Health Psychology Chapter 1 PDF

 1 Part I Being and staying healthy Chapter 1 What is health? Learning outcomes By the end of this chapter, you should have an understanding of: key and current global health challenges historical models of health, illness and disability, including the mind–body debate p...

 1 Part I Being and staying healthy Chapter 1 What is health? Learning outcomes By the end of this chapter, you should have an understanding of: key and current global health challenges historical models of health, illness and disability, including the mind–body debate perspectives offered by biomedical and biopsychosocial models the contribution of psychology, and specifically the discipline of health psychology, to understanding health, illness and disability the influence of lifestage, culture and health status on lay models of health and illness how health is more than simply the absence of physical disease or disability Health is global By definition, global health approaches require an understanding of health, illness and healthcare in an international context, recognising the growing diversity of national populations and the shifts in population health, depending on national policy context and healthcare investment, innovation and availability. Global health approaches recognise that significant increases in international air travel (which ‘opens the world up’ for individuals), brings with it a need for global health security and awareness of non-typical illnesses emerging in new contexts, e.g. symptoms of tropical disease presenting in an individual in the UK may be more slowly recognised than symptoms of a commonly seen condition. Population diversity also calls for greater cultural sensitivity and recognition of the different explanatory models and beliefs around behaviour, health, illness and healthcare that can exist across cultures and microcultures. All of this became very evident in the context of the emergence of a novel and severe acute respiratory syn- drome coronavirus (SARS-CoV-2) in winter 2019 which most readers will know is the virus leading to COVID-19 infection. Just prior to this virus emerging, the World Health Organization (WHO) had launched its new five-year strategic plan – the 13th General Programme of Work – which recognised that: ‘The world is facing multiple health challenges. These range from outbreaks of vaccine-preventable disease like measles and diptheria, increasing reports of drug-resistant pathogens, growing rates of obesity and physical inactivity, to the health impacts of environmental pollution and climate change and multiple humanitarian crises.’ (WHO, 2019). The WHO called for society to address ten major threats to health: pollution and climate change; the rise in non-communicable diseases (e.g. diabetes, cancer, heart disease) and the role played by physical inactivity; a global influenza pan- demic; antimicrobial resistance (reduced effectiveness of antibiotics); outbreaks of Ebola and high-threat pathogens; weak primary healthcare; vaccine hesitancy causing outbreaks of infectious diseases such as measles; fragile environments facing drought, famine, conflict; uncontrolled Dengue fever; continuing HIV infec- tion. They called for these to be addressed from multiple angles and stressed that global health policies and practice should be based on sound evidence drawn from a range of disciplines: epidemiology, medicine, public health and, of course, psychological studies of human behaviour. Few readers will fail to see how this has been exemplified during the COVID-19 pandemic.  While these threats to health may vary in size and salience around the world, without doubt many will have relevance to each of us, with clear implications for human and social behaviour. This textbook has had to quickly integrate new and emerging evidence from studies of the global COVID-19 pandemic with longer-standing evidence relating to other health threats. Across the world, common diseases, with behavioural under- pinnings, are killing people in large numbers. While health and illness is primarily a personal experience, the geographical, cultural and social economic setting, the dominant government and its health policies, and even the time in which we live, all play a part in wider personal and social wellbeing. The relevance of global health to an opener in a health psychology textbook is that the health and wellbeing challenges society faces call for evidence to inform effective intervention. We hope here to bring together evidence that can not only educate the aspiring health psychologist, but can also help inform health policy and practice – the extent to which we achieve this impact will depend on what we ‘do’ with our evidence as described in the final chapter. Chapter outline Around the world, in spite of huge differences in life expectancy, there is reasonable con- sistency in the ‘top killers’ in terms of disease. It is acknowledged that most, if not all, of these diseases have a behavioural component and thus potentially fall within individual influence. Knowing this does not mean behaviour will change, because humans are complex in their thoughts, emotions and actions with regards to their health behaviour. This chapter introduces the common causes of mortality, before providing an historical overview of the health concept. It introduces an evolving understanding of how the mind and body interact throughout history, and the reader will learn of key models on which our discipline is founded – the biomedical and the biopsychosocial models of illness. We also illustrate how health and illness belief systems vary according to factors such as age and developmental differences, culture and cultural norms and health status. To conclude the chapter we outline the field of health psychology and highlight the ques- tions health psychology research can address.  