Social Construction of Health: Using a Discursive Approach to Understanding Health
Abstract: Health is one of those everyday words that only seems self-evident in its meaning. Using discourse analysis, the author attempts to understand the conception people have about their health and feeling healthy through personal accounts. The interest was primarily in examining how, in their individual descriptions, people reconciled their representations of health, and negotiated and regulated their self-concept in the face of a largely bio-medical discourse of health. Sixteen women were interviewed for this study. The data were analyzed using constant comparison and themes were identified. The themes revealed that people experience health at different physiological, psychological and emotional levels.
Pratibha Shukla,
Ph.D
Department of
Communication Studies
Ph:
940-565-2819
Fax:
940-565-363
Pratibha Shukla,
PhD is working as Assistant Professor at the
Social Construction of Health: A Discursive Approach
Health is of central importance to the quality of life outcomes. In fact one operational definition of quality of life is a person’s subjective appraisal of well being (Muldoon, Berger, Flory & Manuck, 1998). Health has long been a key concept in the nursing profession and an important topic of research in medical sociology. However, social science and communication scholars have demonstrated a renewed interest in understanding subjective well being. During the past decade, scholars from a wide range of fields have examined the meaning of the health concept (Phillips, 1990; Jones & Meleis, 1993; King, 1990; Kulbok & Baldwin, 1992; Long, 1993; Morse, 1987; Newman, 1991; Parse, Coyne, & Smith, 1985; Pender, 1990; Reynolds, 1988; Tripp-Reimer, 1984). However, only limited research has been conducted on laypersons’ concept of health.
In her essay, On Being Ill, Virginia Woolf pondered the absence of illness as a major theme in literature. One would expect "novels . . . devoted to influenza; epic poems to typhoid; odes to pneumonia; lyrics to toothaches . . .. Considering how common illness is," she wrote:
‘How tremendous the spiritual change that it brings, how astonishing, when the lights of health go down, the undiscovered countries that are then disclosed, what wastes and deserts of the soul a slight attack of influenza brings to view, what ancient and obdurate oaks are uprooted in us by the act of sickness . . . it seems strange that illness has not taken its place with love and battle and jealousy among the prime theories of literature.’ (cited in Ginsberg & Gottlieb, 1967, p. 193).
Woolf's essay highlights the crucial and often pivotal role played by illness in human experience, and the appropriateness of literary avenues for exploring this dimension of life. Literary critics have analyzed the dialectics of illness, literature, and culture. For example, Susan Sontag (1977) provided an insightful analysis of the ways in which social context shapes the imagery of tuberculosis and cancer. In a study of Italian novels, one critic argued that disease
"is an
integral element of a given historical and social structure taken into
consideration by literature; therefore, disease often becomes a point of view,
an instrument of knowledge and of totalizing judgment for an author" (Biasin
1975, p. 24).
The present study uses a discursive approach to examine the people's perception of health by determining how a layperson talks about health and how he or she identifies what is important for feeling healthy. The review of existing literature demonstrated that the concept of health has been explored in multitude ways. Most work in this field has been conducted using quantitative methodologies. Laffrey (1986) developed an instrument to measure the concept of health that focused on four categories: clinical, role performance, adaptive, and eudemonistic (well-being and self-realization). Woods et al. (1988) conducted telephone interviews about health with more than 500 women, 18 to 45 years of age. The findings included health conceptions that expanded Laffrey's (1986) work. The health categories reported most frequently in Woods et al.'s (1988) study were clinical, positive affect, fitness, practicing healthy life ways, and harmony; they did not mention role performance or adaptation.
Kenney (1992) extended the focus of the previous studies in a report on the responses of 65 adults to a questionnaire with 34 definitions of health. She found that her respondents ranked self-concept, fitness, and role performance as the most robust indicators of health. In a related study, Hartweg (1993) described the self-care actions taken by healthy middle-aged women to promote their well-being. Van Maanen (1988) reported that in a comparison of American and British respondents 65 years of age or older, perception of health was determined by a state of mind rather than just physical functioning. Wondolowski and Davis (1991) posited that health for the oldest old--those over age 80--meant a vitality that generated fulfillment.
The intention of the present study is an in depth understanding of the concept people have about health and feeling healthy through their personal accounts. This study therefore goes beyond the empirical studies that provide only abstract categorizations of health, by helping us understand how individuals frame the concept of health. Therefore, the scope of the present study is realized in understanding how people describe what health means to them through the use of discourse analysis as a method.
Health
One might assume that just as grocers know what they mean by groceries, so health care providers surely must have clear concept of health in mind when they use the word. Health is one of those everyday slippery-as-mercury words, the meaning of which seems so obvious and self-evident that we seldom make an effort to define the term consciously for ourselves. This oversight is unfortunate because the health care providers cannot: (1) recognize which of the patients' expectations are authentically medical, (2) identify the appropriate role of physicians in an increasingly technological profession, and (3) understand the interrelationships of health, medicine, and the good life. If anything health care providers have only an amorphous idea of what it is to be healthy beyond simply being "well-functioning;" a clearer concept of health could add some form and substance to this vague awareness.
