Health Psychology. Michael Murray
(Fine and Asch, 1982). It is unlikely that a woman would be encouraged to terminate a pregnancy because a test indicated the child is likely to have ginger hair; however, the same is not true when a test suggests a possibility of impairment. It is this difference that makes it an issue of discrimination. The disablement movement also asserts the rights of disabled women to have children. This fundamental human right is denied to many women, particularly those with cognitive and emotional impairments, as the additional support and resources that they need to allow them to raise a child are often not available. In some countries forced sterilization still occurs, including Australia, Spain and Japan.
The right-to-die debate revolves around the argument that people with severe or terminal illness and people with disabilities have the right to end their lives when they feel life has become unbearable, and that assisting them to do so should not be illegal. We discuss this issue in more detail in Chapter 24.
The argument against the right-to-die lobby, although implicitly anti-suicide, is not necessarily about whether suicide is right or wrong per se. It should be viewed as being about the differential treatment of the issue for people with disabilities and severe illnesses as opposed to ‘healthy’ people. Morally sanctioning assisting people with incurable terminal or non-terminal conditions to end their lives or withholding life-sustaining treatment/support, while morally opposing the right of suicidal ‘healthy’ individuals to end their lives (and offering them suicide prevention interventions), equates to a severe form of discrimination based on the stigmatization of these individuals.
Reducing Inequalities
If inequalities can be reduced at all, the evidence suggests that this will only happen by adopting a thoroughly multi-layered approach. Dahlgren and Whitehead (1991) identified four different levels for tackling health inequalities:
Strengthening individuals.
Strengthening communities.
Improving access to essential facilities and services.
Encouraging macroeconomic and cultural change.
These four levels correspond to the four layers of influence in Whitehead’s ‘Onion Model’ of the determinants of health outlined in Chapter 1 (see Figure 1.5). Extra microsystem and mesosystem levels, as in Bronfenbrenner’s model, could perhaps be added to Whitehead’s list. Psychologists do not usually talk quite so simplistically about ‘strengthening’ individuals; they analyse the personal characteristics and skills associated with positive health (e.g., self-efficacy, hardiness, sense of coherence, social skills). Developing interventions aimed at individual health beliefs and behaviours is a core feature of psychological theory, research and practice.
Interventions aimed at tackling inequalities at an individual level have shown mixed results. There are four possible reasons. First, people living and working in disadvantaged circumstances have fewer resources (time, space, money) with which to manage the process of change. Second, health-threatening behaviours, such as smoking, tend to increase in difficult or stressful circumstances as they provide a means of coping. Third, there may have been a lack of sensitivity to the difficult circumstances in which people work and live that constrain the competence to change. Fourth, there has been a tendency to blame the victim. For example, cancer sufferers may be blamed for the disease if they are smokers on the grounds that they are responsible for the habit that caused it.
Overall, efforts directed at the individual level have been inconclusive and small-scale. Because most health determinants are beyond the control of the individual, psychological interventions aimed at individuals have limited impact on public health problems when considered on a wider scale. There is a need for psychologists to work beyond the individual level, with families, communities, work sites and community groups. We are not alone in thinking that structural changes at a societal level are ultimately required if the prevalent inequities are ever going to be reduced. Anything else is simply tinkering, a case of ‘fiddling while Rome burns’.
Social Capital
There is increasing interest in social capital as an aid to explaining social variations in health. The concept was especially promoted by Robert Putnam, who used it to characterize civic life in Italy (Putnam et al., 1993). He argued that certain communities had higher degrees of civic engagement, levels of interpersonal trust and norms of reciprocity. Together, these characteristics contributed to a region’s degree of social capital. Putnam (2000) subsequently explored the extent of social capital in the USA, and argued that over the past generation there has been a steady decline in participation in social organizations and thus a steady decline in social capital. An important distinction that Putnam (2000) makes is that between ‘bridging’ and ‘bonding’ social capital. ‘Bridging’ social capital refers to links with diverse groups and provides an opportunity for community members to access power and resources outside their community, whereas ‘bonding’ social capital refers to inward-looking social ties that bond the community together. Campbell (2004) stresses that both forms of social capital are essential in building healthy communities.
There has been a series of studies investigating variations in social capital and its connection with health. For example, in a national cohort of Open University adults in Thailand (n = 82,482), self-assessed health was shown to be significantly associated with social trust and social support (Yiengprugsawan et al., 2011). Gilbert et al. (2013) conducted a meta-analysis of social capital, self-reported health and mortality. A total of 39 studies were included in the analysis. Findings suggested that high social capital can increase the odds of good health by 27%. Furthermore, social capital variables, such as reciprocity and trust, increased the odds of good health by 39% and 32%, respectively.
Studies have explored the pathways linking social capital with health. In a study with church-going Latinas in California, Martinez et al. (2013) explored the relationship between leisure/physical activity and social cohesion. Leisure/physical activity and neighbourhood cohesion were assessed at baseline, three months and six months after the implementation of a promotora-delivered pilot intervention. Promotoras are community health leaders who help with the dissemination of health information to community members. They are locally based and have very similar characteristics to the target population. They were given training on how to lead walking groups, general information on the health benefits of physical activity, and information on the barriers to and facilitators of physical activity, especially among the Latino community. Evaluation of this intervention showed that social cohesion was an important predictor of physical activity (i.e., social cohesion at three months can predict levels of physical activity at six months). The authors suggested that it is possible that the promotoras enhanced social cohesion by providing participants with a sense of belonging and friendship while facilitating these activities. Considering the effectiveness of this approach in promoting leisure-time physical activity, it was argued that intervention coordinators can learn to maximize the benefits of working with community-based facilitators to promote health and well-being.
Participatory and community-based approaches can help to address issues related to poverty and health by empowering individuals and communities more widely (Ng, 2010). For example, Lawson et al. (2014) explored the benefits of participating in a community arts project among people living with mental health problems. The community members selected artwork and curated a public exhibition. Interviews suggested that participants had improved self-worth and lost some of the stigma associated with mental health issues. The project also offered a sense of belonging and helped participants to develop new knowledge and skills.
Scheib and Lykes (2013) facilitated a participatory action and photo elicitation research project in post-Katrina New Orleans from 2007 to 2010. Eleven African-American and Latina women took part in the project. Findings suggested that in developing ties and new ways to respond to the consequences of an ‘unnatural disaster’, the participants developed intra- and inter-group empathy and the capacity to critically examine the social and structural determinants of health inequities.