sharing of satisfactions, relief, and forward-looking plans and purposes –wellness at its most meaningful dynamics (Gheondea-Eladi, Reference Gheondea-Eladi2017).
The macro-level scenario of wellness refers to the community contacts or factors having to do with the individual’s surrounding society (Dahrendorf, Reference Dahrendorf1959). The perception of such factors and of their impact on the everyday life of the population will result – if positive and favorable – in a collective sense of an “accomplished mission” or the most genuine experience of true and productive solidarity. On the contrary, if the results are negative or below expectations, the social harmony component of wellness will serve as a pillar of recovery or a reminding testimony of hope.
Many students of the ontology of wellness would also agree on placing the concept inside the broad field of public health, not only as an objective of a variety of principles, practices, and efforts but also as a powerful mechanism in pursuit of a solid, sustainable collective well-being. This would then culminate in the elaboration of norms and laws linking health aspirations and expectations with concrete and evident achievements regarding the patients’ whole health (Hinchliffe et al., Reference Hinchliffe, Jackson and Wyatt2018; Sinkfield-Morey, Reference Sinkfield-Morey2018).
5.3 The Role of Culture and Its Components
All of the above-described conceptual pieces of wellness, health-based and socially related as they are, can be also strongly associated with the various components of what is known as culture (Asad & Kay, Reference Asad and Kay2015; Tseng, Reference Tseng2001). However, there are more, perhaps subtler yet undeniably relevant and equally interactive cultural components: religious/spiritual, teleological, and ethical. The first is a primary element of the feeling of totality and thoroughness that wellness possesses, and the integration between physical and spiritual stability (with tranquility or serenity as synonyms) has been described in multiple ways (Berlinger & Berlinger, Reference Berlinger and Berlinger2017). Traditions, beliefs, religious practices, rituals, venerations, and texts (many times called “sacred”) shape up notions of health among individuals and groups across the world; nevertheless, these cultural sets differ significantly among societies or cultures established in diverse world regions. The definition and actual experience of wellness respond, sometimes dramatically, to the religious texture of specific individuals and communities.
Closely related to religious and spiritual factors, the teleological component of wellness has to do with the possession and cultivation of values, principles, and norms of significant behavioral impact despite their various levels of strength. Values inspire tolerance or rejection, acceptance or indifference vis-à-vis individual or collective wellness: Breaking or moving away from them destabilizes the nature of wellness as a truly genuine way of living with and among others (Baumeister, Reference Baumeister1986). Finally, ethical or moral precepts provide wellness with a unique dimension, a powerful defining summary of the concept and its practice (Bhugra, Reference Bhugra2014; Gheondea-Eladi, Reference Gheondea-Eladi2017).
In effect, a healthy interaction of all the above elements leads to integral wellness, the essential objective of social, mental, and public health actions. Regrettably, the opposite can also potentially occur. Deficits or “defects” in family life, deficient conveyance of beliefs, values, or religious notions, inconsistent or misleading educational efforts, and ethically diminished practices are all detrimental factors in the wellness-making processes and the actual wellness experience (Napier et al., Reference Napier, Ancarno and Butler2014). Such conflicting outcomes become eloquent representations of social, cultural, or political failures in the lives of individuals and communities.
The presence of cultural factors in the nature and actual experience of wellness demonstrates the role of culture as an active engine of individual and social behaviors; to use a graphic metaphor, the “anatomy” of wellness is the recognized collection of its bio-psycho-social components, whereas its “physiology” is determined precisely by the active, dynamic nature of culture and cultural factors in the everyday life of individuals and societies. Such influence takes place (and materializes) with specific ingredients in each step of the life cycle, hopefully contributing to a healthy personal development. Family life is the most typical setting of early cultural interactions leading to the delineation of identity through the utilization and enhancement of language resources, the active (and passive) transmission of traditions and beliefs, of history and stories, of social relations and their existential script levels of expressiveness and spontaneity (Bhugra, Reference Bhugra2014; Brislin, Reference Brislin2000; Napier et al., Reference Napier, Ancarno and Butler2014).
5.4 Wellness across World Cultures
The following sections of this chapter attempt to review the different versions, components, creations, and outcomes of wellness in the various world regions or continents examined from both geographical and historical perspectives. They will describe the main features of wellness in such regions and examine current experiences of wellness in the field and its impact on people and society. The main obstacles, deficiencies, and needs related to these issues will also be assessed. There is agreement in considering Africa as perhaps the oldest continent, the one where the human race probably emerged from. For its part, Asia was probably the crib of the first organized cultures, from original tribal groups to sophisticated civilizations engendered by and through military and commercial enterprises. Europe then became the “center of civilization” (through explorations, discoveries, conquests, and colonization) with also a variety of subregional compartments. Finally, America, the “New Continent,” emerged with its different geographic, ethnic, and language-based segments. Populations or human groups in Australia/New Zealand will also be mentioned.
The history of Africa makes the continent a vivid example of humanity’s stormy journey through the times. Students of this journey have focused mostly on the subjugation of its original inhabitants at the hands of European conquerors that combined adventurous boldness with cruel exploitation and exterminating practices to decimate communities and give birth to the different versions of slavery. Health care of African-born people was not exactly a priority in this process, and their wellness was left up to their centuries-old ideas, and in the hands of their original shamans aided by a few pious Westerners accompanying the invading armies.