BEHAVIOUR, DEATH AND DISEASE 5 Behaviour, death World Bank data drawing from United Nations data and a range of national data sources. The most long-lived and disease population continues to be located in Japan, although the figures have dropped by a couple of years over the past decade and the gender differential has widened. In The dramatic increases in life expectancy witnessed in Russia, the gender differential exceeds ten years. UK life Western countries in the twentieth century, partially due expectancy at birth has increased from 47 years in 1900 to to advances in medical technology and treatments, led over 81 years in 2015, and is now in the top 20, which is to a general belief, in Western cultures at least, in the a huge change in a relatively short period of time (WHO, efficacy of traditional medicine and its power to eradicate 2016). Exposure to health risks and behavioural factors disease. This was most notable following the introduction are thought to account for gender differences (including of antibiotics in the 1940s (although Fleming discovered earlier healthcare-seeking behaviour among females) penicillin in 1928, it was some years before it and other (see Chapter 9 ☛). antibiotics were generally available). Such drug treat- At the other end of this ‘league table’ average life ments, alongside increased control of infectious disease expectancy drops dramatically from the low–mid 70s through vaccination and improved sanitation, are partial through to a fairly horrendous average life expectancy explanations of increases in life expectancy seen globally. of just 53 years, with little gender difference, in Sierra United Nations figures show that, in 2018, world- Leone and in many other African nations. wide the average life expectancy at birth is 72.56 years Such life expectancy at birth statistics tell us that, in (70.39 for males, 74.87 for females), with significant and some countries, reaching a 60th birthday is simply not sometimes shocking variation between countries (World typical. These cultural variations can be explained to a Bank, 2019) (see Table 1.1). Notably, within the EU this large extent by political and environmental challenges, life expectancy figure is almost ten years higher, at 81 for example years of war or famine in some African years (Eurostat, 2019). Table 1.1 presents a selection countries, or for example in Mozambique, high HIV from the top and bottom of the ‘league tables’ with the prevalence. Table 1.1 Life expectancy in selected global countries (2018) Overall (years) Male (years) Female (years) Japan 84.2 81.1 87.1 Spain 83.0 81.0 86.0 Australia 83.0 81.0 85.0 Greece 82.0 79.0 84.0 Sweden 83.0 80.6 84.1 Netherlands 82.0 80.0 83.2 UK 81.0 80.0 83.2 USA 79.0 76.0 81.0 Serbia 76.0 74.0 78.0 Hungary 76.0 73.0 80.0 Bulgaria 75.0 72.0 79.0 Russia 73.0 68.0 78.0 Bangladesh 72.0 71.0 74.0 Myanmar 67.0 64.0 70.0 Ethiopia 66.0 64.0 68.0 Afghanistan 64.0 63.0 66.0 Mozambique 60.1 57.7 63.0 Nigeria 54.0 53.0 55.0 Sierra Leone 53.1 52.5 55.0 Source: World Bank, 2021. 6 CHAPTER 1 WHAT IS HEALTH? Differences in lifestyle and diet also play a role since the mid-1990s, with some variations seen between (Chapter 3 ☛). There is some concern around rising obe- Western, Eastern and central regions (and with a ‘blip’ sity among children and the consequent health effects that increase in 2015, attributed to deaths among over-75s). may be seen in adulthood and in terms of a life expectancy Declines in some countries, for example Ireland which a decrease in future generations. This would dispropor- has seen a decline of over 30 per cent, have been attrib- tionately affect developed countries such as the UK and uted mainly to reductions in deaths from cardiovascu- the USA which have high levels of obesity and inactiv- lar and respiratory disease, which in turn may reflect ity (Chapter 3 ☛). In fact, the gains in life expectancy improved living standards and healthcare investment. achieved every decade within EU countries have been In countries where the decline has been closer to 20 per slowing since around 2011, with decreases seen in 19 EU cent, for example in Belgium, Greece and Sweden, the countries by 2015, including UK, France, Germany and countries had lower rates to start with. Italy. In Wales there has been a 0.1 year decline in life The physical causes of death have changed dra- expectancy for both sexes since 2010 (ONS, 2017). More matically also. If people living in 1900 had been asked research is needed to explain this slowdown, as multiple what they thought being healthy meant, they may have factors may be at play, for example some point to the replied, ‘avoiding infections, drinking clean water, living damaging effects of austerity in health spending within into my 50s/60s’. Death then frequently resulted from the UK for example (Raleigh, 2018). highly infectious disease such as pneumonia, influenza or It is worth noting that life expectancy is not the same as tuberculosis becoming epidemic in communities unpro- healthy life expectancy – the latter relates to whether gains tected by immunisation or adequate sanitary conditions. in life expectancy are lived in good health as opposed to However, at