Physiological measurements alone fail to capture the subjective dimension of health. "Health" is an end and a means--it is a foundation for achievement, an achievement itself, and a precondition for further achievement. Twaddle (1974) explained health as a concept linked to status and role. Twaddle stated that health and illness could be conceptualized with respect to the biophysical changes in the organic states of individuals. He clarified that health and illness, in a somatic sense “constitute standards of adequacy relative to capacities, feeling states, and biological functioning needed for the performance of those activities expected of members of society.” (p. 37, Twaddle, 1974) These expectations he argued varied with age and gender of the individual.
Morris
(1998), a postmodern scholar, described illness as the existential marker of
human beings. Morris emphasized the need to understand the relationship between
biology and culture as incumbent to the study of health. Parson (1951) argued
not only for the interconnections between medicine and culture but also for the
inclusion of society as the point of reference for patient-physician
interaction. Parson (1978) defined health as the “capacity to maintain a
favorable, self regulated state that is prerequisite of the effective
performance of an indefinite range of functions both within the system and in
relation to its environment ” (p. 69). Parson’s definition encompassed the
teleological meaning of health and, therefore, besides the physical and organic
meaning, argued for the inclusion of psychological and sociocultural meanings
for understanding the concept of health.
Descriptions of health based on physiological measurements ignore the idea of health as a value. What they offer in precision, they lack in depth; for, surely, being healthy is much more than having all one’s organs quietly functioning within plus or minus one standard deviations of normal. Value free descriptive definitions of health cannot be more than one component of a comprehensive concept of health, for health is valued. Health is a value beyond formal knowledge. However, value-based definitions of health lack universality; they depend on the individual's (or the culture's) determination of what is to be valued (Kovács, 1998).
The World Health Organization (WHO) defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO Report, 1946). This definition, if taken literally, is meaningless. However, the author believes that all normative definitions of health, including this hopelessly utopian WHO vision, derive from a common ground, a core meaning or experience of health that requires interpretation (Mordacci, 1995). With the change in worldviews from modernism to postmodernism, new dimensions of illness and health have emerged that elicit how we study the two. The postmodern view of illness as an experience that an individual goes through during his or her life contrasts with the modern era view of illness as an entity that threatens life. The author espouses the postmodern view, in that I understand health as a subjective experience that is socially constructed.
Schutz (1945, 1967) discussed the inter-subjectivity and existence of more than one reality that enables us to recognize the coexistence of and interrelationships between multiple realities. Berger and Luckman (1966) stated that the traditional definition of reality inhibits social change. They also argued that through subjective experience we as humans not only understand each other’s definition of shared situations but we construct them reciprocally, thereby discovering alternate realities. Following this line of thought the present study seeks to determine interpretations of ‘health’ from the point of view of common human experience. The author thinks that such an understanding of health and the ‘multiple realities’ of experiencing health will provide vital information critical to interpreting health behavior.
How people talk about health is important. Frank (1995)
offered the powerful metaphor that ill people were more than victims of disease
or patients of medicine; they were wounded storytellers. He argued that people
tell stories to make sense of their suffering; when they turn their diseases
into stories, they find healing. Research
has shown that stories represent certain values and knowledge, and depending on
the contexts in which the tellers are situated, the stories are told
differently. However, because we
live our lives immersed in competing discourses, the stories we tell give voice
to and recreate competing discourses (Novinger & Compton-Lilly, 2005).
Stories simultaneously present competing agendas in order to get heard in social
context. On different discursive levels of interaction, the same story can be
understood differently depending on the relationship between the speaker and the
audience and their relative positions in the specific social context. Depending
on the storyteller’s access to power, some stories are effective in
accomplishing their goal whereas others go unheard.
This access to power coincides with a strong belief that exists in the North American health care culture that eliciting, discussing, and expressing one's illness story and accompanying emotions can be healing. Families also share this cultural belief and have often remarked in clinical settings how they appreciated the opportunity to talk about the effect of illness on their lives and relationships. A study by Robinson (1994) about families, illness, and intervention conducted in the Family Nursing Unit, University of Calgary, provided further validation that families find nurses’ invitations to engage in meaningful conversation about the effect of illness on their lives to be one of the most useful interventions in assisting families to move beyond and overcome problems. The capacity of nurses to be witnesses to the stories of the suffering of patients and families has proved central to providing care; telling stories frequently has served as the genesis of healing, if not curing (Frank, 1994; Kleinman, 1988). Several studies (Morris, 1998; Lorber, 1997; Purdy & Banks, 2001; Mattingly & Garro, 2000) have pointed out the interrelationship between discursive practices and extra-discursive social issues like healthcare.