There may only be a mild objection to the notion that spirituality is perhaps the strongest component of the notion of wellness in most African countries, even deeper than the formalized religious fervor of the European colonizers. The opening phrase of an article by Mayer and Viviers (Reference Mayer and Viviers2014, p. 265) (“I still believe …”) eloquently summarizes this process: Located in South Africa, the narrative reflects “a strong intrapersonal interlinkage of spirituality, culture and mental health” and their impact on personal self-construction and social relationships, a process that repeated itself in subregions and countries that experienced their own versions of apartheid. These notions were certainly born out of mythic legends but could also be practically applied to the everyday life of individuals, families, and communities throughout the continent, whose geography imposed a scenario both majestic and intimidating, mysterious and unpredictable. This context accentuated the coherence of relatively small tribes and groups, but also the separation and differences with many others throughout the jungle, the deserts, and the coastal areas.
An interesting example of these heterogeneous realities is provided by Hill et al.’s (Reference Hill, Hess and Aborigo2014) report on the pluralistic maternal and neonatal health care in rural northern Ghana, provided by traditional and “allopathic” (Western-trained) caretakers. From a series of in-depth interviews the researchers extracted three overarching themes: different levels of awareness and information about cultural beliefs and practices; different resulting frameworks for the understanding of health and disease, remedies, and overall management; and, yet, agreement about the need to educate patients and their families to allow a better, more comprehensive care. Thus, wellness in African communities requires an integrated cultural education of the allopathic, non-native providers or healers.
On the basis of such integration, African countries may be the most appropriate settings for the implementation of wellness programs in the health workplace, as experiences in Botswana demonstrate (Ledikwe et al., Reference Ledikwe, Semo and Sebego2017). According to Ledikwe and colleagues (2017), aspects “such as health screening, therapeutic recreation, and health promotion through observation of various commemorations tended to be implemented more frequently than activities related to occupational health and safety as well as psychosocial services” (p. 872), but “administrative support” and “integration of… activities” into organizational culture effectively contributed to ensure the well-being of many healthcare workers (p. 872).
By far the largest and probably the most complex continent in the world, Asia has been divided throughout history in a variety of subregions, many times due to the predominance of political actors and diverging ideologies. It includes China and its dominating presence in the Far East, although India on one side and Russia on the other also claim Asian heritage, in addition to Japan and North and South Korea. The Middle East (Israel, Saudi Arabia, Turkey, Syria, Iran, Iraq, Afghanistan and other countries, including Egypt in the northernmost, Asia-bordering area of Africa) is not only a scenario of active political and military turbulence but also a natural bridge toward Europe.
Religion or, better, a variety of religions play a significant role in the everyday life of most of these countries, presiding governmental structures, provoking confrontations, and promoting pervasive, often rigid, beliefs, traditions, habits, and customs. It is also clear that countries like China, North Korea, or Russia do not have an officially sanctioned religion or church practice but either passively accept its presence in large population sectors, or the government’s ideology operates within religious-like normative rules.
Thus, the nature and the impact of religion in Africa and Asia present different characteristics when wellness is considered. To be sure, there are countries like Japan, India, Egypt, or Jordan where the religious/spiritual component of wellness is significantly relevant in treatment and recovery processes, sometimes experienced as “faith journeys” (Eltaiba & Harries, Reference Eltaiba and Harries2015) at individual, family, and community levels, independent of governmental participation. There are others, like Saudi Arabia, Iran, or Israel, in which religion and politics are actively mixed in the manifestations of the collective life and, finally, a third group of countries like Turkey, that proclaim a “separation of powers” as an operative independence between religion and politics but may strongly invoke the latter when certain circumstances occur. To be sure, these three perspectives maintain wellness as an emblematic component of their existence.
Assessing health literacy (including nonhealth-related items) is considered critical in Eastern and Middle Eastern populations given the influence of the “social desirability” factor (Nair et al., Reference Nair, Satish, Sreedharan and Ibrahim2016). Methodologically, most health-related research in Asian countries seems to overlook the heterogeneity within their populations, according to Maty et al. (Reference Maty, Leung, Lau and Kim2011) in a study that describes “associations between general health status and several sociodemographic and health-related factors in pooled and ethnic group-stratified samples” (Maty et al., 2011, p. 555). The psychological and health effects of social class (translated into social stratification) reflect culturally divergent manifestations in Asian cultures where individuals of high social class, unlike their counterparts in Western cultures, tend to show high conformity and other-oriented psychological attributes (Miyamoto, Reference Miyamoto2017). Furthermore, using a culture-centered approach as a theoretical lens of communication scholarship has enhanced the meanings of health and wellness in many Asian countries: such is the case of biomedical services offered within the larger philosophical understandings of Buddhism in the practices favored by the Tzu Chi Foundation. This perspective cultivates nonbiomedical meanings of health (i.e., wellness) through selfless giving and assistance, simultaneously seeking “purity of the mind, body and soul holistically” (Dillard, Dutta, & Sun, Reference Dillard, Dutta and Sun2014, p. 147) and, thus, broadening the outreach of healthcare delivery “from the narrow focus on curing to the complexly intertwined spaces of health, illness, healing and curing” (Dillard et al., Reference Dillard, Dutta and Sun2014, p. 151). In a more specific context, the same applies to the integrated interventional modality of Kumu Hula-based cardiovascular disease prevention and management programs in the Hawaiian islands (Look et al., Reference Look, Maskarinec and de Silva2014).