least in developed countries over the last in a state of poorer health, with some illness or disabil- century, there has been a downturn in deaths resulting ity. Obviously the older you get, the lower the ratio of from infectious disease, and the ‘league table’ makes no healthy: not healthy years a person has, for example, in mention of tuberculosis (TB), typhoid, tetanus or mea- Europe it is predicted that we live, from birth, about 80 per sles. In contrast, circulatory diseases such as heart disease cent of our lives without disability, whereas once we are and stroke, lung and respiratory disease are the ‘biggest 65, only about 50 per cent of our remaining years will be killers’ worldwide (along with ‘accidents’). These causes lived in health (OECD, 2017). Of course, the measure of have been relatively stable over the past few decades. ‘healthy’ relies often on self-report, varies across countries Alzheimer’s disease and the dementias accounted for and within individuals, as we discuss later in this chapter 12.5 per cent of deaths in England and Wales in 2019, (‘What does being healthy mean?’). with a higher proportion seen among females than males, Much of the fall in annual mortality rates (all causes) explained by females living longer (Office for National seen in the developed world preceded the major immu- Statistics, 2020). nisation programmes and likely reflect public health suc- Worldwide in 2019, the top ten leading causes of cesses following wider social and environmental changes death (all ages) were recorded as listed below, with circu- over time. These include developments in education and latory diseases, such as heart disease and stroke and other agriculture, which led to changes in diet, or improve- non-communicable disease (lung cancers, COPD, kidney ments in public hygiene and living standards (see also disease, dementias, diabetes), accounting for over 44 per Chapter 2 ☛). Mortality rates within the European cent of global deaths and rising; they now make up 60 per Union have shown an overall 25 per cent reduction cent of all EU deaths. Lower respiratory tract infections are the most lethal communicable disease; however these are declining, as are global deaths from neonatal condi- tions and diarrhoeal disease – likely due to advances in mortality healthcare. Likewise deaths from HIV/AIDS have fallen (death): generally presented as mortality statistics, by 51 per cent during the last 20 years, moving from the i.e. the number of deaths in a given population world’s 8th leading cause of death in 2000 to the 19th in and/or in a given year ascribed to a given condition (e.g. number of cancer deaths among 2019. In contrast, diabetes has entered the global top 10 women in 2020) for the first time; this can largely be attributed to obesity (see Chapter 3 ☛).  BEHAVIOUR, DEATH AND DISEASE 7 Although statistics are not recorded similarly in all Within these figures is large geographic variation (see cases, we present comparable EU figures below (avail- Figure 1.1), but circulatory diseases are consistently the able for 2017; Eurostat, 2020). See also Figure 1.1. main causes of death. With the exception of lung cancer, Worldwide (WHO 2020, million) Europe (Eurostat 2020) Ischaemic heart disease (8.9 m) Circulatory disease (1.7 million, heart disease and stroke; 37% of all deaths) Stroke (6.2 m) Cancers (1.2 million; 26% of all deaths) COPD (3 m) Respiratory diseases (COPD, pneumonia) 0.37 million; 8% of all deaths) Lower respiratory infection (2.6 m) Alzheimers disease and dementias (5% of all deaths) Neonatal conditions (2.1 m) Trachea, Bronchus, lung cancer) (1.8 m) Accidents (including suicide) (5% of all deaths) Alzheimer’s Disease and dementias (1.7 m) Diabetes (2% of all deaths) Diarrhoeal diseases (1.5 m) Diabetes mellitus (1.4 million) Kidney disease (1.3 m) Main cause of death, 2017 (%) 0 10 20 30 40 50 60 70 80 90 100 Bulgaria Romania Lithuania Latvia Estonia Hungary Slovakia Czechia Croatia Poland Austria Slovenia Greece Germany Italy Finland Malta Sweden Cyprus Luxembourg Portugal Ireland Spain Belgium Netherlands France (1) Denmark United Kingdom Liechtenstein Switzerland Iceland Norway Diseases of the circulatory system Cancers Diseases of the respiratory system Other (1) 2016 data instead of 2017. Figure 1.1 Main causes of death in EU country, 2017 Source: Causes and occurrence of deaths in the EU, Eurostat. 8 CHAPTER 1 WHAT IS HEALTH? cancer does not appear in the top ten globally; however drinking plus poorer screening uptake – however, given within more developed countries, including Australia, that cardiovascular/circulatory disease deaths are in fact USA and the EU, cancer is consistently placed in the now higher in women, some risk behaviours in women may top five causes of death. In some countries, for example in fact be higher (see changes in smoking, Chapter 3 ☛). in Denmark, Ireland, France and the Netherlands, can- It has been known for several decades now that a sig- cers were the main causes of death (Eurostat, 2020; see nificant proportion of cancer deaths are attributable, in Figure 1.2). EU figures attribute 26 per cent of all deaths part at least, to our behaviour, from early estimates of to cancer in 2017 (23 per cent of female deaths, 29 per up to 75 per cent of those deaths (e.g. Peto and Lopez, cent of male deaths, OECD/EU, 2020). 