Discussing the philosophical basis of discourse, Burman and Parker (1993) provided a working definition of discourse as a system of statements that construct an object. The definition, which Potter and Wetherell (1987) provided in their useful introductory guide, has engaged the interest of a number of researchers. Their definition encompasses much of the material that social psychologists, communication scholars, and anthropologists; discourse includes, “all forms of spoken interaction, formal and informal, and written texts of all kinds” (p. 7).
Discourses are ways of perceiving and articulating relationships. Discourses do not simply describe the social world, they categorize it, they bring phenomena into sight. Once an object has been elaborated in a discourse, it is difficult not to refer to it as if it were real (Burman &Parker 1993). “Discourse analysis, at the most broad level, is the analysis and interpretation of the operation of systems of signs as they relate to communicative practices between humans” (Traynor, 2004). The various practices that go under the name of discourse analysis have tended to develop within two separate, but not completely unconnected, disciplinary areas. The first type considers the analysis of verbal structures and cognitive processes, the second on discourse as interaction in society. Linguistics or conversation analysts, primarily investigate the technical aspects of effective communication, whereas social scientists consider analyze of talk or text in relation to social structures and sociological theory (Traynor, 2004). The field at health care provides enormous opportunity for both, and discourse analysis could prove a powerful approach for studying the field. The author of this paper used the latter approach.
Healthcare
Discourse
Healthcare
has received ample attention in discourse analysis (Anderson, 1987; McKinlay,
Plumridge, McBain, McLeod, Pullon, & Brown, 2005; Tilley,
& Pollock, 1999; Werner, Isaksen, & Malterud, 2004; Horton, 2004;
Zimmerman, 2004).
Horton
(2004) demonstrated how language could be a tool for analyzing and solving
individual problems in healthcare field, specifically in speech therapy.
Horton’s work discussed the use of discourse in topics such as professional-client relationship in health care
setting. Zimmermann (2004) conducted a study on terminally ill patients and the
discourse created around them. The
study found that the families of the patients
were often presented as being “in denial of impending death.” This study
investigates the usage of the term “denial” in the contemporary hospice and
palliative care literature using a qualitative method of discourse analysis.
McKinlay et. al.
(2005) argued that a significant gap exists between the concept of health as it
is understood by health care practitioners and by the general public. The study
evaluated the reception of the recently
implemented New Zealand Primary Health Organization structure by general care
practitioners. The researchers conducted a discourse analysis on data collected
from 18 general practitioners. Their findings illustrated problems in
transferring the concept of health from general public to health care providers.
Addressing
the dominance of the economic reality of health care, Heggen and Willard (2004)
determined that healthcare could be affected by the interdisciplinary flow of
social discourses. They argued that the introduction of economic discourse into
healthcare could change the overall attitude of people toward the profession and
the efficacy of the practice. Despite the good intentions of the care providers,
the introduction of economic discourse could mar the fragile relationship
between nurses and their patients.
Jolanki’s
(2004) examined how old people construct and negotiate meanings of health.
The study analyzed two health research interview cases and illustrated how the
interviewees tended to negotiate and balance different moral arguments in their
responses. Managing the ‘face-threat’ posed by the questioning about health
and being appreciative of good health and activity without being critical of
declining health and diminishing activity are two of the strategies used in
elderly people’s discourse. Their rhetorical constructions challenged the
traditional discourse of old age as decline and fall; instead, they created a
sense of obligation and usefulness naturally associated with ‘old’ age.
Social
pressure is tantamount to oppressing the voices of marginal groups. The fear of
persecution and disclosure causes many people to avoid revealing their painful
experiences and health concerns. One landmark study on the representation of
marginal voices (Werner, Isaksen, and Malterud, 2004), found that women redefine
their health concerns to avoid unnecessary attention as well as to avoid
persecution and mockery.
The researchers examined how the women’s stories were shaped according to
cultural discourses of gender and disease. Using in-depth interviews with a
purposeful sampling of 10 women of varying ages and backgrounds, the study
focused on women suffering with chronic muscular pain. Werner et al. (2004)
interpreted the data using narrative theory and discourse analysis.
As
a plot, their stories attempt to cope with psychological and alternative
explanations of the causes of their pain. As performance, their stories attempt
to cope with the skepticism and distrust they report having been met with.
Finally, as arguments, their stories attempt to convince us about the
credibility of their pain as real and somatic rather than imagined or
psychological (p.1035).
In several ways, the women
seemed to act out their different roles within the parameters of the dominant
social perspective. They lived out their roles and negotiated pictures of
themselves that fit with normative, biomedical expectations of what illness is
and how it should be performed or lived out. They performed their roles in
accordance with the popular mode of thinking in their society, and thus
established credibility as woman and as ill. Their stories are not constructed
not merely on the basis of individual behavior; they also are as organized by
medical discourses of gender and diseases.
Stephen
et al. (2004) studied the concept of ‘health’ in the context of Hormone
Replacement Therapy.