According to Bian, Lui, and Li (Reference Bian, Liu and Li2015), the essentials of Chinese medicine include promoting “health wellness” instead of disease management, largely preceding modern P4 (personalized, predictive, preventive, and participatory/precision) Western medicine. Comparative studies on issues such as geographic features, history, culture of health-seeking behaviors, insurance, and interprofessional relationships assess the overall healthcare environment and its impact on a variety of health professions (Lu, Tung, & Ely, Reference Lu, Tung and Ely2016) and healthcare-related outcomes in China and other Asian countries (Jia et al., Reference Jia, Gao, Dai, Zheng and Fu2017). In turn, concerns over environmental pollution have enriched the so-called therapeutic landscape theory nourishing notions such as longevity culture and its representation by the town of Bama, the “longevity village,” now a preferred target of “wellness tourism” in China (Huang & Xu, Reference Huang and Xu2018): Natural environment, social interaction and symbolic landscape work together in the healing process, longevity symbolizing the alignment of a strong body, a graceful mind, and a pleasant habitat.
In India, traditional medicine branches such as Ayurveda, Siddha, or Unani have, since ancient days, used a large variety of plants with defined pharmacological effects, adding a natural component to a rich wellness-oriented therapeutic arsenal. Lohiya, Balasubramanian, and Ansari (Reference Lohiya, Balasubramanian and Ansari2016) describe how various tribal populations across the subcontinent apply these plants to treatment of chronic conditions and to a basic component of wellness in men: reproductive health issues such as infertility, contraception, libido, sexually transmitted infections, and even cancerous processes. In a truly eclectic approach, Snodgrass, Lacy, and Upadhyay (Reference Snodgrass, Lacy and Upadhyay2017) present another original Indian contribution to emotional wellness: The development of culturally sensitive scales to local clinical populations neither imposing Western nosological categories nor adopting native categories of mental distress. “By sharing traits of both global and locally-derived diagnoses,” write the authors, “approaches like ours can help to identify synergies between them” (p. 174); in other words, the assessment of emotional frailties and of potential sources of resilience and balance can “minimize stigma and increase the acceptability and validity of assessment instruments” (p. 175).
In a similar manner, a culture-centered approach finds common ground in surveys conducted in West Bengal’s and Bangladesh’s rural areas (Dutta & Basu, Reference Dutta and Basu2008; Jamil & Dutta, Reference Jamil and Dutta2012): When resources are limited, the population acknowledges the importance of trust in the relationship with the local provider; health is seen as a collective resource, both an asset and a responsibility of the community. Furthermore, community members negotiate health in terms of poverty, work, and structure, and attempt to solve marginalization through communicative practices and the explorations of “spaces of change.” The universal meaning of principles of health and wellness are well reflected here, as they expand to co-constructed experiences of health among Bangladesh immigrants into the USA (Dutta & Jamil, Reference Dutta and Jamil2013), experiences that constitute a “point of entry” for the potential understanding and integration of migration and healthcare issues.
Saudi Arabia and the Persian Gulf countries present a somewhat unique phenomenon with regards to the provision of health care and its impact on the well-being of the general population. With a majority of their healthcare forces coming from non-Arab countries (e.g., the Philippines), the lack of cultural competence and knowledge about language on the side of non-Muslim health workers constitutes a barrier for the provision of quality care (Almutairi, Reference Almutairi2015).
The impact of psychosocial job characteristics, particularly job autonomy, on health and wellness status is definitely important in Western economies. That is not the case among Thailand-born working adults in England, however (Yiengprugsawan et al., Reference Yiengprugsawan, Lazzarino, Steptoe, Seubsman and Sleigh2015), a finding that could reflect the cultural feature of Thais being less troubled by individualistic expressions at work, although job security, job demands, and employer support were shared characteristics, and public health strategies would certainly promote mental health and well-being in both populations. On the other hand, the role of social hierarchy, strongly linked to socioeconomic status (SES), seems to be gaining ground in Asian societies due to their increasing connection with Western countries. Contrary to the latter, however, Asian countries like Japan and other Confucian cultures show higher SES associated with greater other-orientation, whereas in the USA, the same feature is linked to a greater self-orientation (Miyamoto et al., Reference Miyamoto, Yoo and Levine2018). In another study not focused on religious traits (Balkir, Arens, & Barnow, Reference Balkir, Arens and Barnow2013), healthy Turkish women exhibited relatedness-satisfaction as a better predictor of mental health, whereas autonomy-satisfaction did the same among healthy German women; interestingly, such distinction disappeared among depressed women from both countries.
Culturally appropriate wellness initiatives aimed at improving health behaviors and promoting their sustainability have been effective in programs implemented in a Jewish school system in Chicago. A report by Benjamins and Whitman (Reference Benjamins and Whitman2010) makes clear also their effective applicability in Israel (and perhaps in other Middle Eastern countries) through the initial results of a two-year comparative pilot study implemented by a Wellness Council charged with the elaboration and application of policy changes or activities in five target areas: health education, physical education, school environment, family involvement, and staff wellness.