1990) to a more currently estimated 40 per cent (Cancer What has perhaps become obvious in reading this is Research UK, 2021). The upturn in cancer deaths seen that the leading causes of death have a behavioural compo- over the last century is also, however, due to people living nent, linked, for example, to smoking, excessive alcohol longer with other illnesses they previously would have consumption, sedentary lifestyles and poor diet/obesity. died from; thus they are reaching ages where cancer inci- The higher incidence of cancer deaths among men are dence is greater. attributed to lifestyle – behaviours such as smoking and There is room for optimism, however, as awareness of behavioural risks grows and behaviour changes are made (see Chapters 3 and 4 ☛) along with medical advances incidence in treatment- UK statistics point to a significant decline the number of new cases of disease occurring (over 40 per cent for both genders) in age-standardised during a defined time interval – not to be confused with prevalence, which refers to the number of deaths from circulatory (heart) diseases over the past 20 established cases of a disease in a population at years and a lower but significant (13–15 per cent ) fall any one time for cancer and for respiratory disease, (20–26 per cent) (Office for National Statistics 2020). Lung Colorectal Stroke 5% 3% 8% Breast Ischaemic 2% heart Diseases of Cancers diseases circulatory 26% 12% system Prostate 37 % 1% All deaths 4 640 113 Diabets Respiratory 2% diseases COPD 8% 3% External Alzheimer’s + causes dementias 5% Pneumonia 5% 2% Accidents Suicide 3% 1% Figure 1.2 Main causes of mortality in EU, 2017 (2016 for France) Source: EU Eurostat Database 2018.  WHAT IS HEALTH? CHANGING PERSPECTIVES 9 that included mental and physical aspects; however as we WHAT DO YOU THINK? describe below, this broad view has not held dominance As stated above, the world is facing multiple throughout history. health challenges. The COVID-19 pandemic has Early understanding of illness is reflected in archaeo- brought the need for investment and cooperation logical finds of human skulls from the Stone Age where in responsive public health initiatives (testing, trac- small neat holes found in some skulls have been attrib- ing, immunising), in biomedical science (vaccine uted to the process of ‘trephination’ (or trepanation), and treatment development) and in our health and social care systems. To what extent do you think whereby a hole was made in order to release evil spir- psychology has, and can continue to, contribute to its believed to have entered the body from outside and these initiatives and our responses to them? caused disease. Another early interpretation of disease seen in Ancient Hebrew texts is that disease was a punish- ment from the gods (1000–300 BC). As will be described So, if as a reader you have been asking yourself, ‘why in Chapter 9 ☛, similar beliefs remain today in some do all these figures matter?’ the answer should now be cultures. Understanding such variations in belief systems clear. Our own behaviour contributes significantly to is therefore extremely important to our understanding of our health and mortality. As health psychologists, gain- individuals’ response to illness. Also important however ing an understanding of why we behave as we do and is the shaping, over time, of views of the association how behaviour can change or be changed, is a core part between the mind and the body. of our remit. It therefore is something we discuss a lot in this and the subsequent six chapters! Key behaviours are explored more fully in Chapters 3 and 4 ☛, but the Mind–body relationships increased recognition of the role individual behaviour Humans have physical bodies formed of molecular, plays in the experience of illness is a critical starting point genetic, biological, biochemical and measurable compo- in this health psychology text. nents that enable the ‘machine’ to work, and within those First we address the evolving way of thinking about they have a physical brain. However a broader concept, the relationship between the human mind and the human that of the ‘mind’ has been considered to be non-physical, body and the dominant models of thinking about health, reflecting our consciousness, thoughts and emotions that illness and function. have no physical properties per se. The extent to which history has seen these existing as separate, independent entities (dualistic thinking) with either the body influ- What is health? Changing encing the mind or the mind influencing the body, can be seen in part as the story of the development of health perspectives psychology. The ancient Greek physician Hippocrates (circa 460– 377 BC) considered the mind and body as linked. His Health is a word that most people will use without real- humoral theory of illness attributed health and disease ising that it may hold different meanings for different to the balance between four circulating bodily fluids people, at different times in history, in different cultures, (called humours): yellow bile, phlegm, blood and black in different social classes, or even within the same fam- bile. It was thought that when a person was healthy the ily, depending, for example, on age or gender. Potential differences in perspectives on health can present chal- lenges to those concerned with measuring, protecting, enhancing or restoring health. The root word of health theory is ‘wholeness’, and indeed ‘holy’ and ‘healthy’ share a general belief or beliefs about some aspect of the same root word in Anglo-Saxon: this is perhaps why the world we live in or those in it, which may or many cultures associate one with the other: e.g. medicine may not be supported