Using ‘social cognitive’ frameworks, they examined people’s attitudes
toward illness. The researcher found that the public tended to treat illnesses
as if they were stable entities located within individuals. The study attempted
to understand the apparent contradictions and variations in women’s attitudes
towards Hormone Replacement Therapy (HRT) by using a social constructionist
approach. The data were derived from 7 focus group discussions about HRT with 48
women in
A strong criticism of discursive studies is that discourses allow individuals to focus on things that are not “really” there and, once an object has been defined by discourses, it is difficult not to refer to it as if it were real. However, the study of discourse provides frameworks for debating the value of one way of talking about reality over other ways (Berger & Luckman, 1966). The present study examines how people perceive and talk about health and presents an argument for the need to understand health as a concept that is not limited to the absence of illness, in its social, mental, physical or emotional forms.
Methods
The
main research question addressed by the present study is: How
do people perceive health and talk about health? Using a purposive method of
sampling, 16 women were selected for the present study. The criterion for the
purposive sampling was the participant’s personal experiences with illness. Cazden
(1986) suggested that if the data collection situation permits a combination of
data collection techniques is the best approach. The
data for the present study were gathered through informal interviews and
observation methods. All the participants were provided with an informed consent
form and were made aware of their right to discontinue or withdraw their
responses at any point during the study. The participants were asked three main
probe questions and were encouraged to talk about health, giving accounts of
their personal life experiences.
The interviews were conducted in an informal environment (e.g., meeting over lunch or dinner), thus helping to create a relaxed atmosphere. After three introductory questions (1. What does health mean to you? 2. How did you feel the last time you were sick? 3. Could you give some anecdotal information illustrating your experiences with illness?), the interviews followed a non-standardized, free-flowing format guided by cues from the interviewees in order to draw from the understandings and perspectives of the participants (Guba & Lincoln, 1981).
The participants were all women (N=16), ranging in age from 30 to 80 years. The researcher knew nearly all of the participants personally. Most of the women were professionals with careers. The sample included scientists, researchers, students, senior management professionals, and university professors in science and social sciences. Most of the participants were married at least once and had children. Only two of the women participants did not have children. The participants were selected through the technique of purposive and theoretical sampling (Strauss and Corbin, 1990). Theoretical sampling is especially useful to identify conceptual boundaries and pinpoint the fit and relevance of our categories or themes (Charmaz, 2000). The interviews were tape recorded with prior permission of the participants. Each interview lasted for an average of one and a half hours. Once the data were collected, they were transcribed for the purpose of analysis. Rogoff (1990) argues that the unit of analysis must involve both the individual and his or her activity in context. Therefore, the personal association of the women with their illness was important. The researcher attained that information by asking the participants to provide anecdotal accounts of their illnesses. Consecutively, the data were analyzed using the individual accounts of the perception of health as the unit of analysis.
Methods of Analysis
In keeping with established methods of qualitative research (Glaser & Strauss, 1967; Strauss, 1987), data analysis followed the constant comparative method (Strauss & Corbin, 1990). To begin, data analysis was performed in the field as data were collected and organized into themes.
The researcher followed inquiry and analysis methods that identified emerging themes based on what participants said about their experiences, the dominant thought or concept around which their narratives revolved. The three steps of organizing the data into the emergent themes were unitizing, categorizing, and relating (Blaxter, 1996; Guba & Lincoln, 1989). Therefore, the interview transcripts were read several times to identify the units of sentences that were central to the conveyed meaning, which were then categorized into broader concepts. Following the process of categorization the researcher proceeded to comparing or relating similarities and noting the differences, which were then analyzed, and synthesized. Participants were involved in the process of the analysis, which engaged them in helping to test the emerging findings (Glaser & Strauss, 1967). To facilitate participant involvement, the researcher kept a journal of developing themes related to the topics of talk and continuously reexamined whether they were supported by the interview data. The analysis helped to generate and sharpen additional questions for use in subsequent interviews. In addition, following the tradition of theoretical sampling the researcher shared the emerging interpretations with the participants during the reciprocal interview process by meeting the participants for a second time. In theoretical sampling, the categories and themes take the researcher back to the field to gain more insight about when, how, and to what extent the categories are pertinent and useful (Charmaz, 2000). The researcher asked questions to make certain that participants understood the meanings that participants intended both explicitly and implicitly.
The data were analyzed to identify thematic structures. The present study used a thematic discourse analysis (Potter & Wetherell, 1987; Burman & Parker, 1993) to consider common threads and inconsistencies embedded in the narratives. A broad thematic level of analysis was used to identify the core concepts that emerged repeatedly. The present study uses the method of thematic analysis described by Westerfelt (2004). The general thematic analysis involved repeatedly reviewing data sets to categorize instances of discourse into recurring topics. The categories were then analyzed to identify themes that would link the larger categories. These themes represent the overarching meanings that capture the participants' perspectives.
