Health Psychology. Michael Murray
and community disruption experienced’ (2012: 459). Their summary of this synthesis of the evidence is presented in Figure 5.1.
It is a challenge for health psychologists to position themselves within this movement for change, but it is something that we need to reflect on as scholars and activists (Murray, 2012b). The life of Miguel D’Escoto Brockmann (1933–2017), whose frequently quoted exhortation opened this chapter, reminds us of this challenge. D’Escoto was a priest, a member of Nicaragua’s Sandinista government in the 1980s and ex-president of the UN General Assembly, whose commitment to social justice leaves a legacy and an inspiration. There is a need for a more social and political health psychology that is informed by contemporary debates about social change, but is also committed to the ideals of social justice (Murray, 2012; Tileaga, 2013).
Figure 5.1 Representation of the synthesis of evidence of the cause of the higher rate of mortality in Scotland
Source: Reproduced with permission from McCartney et al., 2012
Future Research
1 There is a need to clarify the character of the psychosocial explanations for the social inequalities in health.
2 Research on social inequalities needs to be combined with further research on ethnic and gender inequalities in health. Qualitative studies of the health experiences of people from different socio-economic backgrounds are of particular importance to our understanding of the psychological mechanisms underlying health variations. Further qualitative studies are also needed to explore the relationship between social positioning and health experience.
3 Forms of research on social inequalities in health need to explicitly consider how they can contribute to reducing them.
4 An essential aspect of future research is to consider the social and psychological obstacles to movements to alleviate social inequalities in health.
Summary
1 Health and illness are determined by social conditions.
2 There is a clear relationship between income and health, leading to the development of a social gradient.
3 Psychosocial explanations of these social variations include perceived inequality, stress, lack of control and less social connection.
4 Material explanations of the social gradient in health include reduced income and reduced access to services.
5 Political factors connect both psychosocial and material explanations in a broader causal chain.
6 Social environment includes the character of people’s social relationships and their connection with the community.
7 Social justice is concerned with providing equal opportunities for all citizens. Socio-economic status (SES) and wealth are strongly related to health, illness and mortality. These gradients may be a consequence of differences in social cohesion, stress and personal control.
8 A health psychology committed to social justice needs to orient itself towards addressing the needs of the most disadvantaged in society.
6 Culture and Health
‘There is no such thing as human nature independent of culture.’
Clifford Geertz (1973)
Outline
The way people think about health, become ill and react to illness is rooted in broader health belief systems that are immersed in culture. In this chapter, we provide examples of different health belief systems that have existed historically and popular belief systems of today. We consider several indigenous health systems and those of complementary and alternative medicine. Finally, we discuss some issues related to rapid cultural change in contemporary society, including racism and how culturally competent health care systems help to bridge cultural, social and linguistic barriers.
What is Culture?
We are cultural beings, and an understanding of health beliefs and practices requires an understanding of the historical and socio-cultural context that gives human lives meaning.
Culture has been viewed principally in two different ways: (1) as a fixed system of beliefs, meanings and symbols that belong to a group of people who speak a common language and may also adhere to a common religion and system of medicine; (2) as a developmental and dynamic system of signs that exists in continuously changing narratives or stories. People’s reactions to illness are driven by a constant struggle for meaning in light of beliefs that are evolving across space and time. These two approaches yield very different kinds of psychological investigation.
Within psychology, the study of culture that uses the first approach is that of cross-cultural psychology. Samples of populations said to be from different cultures are compared in terms of attitudes, beliefs, values and behaviours that are viewed as stable and essential characteristics of particular cultures. This approach is illustrated by research on individualism versus collectivism by Triandis (1995) and Hofstede and Bond (1988). The study of culture that uses the second approach is that of cultural psychology and is illustrated by the work of Valsiner (2013), who views cultural psychology as:
a science of human conduct mediated through signs from beginning to end, and from one time moment to the next in irreversible time. … All phenomena of manifest kind – usually subsumed under the blanket term behavior – are subordinate to that cultural process of irresistible meaning-making (and re-making). Behavior is not objective, but subjective – through the meanings linked with it. … Human psychology is the science of human conduct and not of behavior, or of cognition. (2013: 25)
The concept of belief is a core concept in health psychology but rarely is it defined. Beliefs are viewed as:
durable and implicit; as associated with practices, choices and activities; and as bearing personal significance and import. … Belief tends to reproduce cultural norms, the precepts, expectations and values of particular times and places. … Simultaneously, within such broad cultural patternings, the belief of any given individual is produced through the mediation of that person’s particular history of social relations – with parents, carers, teachers, significant others – with which these acquired norms get inflected. (Cromby, 2012: 944–6)
Belief is viewed in social cognition models such as the theory of planned behaviour (TPB; Ajzen, 1985) as a fundamental theoretical construct, with each of the TPB’s three core constructs – attitude, subjective norm and perceived behaviour control – being underpinned by belief, an enduring, cognitive entity employed in rational thought and detached from feelings. It is often constructed and expressed as a part of discourse and narrative when asked for an account of one’s views about a topic in conversation. Beliefs are therefore constructed ‘on the hoof’ as much as they are a fixed piece of dogma that underlies decisions and actions.
Yet, as we argue elsewhere in this book, beliefs are almost always associated with affect. This is the view of Cromby (2012: 954), who states:
Belief arises when social practice works up structures of feeling in contingent association with discourse and narrative. … Believing is not merely information- processing activity, and belief is not an individual cognitive entity. Belief is the somewhat contingent, socially co-constituted outcome of repeated articulations between activities, discourses, narratives and socialized structures of feeling.
Beliefs are at the core of what we mean when we talk of culture.
Health Belief Systems
As societies evolve, health belief systems develop as bodies of knowledge are constructed and exchanged among those who undergo specialized training. This gives rise to the separation of expert or technical beliefs systems from traditional, folk or indigenous systems. These two types of system