Mental health and psychiatry, as well as related areas including health culture and wellness, could be assessed in Europe from up to three distinctive perspectives: Continental Europe, subgrouped in turn as Western and Eastern; Anglo-Saxon Europe (mostly England and the British Isles); and Scandinavian or Northern countries. For this chapter’s purposes, however, differences will only be pointed out when strictly necessary while similarities and their global message will be emphasized. Europe can certainly be considered the repository of many converging cultures and, on the basis of historical realities, demonstrates the most pluralistic expression of approaches and styles regarding our central topic.
Historically, Continental and Anglo-Saxon (British Isles plus Ireland, Scotland, and Wales) Europe grew up side by side, going overseas and conquering different parts of the world while carefully watching each other, and maintaining an artificial atmosphere of peace until wars became inevitable. In Continental Europe, Germany (with its different names throughout the centuries) and France took the lead (Spain and Italy as well, but the former mostly oriented toward the newly discovered America, and both with the objective of restrengthening Catholicism as the universal religion) and made wellness a seemingly harmonious integration of art, spirituality, wisdom, and an early existentialist component of its powerful Renaissance. For its part, England, the British Isles, or the United Kingdom, combined a nearly invincible military and Navy power full of pragmatic foci with similarly practical, instrumental efforts aimed at research and discoveries in health and related fields. They constituted the essence of wellness, defined then as the full accomplishment of comfortableness, safety, and happiness. Last but not least, the Scandinavian countries ascribed physical health and resilience to their also practical notions of disciplined work, team approaches, and safety as the main ingredients of wellness.
On the basis of the strong role of religion in the construction of wellness in Africa and Asia, it is appropriate to wonder about it in the European continent. Such was the purpose of a study by Nicholson et al. (Nicholson, Rose, & Bobak, Reference Nicholson, Rose and Bobak2009) about the association between attendance at religious services and self-reported health in 18,328 men and 21,373 women from twenty-two European countries. The study findings indicated that men who never attended religious services were almost twice as likely to describe their health as poor with a similar but weaker effect seen in women. The relationships were stronger in people with long-standing illness, less than university education, and in more affluent countries with lower levels of corruption and higher levels of religious belief. Two reviews by VanderWeele (Reference VanderWeele2017a, Reference VanderWeele2017b) commenting mostly on a study by Ahrenfeldt et al. (Reference Ahrenfeldt, Moller and Andersen-Ranberg2017) that correlated “resting” and “crisis” religiousness with good and poor health, respectively, appear to confirm that religious community also constitutes a major pathway to human well-being in Europe.
From another perspective, the role of national European cultures in influencing citizens’ attitudes toward their health systems was the subject of a massive survey of more than forty thousand respondents from twenty-one countries (Borisova et al., Reference Borisova, Martinussen, Rydland, Stornes and Eikemo2017): “Being female, having low or medium education, experiencing financial strain, and reporting poor health and unmet medical needs were negatively associated with individual satisfaction with national healthcare systems” (Borisova et al., 2017, p. 132); this negative evaluation was more likely to occur in “national cultures associated with autocracy and hierarchy” (i.e., mostly Central and Eastern Europe countries; Borisova et al., 2017, p. 132).
A variety of additional issues emerge from works focused on specific countries. From the use of organizational culture concepts in Cyprus, to understand behaviors of individuals and organizations facing external demands and internal social changes while reformulating its healthcare system (Zachariadou, Zannetos, & Pavlakis, Reference Zachariadou, Zannetos and Pavlakis2013), to the assumptions about culture in documents related to ethnic minority health in Denmark (Jaeger, Reference Jaeger2013), wellness becomes a complex, multifaceted expression of collective efforts. Crucial among them is the training of health professionals and the establishment of professional cultures and subcultures with potential implications for patient safety. The case of Sweden in this regard is eloquently exposed by Danielsson et al. (Reference Danielsson, Nilsen, Rutberg and Carlfjord2018): The “competent physician” is expected to be infallible and responsible, while the “integrated yet independent physician” may face organizational barriers and multiple, sometimes contradictory expectations. Collaborative initiatives in Malta (Bonello, Morris, & Azzopardi Muscat, Reference Bonello, Morris and Azzopardi Muscat2018) and the role of culture in their implementation also confront multiple barriers to principles of interprofessional education and the transfer of didactic and practice innovations.
Another study that explored the understanding of wellness by Black ethnic minority individuals (African and Caribbean) at risk of developing psychosis in the UK (Codjoe et al., Reference Codjoe, Byrne, Lister, McGuire and Valmaggia2013) identified six insightful explanations for the concept: a sense of social purpose, a test of a surviving God, internalization of spirituality, attribution of symptoms to witchcraft, avoidance and adversity, and search of help to cope.
The “New Continent” formally entered onto the world’s scene with Columbus’ “discovery” in 1492, but obviously existed for centuries before then, as the testimonies of many cultures demonstrate (De Ventos, Reference De Ventos1987). With two great empires (Aztec and Inca) present at the time of the Europeans’ (Spaniards’) arrival in what are now Mexican and Andean territories, respectively, history registers previous civilizations like the Mayan settled in Central America and the Gulf of Mexico, and several pre-Inca cultures mostly in the currently Peruvian land. This subsection will describe wellness between those periods and contemporary times in North America (the USA and Canada), Mexico/Central America, South America, and the Caribbean subregion.