Earlier qualitative studies described the pervasiveness of medical discourse and how it might enable people to acknowledge distress and to seek help (Daly, 1995). For the purposes of this study, the influences of socio-cultural stereotyping and discourses were examined. The interest was primarily in examining how, in their individual descriptions, people reconciled their representations of health, and negotiated and regulated their self-concept in the face of a largely bio-medical discourse of health. The aim was to be faithful to the phenomena evoked rather than to posit explanations. This approach meant allowing a lived narrative, complex layered web of meanings, to emerge rather than to discover straightforward "facts," a historical "truth" (Spence, 1982).
The following paragraph, for example, illustrates a feeling that absence of health means dependence on others, on medical professionals, and on becoming a subject of pity and sympathy.
Oh it is a complex thing…I mean health is important and I suffered from severe case of RLS [restless leg syndrome], it is better now but sometimes it so bad, and if I tell somebody that I have severe case of RLS, I mean it is not like I have Cancer or anything, but it is debilitating, I feel totally drained off, when I have an episode. It is like getting only 2 or 3 hours of sleep for 4 or 5 days and then I reach a point where my body cannot function anymore…. I don’t need help, I should be able to take care of it by myself, and I should be able to fix it…. Don’t want to admit (I need medicine), I will rarely admit that I am sick (disdain of others) and I don’t want to be babied, I am a big girl….
This example demonstrates that health is understood in reference to its absence. Several cognitive schemas are operating here: first, health is a biological phenomenon; second, absence of health is demeaning; and third, health is a personal responsibility.
Findings and Discussion
This study is based on interviews with 16 women regarding their experiences and understanding of "health." The meanings of "health" were varied, reflecting subjective experience that is essentially socially constructed within the commonly understood and objectively recognized conventions (Thorne, Kirkham & O’Flynn-Magee, 2004). While the overarching theme that emerges from this study is “Health is feeling healthy,” four sub-themes also appeared, namely: (1) health is freedom from disease, (2) health is freedom from stress, (3) health is spiritual/mental peace, and (4) health is physical fitness and ability to perform everyday functions. The organization and discussion of these themes is not based on any hierarchy. Although the discussion is organized into discrete categories, the themes often overlap; moreover, the discussion sections are uneven in size because of the complexity of the topic and author’s perceptions of the participants' meanings. Within each theme, the author provides a brief discussion and analysis of the narratives guided by literature that is relevant.
The
author in this study takes an interpretive approach to understand the subjective
experience of health and illness. An interpretive approach is applied to understand the social meanings.
Therefore, the author acknowledges that all human experiences are subject to
social construction and that resulting social interpretations shape their
understanding, thereby becoming a part of our knowledge systems (Berger &
Luckman, 1966). The author also acknowledge that no a priori theory can
be applied to explain the multiple realities that are encountered in the data
(Thorne, Reimer Kirkham, & O’Flynn-Magee, 2004). Guided by this framework
the author uses inductive method to describe the socially constructed frames of
meaning pertaining to health.
Health
is feeling healthy:
The overarching theme that emerged prominently was the idea that feeling that one is in good health is imporatnt. Almost every participant emphasized how feeling healthy is the single most important feature of being in good health. Most often participants talked about non-medical conditions ( e.g., pain, weakness or feeling less energetic, general fatigue or back ache) to describe being in a non-healthy state.
The narratives that follow exemplify the desire to feel healthy but finding inadequacies in general wellness due to some unexplainable discomfort, coping with changes in body, or not being able to keep up with friends or family.
Being healthy is to feel that there is nothing wrong with you. Some days when I get up in the morning and my whole body is aching, I feel like I want to stay in bed. Now I know that it is probably not any disease but I feel I can not be my hundred percent…the day is unproductive…
In the following example, the respondent explains that cognitive understanding of health is not enough, the ability to cope and adjust with changes in the body due to age is important to feeling healthy. The speaker also suggests a sense of struggle to attain some invisible goal.
Oh I don’t know where to start…I am at a age, (36 years old) where my doctor says I am going through some hormonal changes, and so I gained some weight, but just knowing that does not make me feel any better, it is still frustrating to me…I was never this size... and I hate to be thinking about calories and fat, and polyunsaturated this and …right before every morsel I put in my mouth…I think I am getting obsessive and I know that is not healthy…
Interestingly, some respondents understood health in terms of their ability to meet the expectations of their friends or family. Health also was understood in comparison with the health of friends.
When I go to the malls I feel I can not stay on my feet for any longer than an hour or so and even though I know I am technically healthy I find it difficult to keep up with my friends, some of who are older than me…I get really disappointed in me…I just do not have the energy…I especially feel bad because a lot of times I have to just tell my husband to order-in and it is not that I do not want to cook because I love to cook for my family…but I am tired by evening...