by evidence – for example, men have both roles. Having linguistic roots in ‘whole- women are worse drivers than men ness’ also suggests the early existence of a view of health 10 CHAPTER 1 WHAT IS HEALTH? four humours were in balance, and when they were ill- to have little control over their health, whereas priests, balanced due to external ‘pathogens’, illness occurred. in their perceived ability to restore health by driving out The humours were attached to seasonal variations and demons, did. The Church was at the forefront of society to conditions of hot, cold, wet and dry, where phlegm at this time and so the search for non-religious, scientific was attached to winter (cold–wet), blood to spring (wet– explanations were slow to emerge, and in fact scientific hot), black bile to autumn (cold–dry), and yellow bile investigation such as dissection was prohibited! The mind to summer (hot–dry). Hippocrates thought that the level and body were generally viewed as working together, or of specific bodily humours related to particular person- at least in parallel, but due to constrained medical study, alities: excessive yellow bile was linked to a choleric or understanding developed slowly and mental and mysti- angry temperament; black bile was attached to sadness cal explanations of illness predominated. Such causal and melancholia; excessive blood was associated with an explanations elicited treatment along the lines of self- optimistic or sanguine personality; and excessive phlegm punishment, abstinence from sin, prayer or hard work. with a calm or phlegmatic temperament. Humoral the- These religious views persisted until the early fourteenth ory attributed disease states to bodily functions but also and fifteenth centuries when a period of ‘rebirth’, a Renais- acknowledged that bodily factors impacted on the mind. sance, began. During the Renaissance, individual thinking Healing at this time involved attempts to rebalance the became increasingly dominant and the religious perspective humours, for example, through bleeding or starvation, became only one of many. The scientific revolution of the or even this far back in time, through eating healthily early 1600s led to huge growth in scholarly and scientific (Helman 1978). study and consequently, the understanding of the human This view continued with Galen (c. AD 129–199), body, and the explanations for illness, became increasingly another influential Greek physician in Ancient Rome. organic and physiological. (It should be noted that this left Galen considered there to be a physical or pathological little room for psychological explanations however). basis for all ill health (physical or mental) and believed During the early seventeenth century, the French phi- not only that the four bodily humours underpinned the losopher René Descartes (1596–1650), like the ancient four dominant temperaments identified by Hippocrates Greeks, proposed that the mind and body were separate but also that these temperaments could contribute to the entities. Physicians acted as guardians of the body – experience of specific illnesses. For example, he proposed viewed as a machine amenable to scientific investigation that melancholic women were more likely to get breast and explanation – whereas theologians acted as guard- cancer, offering not a psychological explanation but a ians of the mind – a place thought not amenable to scien- physical one because melancholia was itself thought to be tific investigation! This is defined as dualism, where the underpinned by high levels of black bile. This view was mind exists, but is considered to be ‘non-material’ (i.e. therefore that the mind and body were interrelated, but conscious thoughts and feelings are not objective or vis- only in terms of physical and mental disturbances both ible) and independent of the body, which is ‘material’ (i.e. having an underlying physical cause. The mind itself was made up of real mechanical ‘stuff’, physical matter such as not thought to play a role in illness aetiology. While this our brain, heart and cells). Where the ancient Greeks had view dominated thinking for many centuries, it lost pre- the body ‘in charge’, classical dualism placed the mind dominance in the eighteenth century when organic medi- in charge – the non-physical mind was thought to control cine, and in particular cellular pathology, developed and the physical body and its reactions. Descartes proposed failed to support the humoral underpinnings. Galen’s descriptions of personality types were however still in use in the latter half of the twentieth century (Marks et al., 2000: 76–7). aetiology During the early Middle Ages (fifth–sixth century), (etiology): the cause of disease health became increasingly tied to faith and spirituality. dualism At this time illness was seen as God’s punishment for the idea that the mind and body are separate misdeeds or, similar to very early views, the result of entities (cf. Descartes) evil spirits entering one’s soul. Individuals were thought  WHAT IS HEALTH? CHANGING PERSPECTIVES 11 that interaction between the two ‘domains’ was possi- Biomedical model of illness ble, although initially understanding of how this interac- tion could happen was limited, for example, how could a In this model, health is defined as the absence of dis- mental thought, with no physical properties, cause a bod- ease, and any symptom of illness is thought to have an ily reaction (e.g. a neuron to fire) (Solmes and Turnbull underlying pathology that will hopefully, but not inevi- 