It is a well-known fact that the large North American territory was inhabited by numerous native or indigenous tribes whose interactions, when present, were mostly through wars, nomadic mobility, and local conflicts. For about three centuries, these human groups were either tolerated or persecuted by the British forces first, and the new American government and its Army, later. Cornered by the superior military forces, Native Americans, rhetorically named the First Nation, were allowed to live in so-called Indian reservations, mostly located in the North-Midwestern and Central zones of the North American continent, following the “Big March” that killed thousands (American Heritage, 1985).
Relatively little is recorded about the healthcare and wellness practices of these groups except, once again, the dominant religious, ritualistic infrastructure and the rightful use of medicinal plants. A telling example is the Diné (Navajo) hózhó wellness philosophy, a belief system that combines “living in health, harmony and beauty” (Kahn-John Diné & Koithan, Reference Kahn-John Diné and Koithan2015) and entails an integrative approach. This cultural approach to wellness wisdom offers means to improve whole-person/whole-system well-being, providing an effective, culturally adapted, patient-centered care based on authentic human links. The Diné philosophy is offered as a durable legacy to other American Indian/Alaska native nations, global indigenous cultures, and even nonindigenous peoples across the world. This type of pronouncement, emphasizing the benefits of traditional holistic healing, can enhance the sense of community ownership, empowerment, self-determination, acceptance, reciprocal accountability, and participation of today’s North American indigenous groups in healthcare decisions (Anderson & Hansson, Reference Anderson and Hansson2016; Auger, Howell, & Gomes, Reference Auger, Howell and Gomes2016; Boksa, Joober, & Kirmayer, Reference Boksa, Joober and Kirmayer2015; Snowshoe et al., Reference Snowshoe, Crooks, Tremblay and Hinson2017).
During colonial times and even through the first periods of the life of the United States as an independent country (Canada became independent from the UK in 1867 but remained as a Commonwealth member, and only “patriated” its Constitution and eliminated the word “Dominion” in 1982), North America followed the models of the European power in terms of philosophy and practice of health care and wellness. A complex immigration process, mostly from English-speaking countries but also, gradually, from many others, contributed significantly to what became “the land of opportunity” and “the continent of hope” (American Heritage, 1985; Marías, Reference Marías1986). In such a context, creativity and tenacity combined with openness, constructive critical assessments, systematic dialogues, and solid thinking consistently paved the way toward North America’s advances, not only in the acquisition and dissemination of original knowledge and research, but also in the process of building a genuine culture of health through models, associated metrics, partnerships, and extensive communications to address underlying inequities, affirm life conditions, and improve social cohesion: a modern vision of wellness (Trujillo & Plough, Reference Trujillo and Plough2016).
Hence, wellness, according to North American parameters, is the result of applying research findings, technological resources, coherent administrative norms, and practical procedures to a receptive, cooperative community of patients, fully aware of their rights, protective of their dignity, and respectful of well-established professional approaches. As said previously, this perspective has been historically nourished by the existential, genuinely humanistic philosophy from Continental Europe, and by the pragmatic, precise, and disciplined Anglo-Saxon legacy. It absorbs three pairs of dialectical tensions (autonomy vs. connection, private vs. public, and control vs. lack of control) (Tang, Bajer, & Meadows, Reference Tang, Bajer and Meadows2016). An equally relevant component is the promotion of health services integration aimed at improving quality and efficiency in a safety net that bridges cultural differences (Ko, Murphy, & Bindman, Reference Ko, Murphy and Bindman2015).
A variety of human actors in this wellness scenario convey different sets of realities and expectations. Beginning with training programs, a beneficial cultural change must include positive educational environments for residents and faculty, raising awareness of, for instance, burnout and its symptoms, decreasing concurrent stigmas, and enabling prevention strategies (Eckleberry-Hunt et al., Reference Eckleberry-Hunt, Van Dyke, Lick and Tucciarone2009). A comparison of mental health, quality of life, empathy, and burnout between American and Brazilian medical students revealed that the latter experienced more depression and stress, while US students reported greater wellness and environmental quality of life, and less exhaustion and depression; also US students were older, had smaller class sizes, earlier patient encounters, and more problem-based learning and psychological support (Lucchetti et al., Reference Lucchetti, Damiano and DiLalla2018).
A positive, strength-based approach to understanding the toll of an occasionally overwhelming practice by current and future health professionals is justified. Similarly, at the college campus educational stage, a substantial wellness approach must consider the fact that a majority of college students do not seek healthcare help. Perceived campus culture plays an important role in personal mental health treatment beliefs, so campus mental health policies and prevention programming must consider targeting such campus culture to foster positive mental health (Chen, Romero, & Karver, Reference Chen, Romero and Karver2016). Even in psychiatric hospitals, experiences with peer-run wellness centers reinforce a more recovery-oriented inpatient culture (Reinhardt-Wood, Kinter, & Burke, Reference Reinhardt-Wood, Kinter and Burke2018).