Another dimension of feeling healthy was captured in relation to adapting to the environment:
I moved to this area about two years ago, and I already feel that I am a lot healthier. I guess it is the climate, or the altitude, but I just feel energetic, the mornings here are so crisp I just feel like I will have a good day and I remember when I was living in the other city, I was tired more frequently, it use to drain all my energy, the work commute was so long, and there was humidity….
The respondents, through their subjective experiences imply that it is important for them to feel healthy to be able to function in their lives. The literature on construction of health and disease suggests that feeling healthy is best understood within social norms (Kovács, 1998). These social norms are specific to the society in which one lives. The biological adaptation to changes in body or health as a response to environment, and even health as a process of meeting expectations of the society in which one lives can be explained by the normative view of health (Nordenfelt, 1987; Twaddle 1974). Nordenfelt (1987) described health as the ability of a person to achieve his or her vital goals that lead to attaining minimal happiness. Twaddle (1974) provided a continuum of health ranging from perfect health to normal health to disease. What Nordenfelt described as health was referred to Twaddle as ‘normal health’. The perfect health as described by Twaddle (1974) is the ideal health toward which people are oriented rather than something they expect to attain. The author feels that perfect health would include being healthy as well as feeling healthy.
Health
Is freedom from disease
In the instances of discourse that fit into this category, the interviewees made statements giving the biomedical explanation for health. Describing diagnoses in medical language when asked if they are healthy shows a more immediate concern about their medical state of health. The focus of the discourse is a condition to be fixed, or damage to be repaired. In the following narrative, for example, the participant does not talk about physiological, psychological, or emotional states; rather, she provides names of diseases. The fact that health is understood in the context of medically defined symptoms demonstrates the emphasis on being free from disease as a primary experience of health:
Health means to be free from disease or disorder. I have been diagnosed with Thrombocytopenic purpurea, which does not hinder me from doing anything in my everyday life but I always worry as I constantly think I am sick….
Health as freedom from illness is illustrated in statement from three of the other participants:
To me, physical health means receiving enough food and exercise and being free from illness. Mental and emotional health would mean being free from psychological disorders. I remember that recently I suffered from food poisoning and those three hours from the onset of nausea to … were the most dreadful… I think it was botulism…I mean I thought I was dying…
I am not suffering from any disease but I often have pain, I have headaches or pain in my shoulder, or cramps in my legs and the fact that I have to take painkillers almost on a daily basis worries me, because to me it means I am not well…. Who knows, anything could be going on inside, from arthritis to cancer…but I am not diagnosed with anything.
Feeling physically free from discomfort, that is physical pain, is health. I recently had to go for a biopsy and I was afraid because it may be cancer…my results show that I am not having cancer and so I feel healthy.
The notion
of health expressed in the instances of discourse above is very much in line
with the naturalist view (Boorse, 1977). The naturalist view proposes that
disease is “the inability to perform all typical physiological functions with
at least typical efficiency,” and health is simply the freedom from disease (Boorse,
1977, p542).
When the participants were asked to elaborate their answers, all talked about their present state of health in relation to a disease that affected them at some point in their life. Significantly, whatever claims the individuals make about a disease or syndrome, each still experiences the illness in a subjective manner that acknowledges the constructed and contextual nature of human experience, and that allows for shared realities (Thorne, Kirkham & O’Flynn-Magee, 2004).
In the words of Good and Good (1981), "While all disease has biological or psychological correlates or causes, sickness becomes a human experience only as it is apprehended, interpreted, evaluated and communicated -- that is, as it enters the world of human meaning and discourse" (p-175). This point is supported by the present study, which shows that people from different backgrounds or world-views experience the same so-called disease differently. Striking differences exist between different groups or individuals regarding the description of their illness.
Health Is Freedom from Stress
Under this theme the participants discussed health in conjunction with the amount of stress the participant experienced in relation to their present life circumstances or lifestyle choices.
Certain lifestyles and professions led to more stress in life. In the following narrative the participant discusses why she had to change her profession and accept a lifestyle much different than the one she enjoyed previously. She claims she made the right decision becauses she has much less stress in her life:
My health is much better now then it was, because I have stopped practicing law… and I have decided to do things that I always wanted to do, things that relax me like gardening, going camping… I have to do this to feel healthy and alive…
Life circumstances not in a person’s control may also cause stress and can affect one's sense of well-being. In the following narrative the person is helpless but feels responsible for the situation in her life:
I try to get as much finished in one day as possible so that I have nothing else to do except take care of my daughter who is 16… I constantly worry about my youngest daughter and that sometimes makes me sick due to the stress… I get headaches, I am irritable, and I am not able to sleep well….
In another case the respondent feels she is helpless but can cope with her situation by smoking. She chooses to act in certain way (i.e., smoking) because it helps her achieve more control over stress.
I think it is important for my health that I don't smoke but I just cannot do without smoking. There is too much stress in my life…I need to smoke to be able to function properly….