2002)? The suggested communication between mind and tably, be cured through medical intervention. Adhering body was thought to be under the control of the pineal rigidly to the biomedical model would lead to propo- gland in the midbrain (see Chapter 8 ☛) (interactive, nents dealing only with objective facts and assuming a Cartesian dualism), but the process of this interaction was direct causal relationship between illness or disability, its also unclear. However, because Descartes believed that the symptoms or underlying pathology (disease), and adjust- soul (the ‘mind’?) left the human body at the time of death, ment outcomes. dissection and autopsy study now became acceptable to the This biomedical thinking, is reflected in the World Church and as a result the eighteenth and nineteenth cen- Health Organization’s 1980 International Classifica- turies witnessed a huge growth in medical understanding. tion of Impairment, Disabilities and Handicaps (WHO Anatomical research, autopsy work and cellular pathology IC I-D-H model, also the classification of the conse- concluded that disease was located in human cells, not in quences of disease). This introduced a hierarchical model ill-balanced humours. The dualist notion of the body as a which was utilised in a large body of research exploring machine (a mechanistic viewpoint), understandable only responses to disease. In this, impairments (abnormali- in terms of its constituent parts (molecular, biological, ties or losses at the level of a person’s organs, tissues, biochemical, genetic), meant that illness was understood structures or appearance), lead to disability (defined as a through the study of cellular and physiological processes. restriction or inability to function as ‘normal for a human Treatment during these centuries became more tech- being’) which places disability firmly within the individ- nical, diagnostic and focused on physical evidence, with ual, and in turn disability creates inevitable individual individuals perhaps more passively involved than pre- handicap (whereby a person experiences disadvantage in viously (when at least they had been expected to pray fulfilling their normal social roles). or exorcise their demons in order to return to health). This approach underpins the biomedical model of ill- ness. Within this approach, the ‘mind’ is considered part of the material ‘stuff’ by virtue of it being a func- tion of the brain, and the study of mental processes is mechanistic then mapped through physical, neural processes of the a reductionist approach that reduces behaviour to the level of the organ or physical function – brain (this monist materialism reduces the mind to associated with the biomedical model objectifiable brain processes, and is supported by the huge growth in neuropsychology and brain imaging biomedical model research). Behaviourism is similarly monist, and at its a view that diseases and symptoms have an underlying physiological explanation extreme, rejects the study of the non-visible mind and its thought processes in favour of observeable stimuli monist and responses. Humanism (e.g. Carl Rogers) in contrast the idea that the non-physical mind cannot be would argue that only through understanding the unique studied separately from the physical brain human subjective experience will we gain understanding behaviourism of individual behaviour. this approach emphasises objectifiable actions Where we are today in relation to mind–brain–body and the environmental factors that shape action/ debates, is that we seek scientific evidence to help explain behaviour (c.f. Skinner, classical conditioning) the human experience – be it objective, subjective, or humanism demonstrating a relationship between these, although the this approach emphasises the inner feelings and growth in neuroscience might suggest materialism cur- needs of individuals (c.f. Rogers, Maslow) rently has the upper hand! 12 CHAPTER 1 WHAT IS HEALTH? The assumption is that removal (i.e. treatment) of of life, an exclusion from normal function and roles, and, the pathology through medical intervention will lead as many studies have shown, increased depression. For to restored health (i.e. illness or disability results from others, disability presents a challenge, a fact of life to be disease either originating outside the body (e.g. germs) lived with, rather than something which prevents them or through involuntary internal changes (e.g. cell muta- living fully (see Chapter 14 ☛). As seen in relation to tions)). This relatively mechanistic view of how our body developing concepts of illness, evidence of individual and its organs work, fail and can be treated, allows little variation in the response to impairment and disabil- room for subjectivity. ity challenges biomedical thinking and opens the door The biomedical view has been described as reduction- for biopsychosocial thought. People do not inevitably ist: i.e. the basic idea that mind, matter (body) and human become equally or similarly ‘disabled’ or ‘handicapped’ behaviour can all be reduced to, and explained at, the even where impairment is similar (e.g. Johnston and level of cells, neural activity or biochemical activity. How Pollard 2001). then would we deal with evidence of debilitating, but While aspects of reductionism and dualistic thinking medically unexplained symptoms? (see Chapter 9 ☛). have been useful, for example, in furthering our under- What then are the implications of such a medical and standing of the aetiology and course of many acute and