As host countries for immigrants of many origins, and land of birth for subsequent generations, the topic of wellness in North America shows a unique trait: The mixing of numerous ethnicities throughout centuries. In the United States, the African American community is the oldest and, currently, second-largest minority. A suggestive review by Swierad, Vartanian, and King (Reference Swierad, Vartanian and King2017) concluded that African Americans position both their own ethnic and the mainstream (White majority) culture as important influences on their health behaviors, particularly those pertaining to food intake and physical activity with practical considerations such as affordability and social support. Community-based organizations advance the understanding of a culture of engagement by marginalized populations, according to Bloemraad and Terriquez (Reference Bloemraad and Terriquez2016). Going beyond attention to social networks and identities, these organizations empower civic capacities and personal efficacy of minority group members, foster solidarity, and enhance their voice in health-related policies and programming. Results of clinical effectiveness of culturally tailored wellness programs among African American depressed patients have also been reported (Nicolaidis, McKeever, & Meucci, Reference Nicolaidis, McKeever and Meucci2013).
Similar findings have taken place among Asian American, Native American and Canadian, and Latino subpopulations (Barker, Goodman, & DeBeck, Reference Barker, Goodman and DeBeck2017; Campos & Kim, Reference Campos and Kim2017; Park et al., Reference Park, Chesla, Rehm and Chun2011). Wellness, culture, and cultural intervention practices, explored from an indigenous perspective with adapted evaluative and therapeutic instruments, demonstrated that culture and culturally focused health promotion interventions had a positive impact on a variety of clinical conditions including alcohol use, abstinence, self-efficacy, depression, and low self-esteem (Fiedeldey-Van Dijk et al., Reference Fiedeldey-Van Dijk, Rowan and Dell2017; Gray et al., Reference Gray, Mays, Wolf and Jirsak2010; Hodge, Limb, & Cross, Reference Hodge, Limb and Cross2009). By the same token, outreach interventions, contextualized by interpretation and transformation of qualitative data according to characteristics and perspectives of Latino communities (i.e., gender relations and religious affiliations and experiences), show positive outcomes (Erwin et al., Reference Erwin, Treviño and Saad-Harfouche2010). Latinos in the USA (currently the largest minority group) show a significant association between high behavioral familismo and increased odds of using informal or religious services but not specialty or medical services; self- and socially perceived (by family members and friends) needs for care were also significant predictors of service use (Stacciarini et al., Reference Stacciarini, Wiens and Coady2011; Villatoro, Morales, & Mays, Reference Villatoro, Morales and Mays2014). The same feature, the vitality of social and natural connections that emphasize the importance of a traditional lifestyle, plays a critical role in the promotion of optimal health among Alaska Eskimo natives (Wolsko et al., Reference Wolsko, Lardon, Hopkins and Ruppert2006). That is why national dialogues among stakeholders about content and investments to improve population health and wellness are being promoted in different parts of the world, in order to establish a paradigmatic culture of health (Acosta et al., Reference Acosta, Whitley and May2017).
Latin America, extended from Mexico to Patagonia and including for practical purposes a number of Caribbean countries, exhibits a rich tradition of wellness evidenced by the history and accomplishments of its main pre-Columbian cultures. Mayan, Aztec, pre-Inca, and Inca cultures embraced wellness through a strong religious approach, a mix of magic, idolatrous, and divine/polytheistic conceptions supported by authoritarian political/military regimes that, nevertheless, paid due attention to spiritual and social harmony, collective progress, and moral principles (Alvear Acevedo, Reference Alvear Acevedo2000; Lastres, Reference Lastres1951). The three main moral precepts of the Inca Empire were “Do not lie,” “Do not steal” and “Do not be lazy.” The shamans or curanderos and the wisemen (Huetlatoani in Mexico, Amautas in Peru) were part of privileged layers in these societies; the use of medicinal plants and persuasive collective ceremonies (including human sacrifices) sustained a healthy population and a productive economy. The arrival of the European conquistadores (Spanish and Portuguese, the latter exclusively in the territory that is today’s Brazil) did profoundly affect the bases of these political entities, fostering a sense of failure, decadence, and existential confusion. The ulterior exploitation, abuse, and near-slavery conditions of agricultural and mining work in colonial times reduced wellness to a set of nostalgic memories somehow saved in pieces of art, tools, or rustic documents (Vargas Llosa, Reference Vargas Llosa2005).
The Independence Wars in Mexico and South America took place during the 1800s, after three centuries of colonial administrations whose religious practices played an important role in health and wellness. Actually, the first schools of medicine in the subcontinent were founded in the sixteenth century in Lima, Santo Domingo, and Mexico. The growing creole population (generations of descendants from the Spanish conquerors) occupied the highest portion of the social hierarchy enjoying the wellness of the time, whereas heirs of the subjugated Aztecs or Incas were mostly used as cheap workers. Wellness for the latter became a question of survival from malnourishment, epidemics, poverty, and deprivations. It may not be an exaggeration to say that wellness then turned out to be a political label, a piece of demagoguery, or an anti-cultural assault, particularly for Latin American natives and women (Alarcón, Reference Alarcón2003).