Stress is again exemplified as a major cause of bad health in the following narrative. The participant claims that she feels much healthier now that her stress is under control:
I feel healthier now because I feel more at peace with many stressors related to personal issues, work, family (parents, siblings)….
These instances of discourse show that the participants have some notion of personal health and they understand that good health can be achieved with less stress in their lives. They see stress as the reason that they do not enjoy good health. Interpreting a stressful event as harmful or as a loss reflects the amount of damage that has already occurred due to the stressors in the lives of these people.
In fact, most people who experience stress attest to the causal link between stress and health problems. Research confirms that stress exacerbates disease; however, this dimension of health has only recently found a place in the medical thinking with the developments in the field of psychoneuroimmunology. Kopinsky, Stoff and Rausch (2004) have suggested that psychological factors such as stress, or psychiatric conditions such as major depression, may influence the immune system, thereby altering host susceptibility to viral or other types of infection.
Health Is Spiritual/Mental Peace.
The spiritual dimension has not been adequately defined, researched, grounded in theory, or integrated into the study of health. Historically, mental health researchers and practitioners have neglected spirituality, preferring to look at the effect of organized religion (Longo & Peterson, 2002). A growing body of evidence, however, points to the important role of spirituality in treating medical and psychological conditions. Researchers have found a negative relationship between spiritual well-being and uncertainty, and a positive relationship between psychological adjustment and spiritual well-being (Longo & Peterson, 2002; Gurklis & Menke, 1988). Many observers have suggested that the public interest in spirituality is a symptom of increasing levels of isolation, disconnection, and existential frustration in our society (Fahlberg, 1991). Optimism and a sense of coherence directly affect overall wellness. The cultivation of a purpose in life is a goal that may enhance overall wellness. The following instances of discourse illustrate the need to attain a balance in life through spiritual and mental peace as central to feeling healthy.
Health means well-being. This includes both our physical and mental health as well as spiritual, which to me is part of having a fuller life experience…Being healthy includes being able to function within this world and act responsibly and mindfully.
This quote illustrates that the participant perceives that achieving spiritual and mental health is important for living a satisfying life.
Spiritual and mental peace is also important, as a source of strength to fight disease. The instance that demonstrates the personal thought process of a participant when she discovered that her physical condition showed the importance of spiritual strength in fighting a disease:
Disease or illness is one of the great 'tests' in life. It teaches you something that you should learn…. For example, I was told that I had a breast lump this spring that needed to be removed because it could be cancerous. I wanted to know as much as I could…. It turned out benign.… But I thought if this is cancer then I 'm going to think of it as an enemy and do everything I can do to stop it. I am not going to be afraid of it…
While giving an account of trauma and bad circumstances, this respondent revealed that even though she was in good physical health, she was not able to live a normal life.
One participant understood the centrality of spiritual and mental health in gaining control over life:
I have experienced mental sickness, and I was bulimic for ten years. I was being sexually abused…. However, I maintained my physical health, yet my spiritual health and my spiritual self was battered, weak…. I was very unhealthy.… I was sick.
Health is also equated with spiritual and mental peace as it is considered important in creating a balance and a sense of self-control, as is evident in the following instance of discourse:
Health is being in 'harmony' with the internal and external self…feeling content, peaceful, free from mental anguish, worry...the ability to deal with worry or sadness...being healthy is knowing oneself to be at peace, cope with pain both mental and physical…I am healthier because I can distinguish better between what I can control or change and what I can't…I am healthier because I feel comfortable with my spiritual life….
Interestingly, an emphasis on spirituality is evident in literature on holistic health (Hawks, 1994; Benzein et. al, 1998). Though the concept is primarily Eastern, it has caught the attention of Western societies. In addition, medical practitioners have begun to recognize the influence of spirituality on illness (Dossey, 1993). Spirituality has been recognized as an important but insufficiently developed dimension of wellness (Chapman, 1987).
Health is Physical Fitness and Ability to Perform Everyday Functions
Perhaps the most visible factor in evaluating health is physical fitness, the ability to use every muscle, every part of body, and the ability of the body to perform functions and be agile. We are our bodies and only in and through them do we know ourselves and our relationships with others (Clarke, 1992).
The belief that health is about physical fitness is exemplified in the following account, which describes a respondent’s health condition and how she evaluated her health in terms of her lack of mobility:
In the last three years I have started to lose a lot of my flexibility and mobility…. The problems I have with my knees prevent me from doing things I used to do and would like to do. There is only so much drug therapy can accomplish…. I think I need to bring some change in my exercise behavior
Another account presents a more straightforward description of health, displaying a greater internal locus of control, visualizing health as an output of one’s effort:
In my eyes healthy is actually having a good self-image or at the very least one that doesn't get in the way of doing things. Exercise both mental and physical keeps one healthy…although I am not an 'exerciser'…. I try to keep fit…. I play basketball with my kid and also do running around with our cats….