positivistic/functionalistic view for the treatment of infectious diseases, the role of the ‘mind’ in the manifes- impairments (especially if we believe in a need to nor- tation of, and response to, illness is crucial to furthering malise)? For example, are cochlear implants for those our understanding of the complexities of health and ill- with hearing impairments a more appropriate response ness. Psychology has played a significant role in this than those around the individual with hearing difficul- altering perspective. For example, a key role was played ties learning sign language? Whose ‘problem’ is hearing by Sigmund Freud in the 1920s and 1930s when he impairment? redefined the mind–body problem as one of ‘conscious- Reductionism also tends to ignore evidence that ness’ and postulated the existence of an ‘unconscious different people respond in different ways to the same mind’ seen in a condition he named ‘conversion hys- underlying disease pathology because they vary in, for teria’. Following examination of patients with physical example, personality, cognition, social support resources symptomatology but no identifiable cause, and by using or cultural beliefs (see later chapters). hypnosis and free association techniques, he identified While the biomedical model underpins many suc- unconscious conflicts which had been repressed. These cessful treatments, including immunisation programmes unconscious conflicts were considered to ‘cause’ the which have contributed to the eradication of many life- physical disturbances including paralysis and loss of threatening infectious diseases, significant challenges to sensation in some patients where no underlying physi- dualism, and to a purely biomedical approach exist, as we cal explanation was present (i.e. hysterical paralysis, e.g. discuss more fully below. Freud and Breuer 1895). Freud stimulated much work into unconscious conflict, personality and illness, link- ing the mind with the body and ultimately leading to the Challenging dualism and the development of the field of psychosomatic medicine (see emergence of (bio)psychosocial later section). As a discipline, psychology has highlighted the models of health and illness need for medicine to consider the role played in the In terms of mind–body associations, what is perhaps aetiology, course and outcomes of illness, by psycho- closer to the ‘truth’, as we understand it today, is that logical and social factors. Consider, for example, the there is one type of ‘stuff’ (monist) but that it can be extensive evidence of ‘phantom limb pain’ experienced perceived in two different ways: objectively and subjec- in amputees – how can pain exist in an absent limb? tively. For example, many illnesses have organic under- Consider the widespread acknowledgement of the pla- lying causes, but also elicit uniquely individual responses cebo effect – how can an inactive (dummy) substance due to the action of the mind, i.e. subjective responses. lead to reported reductions in pain or other symptoms For some people, acquiring a disability signifies the end which are equivalent to reductions described by those  WHAT IS HEALTH? CHANGING PERSPECTIVES 13 Photo 1.1 Having a disability does not equate with a lack of health and fitness Source: flySnow/iStock/Getty Images. receiving an active pharmaceutical substance or treat- mind–body split’ and noted that simply because neurosci- ment (Chapter 16 ☛)? In addition, a linear model, such ence enables us to explore the ‘mind’ and its workings as seen in the WHO ICIDH would fail to explain how a ‘objectively’ by the use of increasingly sophisticated scan- Paralympian in spite of sensory or physical impairments, ning devices and measurements, this did not mean we are functions at a level of physical performance many of us furthering our understanding of the subjective ‘mind’ – without such impairments perform? How do we describe the thoughts, feelings and the like that make up our lives the person with juvenile diabetes who has ‘impairment’ and give it meaning. Their comment that ‘conceptualis- in terms of pancreatic dysfunction (see Chapter 8 ☛), ing our mental life as some sort of enclosed world living but as long as they adhere to medication, function as inside our skull does not do justice to the reality of human any typical adolescent, without any evidence of disabil- experience’ (p. 1434), combined with the fact that this ity? This same juvenile may, however, skip school as editorial was presented in a medical journal with a tradi- a result of perceived stigma and therefore miss out on tionally biomedical stance was evidence of a weakened the associated social relationships and potential long- Descartian ‘legacy’. term employment benefits (i.e ‘handicap’ without dis- This is not to say that healthcare professionals did ability). An individual’s context and their subjectivity not believe in the role played by psychological or social in terms of beliefs, expectations and emotions interact factors in illness, it was just not an explicit part of their with bodily reactions to play an important role in the operational frameworks, nor to a large extent was it inte- illness or stress experience (see Chapter 9 ☛ in terms gral to their training. Shifts in thinking over time have of symptom perception, and Chapter 11 ☛ in terms of enabled the field of health psychology to emerge, a field stress reactivity). which adopts a biopsychosocial perspective on health, Evidence of such changed thinking was nicely, and illness and disability/activity limitation which can offer importantly, illustrated in an editorial in the British potential for a range of interventions, not solely targeting Medical Journal twenty years ago (Bracken and Thomas pathology or physical symptomatology. This approach is 2002). The authors suggested a need to ‘move beyond the reflected in this textbook. 