The new nations allowed a gradual arrival of new scientific findings and clinical information, mostly from Europe and, with them, a subsequently more consistent conception of wellness. To be sure, traditional values such as religious support and family-based solidarity still occupy preferential levels in the new definitions, but other considerations have been added and gained ground. This is probably due to political uncertainties, for instance, social instability and a massive rejection of realities such as violence, poverty, corruption, and abuse are relevant factors in the process of building a safety culture as part of a new, well-targeted wellness (Lawati et al., Reference Lawati, Dennis, Short and Abdulhadi2018; Mitchell, Steeves, & Dillingham, Reference Mitchell, Steeves and Dillingham2015). Challenges for the implementation of this and other measures include leadership education, additional resources, and work on hierarchical relationships; further assessments of clinical outcomes and organizational performance would permit the establishment of this philosophy in a variety of health areas in Latin American and other Low and Middle Income Countries (LMICs) across the world (Castro, Barrera, & Holleran Steiker, Reference Castro, Barrera and Holleran Steiker2010; Cunningham & Jacobson, Reference Cunningham and Jacobson2018; Rice et al., Reference Rice, Lou-Meda and Saxton2018; World Health Organization, 2017).
In Caribbean countries, a good example of wellness and its tribulations is given by Wagenaar et al. (Reference Wagenaar, Kohrt, Hagaman, McLean and Kaiser2013) in a study that examined patterns, determinants, and costs of care-seeking for mild to moderate mental health problems in rural Haiti. One-third of 408 adults surveyed in the country’s Central Plateau endorsed God as their first choice for care if suffering from mental distress, and a close 29% endorsed clinics and hospitals; almost half of the respondents chose potential providers on the basis of anticipated efficacy, and for different clinical situations (suicide included) three out of four rural Haitians would prefer community-based providers (herbal healer, church priest or pastor or vodou priest) even though they charged much more than hospitals or clinics. The authors rightly conclude that isolated clinical interventions may have limited impact because of less frequent use, born out of a culturally acquired, and prevalent, notion of wellness and its maintenance.
5.4.5 Australia and New Zealand
The Anglo-Saxon connection of these territories does not discard the strong indigenous heritage from large tribal groups prior to the arrival of the British First Fleet by the end of the eighteenth century. A solid example of this is the concept of health and the practice of health care held by the Maori aboriginal group. Maori methodologies and knowledge are based on principles such as respect for people, cautiousness, and the ability to “look, listen and speak” (Hopkirk & Wilson, Reference Hopkirk and Wilson2014, p. 158). In turn, key concepts held by Maori therapists include spirituality, holistic views, client-responsive practice, and favorable environmental contexts emphasizing the importance of the individual within the extended family.
5.5 Discussion: Wellness and the Culture of Health
The semantics of wellness is undoubtedly the first point that needs to be solved when attempting to discuss the meaning of this term across cultures. The risk of such an attempt is a conceptual collision about the priority of its components, so consensus must be sought through careful choices. The first agreement would certainly reside in the acceptance of health as the vertebral column of wellness. Yet, it would not just be health alone, but what has come to be known nowadays as integral health, a total, thorough, complete health. Following the route of the World Health Organization’s definition of health initiated near the mid-twentieth century, it is to be reiterated that health is not only “the absence of disease” but a comprehensive sense of well-being that initially was labeled as “bio-psycho-social,” with “cultural” being added years later and, finally, “spiritual”: Health is a state of bio-psycho-socio-cultural-spiritual well-being, the closest and eventually more acceptable, comprehensive explanation of wellness (Alarcón et al., Reference Alarcón, Westermeyer, Foulks and Ruiz1999; Guerrero & León, Reference Guerrero and León2008).
There are more terminological reflections. As the realities of globalization became the challenge they are today, the World Health Organization, again, proclaimed, after decades of hesitating delays, that “There is no health without mental health,” thus rescuing the precious combination of psycho-socio-emotional facts and experiences that constitute our mental well-being (it must be noticed that “bio” is not included, because conventionally it belongs to an organ – the brain – and to a system, that of the central nervous system, mostly in charge of physiological, regulatory, and cognitive tasks). And, at a time when biological, neurophysiological research in psychiatry, assisted by unstoppable-looking technological advances, seems to govern all areas of health-related investigations, the world has also seen the solid, persuasive reemergence of cultural and social inquiries, investigations, and, above all, the vindication of human and humanistic considerations in the articulation of a genuine wellness (Montiel, Reference Montiel2000; Swartz et al., Reference Swartz, Kilian, Twesigye, Attah and Chiliza2014). That is why this author would suggest that another phrase must be coined: “There is no mental health without culture and cultural facts.”