One respondent saw her body as a machine, a set of parts that need maintenance, something that can be manipulated at one's own desire:
Self image is not an issue but I would like to have a flatter stomach, but apparently it does not bother me enough to do anything special to tighten those muscles like crunches, machines …I guess I could do it but…
The notion that the ability to function is being healthy is exemplified in the following statement in which the participant describes doing gardening as a measure of her health and fitness state:
"I think I am healthy because I feel I can do anything I want to…about a week ago, I started a garden patch in the lawn. I had to spade up an area, remove turf and sod, haul the sod, dig up and haul in the transplants, and reset the soil. This took several hours of spading, lifting, kneeling, etc. I thought I would feel tired and sore when I was done. Instead, I felt quite good even though I had been quite sedentary for the last few months as I gave birth only nine weeks before…Because I was not limited in reaching my physical goal, I feel physically fit….
Another participant who had to face her inability to maintain earlier levels of physical activity illustrates the belief that regular exercise is a measure of health:
I don't think I am healthy. Earlier I was able to exercise two to three times a week and run about 30-40 minutes, but of late I have noticed I am not able to do it…I get easily tired…am tired after I come from my work…I am trying to conserve my energy.
One respondent equated physical ability to perform her job as an essential quality of good life. She characterizes anything that disrupts the routine of going to work and putting in set hours is designated as a sign of bad health.
Health is to be able to work. It is something like everyday condition. In my opinion, health is an essential quality of good life. If you don’t have to rearrange something for you and you can work and live your usual life, it is health. Being able to live and enjoy ordinary day is health... If you are working your regular routine and if you are physically okay, then you are healthy. You can be thin and still be healthy. But if you change all of a sudden and for some uncomfortable reason, then you are not healthy.
Clearly, the participants place high value on physical fitness and have a general perception of the connection between personal efforts and health outcomes. Physical fitness is emphasized more in Western societies and, therefore, maintaining physical fitness is considered a basic need. This emphasis is also evident in the strong consciousness about body image, a new concept in Eastern thinking. Additionally, in a productivity conscious world inability to accomplish whatever constitutes “work” is considered a personal failure.
The functionalist or the objectivist view of health, which is conceptually closer to the naturalist view, also emphasizes the body’s functioning as a marker for health or its absence. Lennox (1995), for example, described, health as “the state of affairs in which the biological activities of a specific kind of living thing are operating within the ranges which contribute to continued and uncompromised living (p. 502).” Sade (1995) also provided the same description of health in his essay on theory of health and disease.
Conclusion
If it is true that high levels of wellness cannot be achieved without a balance in the various dimensions of health (World Health Organization, 1946), then scholars and health care professionals need to pay more attention to the way people understand health--specifically, what it is and how it relates to and interacts with other dimensions of health. The present study finds a range of meanings used in the dimensions used in discourse about health. The discourse suggests a need for integrating the various dimensions of health
This study expresses not only a factual situation (i.e., what health is and means to people and society at large), but also demonstrates how the health care system has been unable to meet this implicit challenge. That insight together with other developments constitutes a powerful claim for taking seriously the way in which people become ill and get healthy. An understanding of illness conditions and healing practices should acknowledge the multifaceted nature of health. The findings of this study suggest that the shift to an integrated approach to illness and health matters cannot bypass the problem of opposing world-views (the patho-physiological vs. the concept of holistic health). Finally, the present study provides more than just the different dimensions of seeking and achieving health. Most quantitative studies have followed that approach (Alonso, 2004; Laffrey, 1986). The value of the present study is in providing an opportunity to understand people and to realize the way they think about health. The study suggests that medical and health care-giving institutions should rethink the model used for providing services that are one of the most integral components of the health and medical care establishment.
To be successful, disease prevention and health promotion programs must integrate these concepts into their programs. When developing a program designed to prevent disease among a certain population, health care professionals should discuss the disease in the context of how it affects emotional, mental, and spiritual well-being. In addition, this study helps health care providers to understand health in ways it affects people's ability to care for themselves, and how it affects them in their day to day aspects of living their lives. In short, health care professionals must understand what health means to the people they seek to treat. One of the consistent undercurrents that connect all the themes identified in the present study is the perception that feeling healthy is important to overall health. Most often, health programs and services focus on treating people with defined illnesses or on preventing health problems. Scholars such as Izquierdo (2005) have pointed out that often the general population is trapped in the un-definable situation of not ill but also not being healthy. This study is an attempt to understand that intangible and un-definable situation of not ill but not feeling healthy.
The findings of the present study are limited to the present participants. Nevertheless, they suggest themes that may be representative of how people conceptualize health in ways different from the patho-physiological perspective that is generally held by medical professionals. People should be examined not as demographic units, but as groups based on life experiences and indigenous culture. Future research could explore health concepts of people as groups based on experiences, or cultures, and not only demographic characteristics. This research suggests that understanding people on the basis of how they perceive health can help in diagnosing disease, perhaps before the onset of actual symptoms of a disease.
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