Cultural dimensions and expectations towards use of aripiprazole, duloxetine and pregabalin in EU member states
The effect of cultural dimensions is complex. It influences a multitude of social phenomena on the macro, such as patterned relations between large social groups, and micro level, e.g. the behavior of individualistic members of the society. The dynamic nature of culture conveys the top-down and bottom-up processes where one cultural level affects changes in other levels of culture [
19]. Macro-level systems appear increasingly likely to influence the nature of micro-level interaction. Reciprocally, behavioral changes at the individual level, through bottom-up processes, become shared behavioral norms and values, modifying the culture of a macro level entity [
19,
20]. Coleman’s scheme of the micro-macro linkage is one of the most useful expository vehicles for thinking about multi-level issues in social science research [
20]. It indicates the relationship between macro factors (e.g. institutions) and the micro factors that underlie their causal relation (values, economic behavior). Most of the research on culture has focused on identifying the core cultural values that differentiate cultures on a macro level. An example of a popular and validated approach is Hofstede’s model of cultural dimensions [
21]. He distinguished six dimensions along which cultural values can be compared with other cultures: individualism-collectivism; uncertainty avoidance; power distance (strength of social hierarchy); masculinity-femininity (task orientation versus person-orientation); long term-short term orientation and indulgence-restraint (see Table
1) [
22]. As Hofstede transformed the concept of culture into quantifiable measures, it can be used in cross-national country comparative studies [
6,
7].
Power distance (PDI) relates to the extent to which the less powerful members of a society accept and expect that power is distributed unequally. It suggests that a society’s level of inequality is endorsed by the followers as much as by the leaders [ 7].
Power distance is hypothesized to be positively associated with the use of the case study medications.
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Individualism (versus collectivism) (IDV) A society’s position on this dimension is reflected in whether people’s self-image is defined in terms of “I” (individualism) or “we” (collectivism).
Individualism is hypothesized to be positively associated with the use of the case study medications.
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Masculinity (versus femininity) (MAS) refers to the distribution of emotional roles between the genders. The masculinity side of this dimension represents a preference in society for achievement, heroism, assertiveness and material reward for success. Society at large is more competitive.
Masculinity is hypothesized to have no effect on the use of the case study medications.
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Uncertainty avoidance (UAI) indicates the degree to which the members of a society feel uncomfortable with uncertainty and ambiguity, and shows how comfortable society is in unstructured situations that are novel, unknown and surprising.
Uncertainty avoidance is hypothesized to have no effect on the use of the case study medications.
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Long-term (versus short-term orientation) (LTO) fosters pragmatic virtues oriented towards future rewards, in particular saving, persistence and adaptation to changing conditions.
Long-term orientation is hypothesized to be negatively associated with the use of the case study medications.
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Indulgence (versus Restraint) (IVR) Indulgence stands for a society that allows relatively free gratification of basic and natural human drives related to enjoying life and having fun.
Indulgence is hypothesized to be positively associated with the use of the case study medications.
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Based on Hofstede’s model of cultural dimensions, we assume the following relation between these cultural dimensions and the use of aripiprazole, duloxetine and pregabalin.
Power distance refers to ‘preferences of how persons with a different (social) status communicate with each other’. Albeit patient empowerment is a topic of interest in current health care, the asymmetry in status between doctors and patients remains persistent [
23]. Still countries differ in their power distance and Deschepper et al. (2008) showed that power distance was positively correlated to the use of antibiotics [
6]. They stated that in countries with a low power distance, a preference for deliberation about the use and perception of antibiotics between patients and doctors might affect the prescription of antibiotics [
6]. Furthermore, low country scores on Power Distance may have implications for collaboration between doctors and other health care professionals, resulting in exchange of information about (optimal) medications therapy. This same phenomenon can be expected to occur with the utilization of other medications. A preference for discussion about the use and perception of new CNS medications might be favored in countries with a low power distance leading to lower use as contrasted with a ‘doctor knows best’ attitude in countries scoring high for power distance.
Individualism concerns with ‘the degree to which individuals are integrated into groups or not’. Previous literature indicates that people from individualist cultures are more likely to tolerate diversity and deviation from the norm because such cultures are extremely fragmented, with extensive individuality, due to the desirability of personal goals. Individuals are therefore less likely to be part of a group [
21,
24,
25]. Diseases interfering with the CNS are more likely to cause behavior deviated from the norm. In individualistic countries CNS patients may be less stigmatized and access to appropriate services and/or use of CNS medication might be more common [
24].
Masculinity can be defined as ‘the distribution of emotional roles between the genders’ and is expected to have contradictory effects on the use of these three medications. On the one hand, countries with a masculine culture may be expected to correlate negatively with the use of CNS medications, e.g. because these countries value a “live to work” ethic, rather than a “work to live” ethic, value ‘things’ more important than ‘quality of life’, are ego orientated and failing is seen as a disaster. On the other hand, these countries are strongly result oriented which hypothetically may lead to a quicker initiation of treatment in order to overcome negative effects of the disease and thus to a higher level of use.
Uncertainty avoidance has to do with ‘a society's tolerance for uncertainty and ambiguity’. In countries with high uncertainty avoidance more CNS medications may be used because doctors and societies want to avoid unstructured situations (behavior different from usual) in cases of severe CNS disorders. However, because these are new medications related to uncertainty and ambiguity with regard to effectiveness, long term side effects, and/or cost-effectiveness, doctors and patients might be less willing to use these medications compared to older, more commonly used medications in countries with a strong uncertainty avoidance. However, it should be kept in mind that uncertainties about the effectiveness of those medications may also exist.
Long-term orientation indicates the extent to which a society focuses on the future instead of the present only. Countries with a short-term orientation are normative in their thinking but also have a focus on achieving quick results whereas societies with a long term orientation show perseverance in achieving results. In addition, countries with a short term orientation may adapt to changes, such as the introduction of new medications, more rapidly than countries with a long term orientation, resulting in a higher use of these new CNS medications.
Indulgence is the feature of a society that allows satisfying, relatively free, feelings and desires.
The opposite is restraint which stands for a society that ‘suppresses gratification of needs and regulates it by means of strict social norms‘[
21]. Indulgence can be expected to relate positively with the use of CNS medications, as these medications may have a rewarding effect on patients and the incentive of discontinuation might therefore be lacking. Countries with a high level of restraint might suppress the use of these new medications. Stricter regulations in these societies are either due to the higher treatment costs associated with the use of these medications and/or little additional therapeutic value or due to the risk of dependence.
Based on these hypotheses we expect that power distance, individualism, long-term orientation and indulgence may be correlated with the consumption of aripiprazole, duloxetine and pregabalin. For a summary of the hypotheses, see Table
1.