A crucial point in the assessment of wellness across cultures is that a culture of health (CoH) must be clearly articulated as its main support (Kagawa-Singer, Dressler, & George, Reference Kagawa-Singer, Dressler and George2016; Plough, Reference Plough2014; Weil, Reference Weil2016) and as an expression of the human rights movement (Mariner & Annas, Reference Mariner and Annas2016) applied to health. Not to be confused with “caring cultures” resulting from compassion- and solidarity-inspired approaches (Gillin, Taylor, & Walker, Reference Gillin, Taylor and Walker2017), the CoH concepts have, in fact, grown exponentially in recent years to the point of being considered an imperative for a multitude of areas having to do with wellness: workforce engagement, patient experience, social interactions, and even financial transactions or value-based purchasing (Gage-Bouchard, Reference Gage-Bouchard2017; Kagawa-Singer, Reference Kagawa-Singer2011; Owens et al., Reference Owens, Eggers, Keller and McDonald2017); in spite of difficulties in the plausibility of some of its pathways (Hruschka, Reference Hruschka2009), CoH can be applied to all areas covered by wellness and, definitely, impacts social processes, teaching/training programs, clinical outcomes, cross-sector collaborations, behavioral economics, and legal initiatives (Daskivich et al., Reference Daskivich, Jardine and Tseng2015; Flynn et al., Reference Flynn, Gascon and Doyle2018; Martsolf et al., Reference Martsolf, Sloan, Villarruel, Mason and Sullivan2018; Melnyk et al., Reference Melnyk, Amaya, Szalacha and Hoying2016; Milner, Bradley, & Lampley, Reference Milner, Bradley and Lampley2018; Volpp & Asch, Reference Volpp and Asch2017). Furthermore, it provides wellness with psychometric measurement options at different stages (Lin & Lin, Reference Lin and Lin2014; Melnyk, Szalacha, & Amaya, Reference Melnyk, Szalacha and Amaya2018; Rafferty et al., Reference Rafferty, Philippou, Fitzpatrick, Pike and Ball2017) through instruments that gauge the attributes of care culture perceived by staff, organizational agencies, patients, and communities.
The field of education for health professions is also essential for a successful development of wellness (McClafferty et al., Reference McClafferty, Brown and Vohra2014; Walsh, Reference Walsh2016). It is, indeed, the classical setting in which the contemporary learning health systems require the bridging of two “cultures”: health data sciences or bioinformatics and effective healthcare system design and implementation (clinical informatics or digital health) (Scott et al., Reference Scott, Dunscombe, Evans, Mukherjeee and Wyatt2018). In 2017, the Resident Wellness Consensus Summit developed a longitudinal curriculum to address wellness and burnout following an evidence-based research covering self-care, physician suicide and self-help, and clinical-care series (Arnold et al., Reference Arnold, Tango and Walker2018; Place & Talen, Reference Place and Talen2013); bullying has fostered a dangerous “culture of silence” in many healthcare workplaces (Fink-Samnick, Reference Fink-Samnick2018). Facilitators, barriers, potential best practices, and lessons learned should all lead to wellness-oriented processes based on equity, cultural adaptations, ongoing multi-inputs, adequate incentives, correction of structural inequalities, transformational leadership, and institutionalization of health promotion efforts (Aarons et al., Reference Aarons, Ehrhart, Farahnak, Sklar and Horowitz2017; Beckett et al., Reference Beckett, Field and Molloy2013; Laurie et al., Reference Laurie, Linnea Warren, Weilant, Acosta and Chandra2018).
While universal in its presence and value, wellness represents a prominent objective for public policies and even sociopolitical stability in LMICs (Mbau & Gilson, Reference Mbau and Gilson2018). The challenges of poverty, violence, or corruption have been mentioned. Stigma is one of the biggest obstacles in many clinical/mental health segments of the wellness route (de Figueiredo & Gostoli, Reference de Figueiredo and Gostoli2013; Yang et al., Reference Yang, Purdie-Vaughns and Kotabe2013, Reference Yang, Thornicroft, Alvarado, Vega and Link2014), but also affects areas in which the use of culturally induced stereotypes accentuate disadvantages, such as aging (Hess et al., Reference Hess, O’Brien and Voss2017; Löckenhoff et al., Reference Löckenhoff, De Fruyt and Terracciano2009), discrimination, and racism (Viruell-Fuentes, Miranda, & Abdulrahim, Reference Viruell-Fuentes, Miranda and Abdulrahim2012). The latter becomes part of the emotional and behavioral repertoire of immigrants on whom multiple dimensions of inequality intersect in the context of a “dual culture” to have an impact on wellness and health outcomes (Connell, Reference Connell2014).
A strong research culture in health services can be the optimal resource to a better wellness not only through interventions addressing the needs of the communities and the health workforce that serves them (Harding et al., Reference Harding, Lynch, Porter and Taylor2017), but also in areas such as historical context, practice changes (Al-Bannay et al., Reference Al-Bannay, Jarus, Jongbloed, Yazigi and Dean2014; Kagawa-Singer, Reference Kagawa-Singer2012) and health promotion (Lakeman, Reference Lakeman2013). A multidisciplinary approach would be a powerful means oriented to respect and preserve the dignity of the populations being served (Vrzina, Reference Vrzina2011). At individual and group levels, wellness research also must address features of particular impact in the handling of adversities (e.g., resilience, emotional intelligence, solidarity, or creativity).
Wellness is, quite probably, the health field with the broadest implications in contemporary times. As it reflects a variety of concurrent factors to reach its place in the life of human beings, its study, research foci, achievements, and challenges occupy the attention of many disciplines. Yet, at the center of such views, a cultural approach operates as the integrating factor of wellness and, as such, its impact is being strongly assessed from many perspectives. Culture penetrates the definitions, concepts, status, quality, operationalization, performance, and results of the many facets of health and health care, pillars of a strong wellness. Cultural variables reinforce comprehensive approaches to wellness and contribute to its commonalities and distinctions in all regions of the world and in all societies and communities along time and history. The main task of those dedicated to this field of health studies and knowledge is to identify theoretical principles and practical applications that will allow and strengthen advances in universal wellness while also adapting it to the respective cultural contexts.