14 CHAPTER 1 WHAT IS HEALTH? Biopsychosocial model of illness is trying to function within, and on their own personal characteristics, behavioural and illness related beliefs and The biopsychosocial model signals a broadening of a feelings (Quinn et al. 2013) (see Chapter 9 ☛). disease or biomedical model of health to one encompass- ing and emphasising the interaction between body and mind, between biological processes and psychological and social influences (Engel 1977, 1980). In doing so, it offers a complex and multivariate, but potentially a more Individual, cultural and comprehensive model with which to examine the human experience of illness. As a result of the many challenges to lifespan perspectives the biomedical approach described above, the biopsycho- social model is employed in several allied health profes- on health sions, such as occupational therapy, as well as in health Given the previously presented evidence of the changes psychology. Although also increasingly assimilated within in what people are dying from, and changed views of the medical profession there exists some pessimism that it whether and how our minds can influence our bodies, it is feasible to address all components, no matter how valu- is perhaps not surprising that views of what health is have able, given constraints facing our healthcare systems (see also changed over time. In the eighteenth century, health editorial by Lane, 2014). Health is, however, recognised was considered an ‘egalitarian ideal’, aspired to by all as more than simply the absence of disease. This text will and potentially under an individual’s control. However, illustrate that psychological, behavioural and social fac- doctors were available to the wealthy as ‘aids’ to keeping tors can add to the biological or biomedical explanations oneself well, but were less available to the poor. By the and, rather than replacing these explanations of health and mid-twentieth century, accompanied or perhaps preceded illness experiences, build on them. by new laws regarding sickness benefit, and medical and Reflecting these changes in thinking over recent dec- technological advances in diagnostic and treatment pro- ades, a subsequent WHO model, the International Classi- cedures, health became increasingly and inextricably fication of Functioning, Disability and Health (ICF, WHO linked to ‘fitness to work’. Doctors were required to 2001) takes a much broader approach than its original declare whether individuals were ‘fit to work’ or whether ICIDH model. The ICF presents a universal, dynamic and they could adopt the ‘sick role’ (see also Chapter 10 ☛). non-linear model whereby alterations in bodily structure Many today continue to see illness in terms of its effects or function (replaces impairment); activities and limita- on their working lives, although research increasingly tions therein (replaces disability), and participation or addresses the opposite direction of effects, i.e. the influ- restrictions therein (replaces handicap) can potentially all ence work role and conditions have on illness (see discus- interact and affect each other. Furthermore, the ICF rec- sion of occupational stress in Chapter 11 ☛). ognises that the relationship between structures, activities Also perhaps changing over time is the assumption and participation are influenced by both external, environ- that traditional medicine can, and will, cure us of all ills. mental and personal factors. A person’s ability to perform Over recent decades, many more people have acknowl- at ‘capacity’ (i.e. at the best possible, given their physical edged the potential negative consequences of some phar- status) is not solely due to the level of impairment (think macological treatments (consider for example long-term of a Paralympian). Disability no longer resides within the use of anxiolytics such as Valium), and as a result the individual, but is a response to other factors including ‘complementary’ and ‘alternative’ medicine industry has the physical, social and cultural environment the person burgeoned. Most countries are seeking, in what is known as the ‘post 2015 development agenda’, to better measure biopsychosocial their populations health and wellbeing, given the chang- ing nature of disease (from acute infectious disease to a view that diseases and symptoms can be explained by a combination of physical, social, chronic disease) and the population (an ageing one). cultural and psychological factors (cf. Engel 1977) Within the United Nations, 17 Sustainable Development Goals were set as part of a 2030 Agenda for Sustainable  INDIVIDUAL, CULTURAL AND LIFESPAN PERSPECTIVES ON HEALTH 15 Development (United Nations, 2015); one of which is to (poor/fair; good; very good/excellent) influenced these ensure healthy lives and promote wellbeing at all ages. judgements: those in poor/fair health based their health Within this goal is a specific target to reduce by one-third assessment on recent symptoms or indicators of poor the premature mortality arising from non- communicable health, whereas those in good health considered more diseases through prevention and treatment and, in rec- positive indicators (being able to exercise, being happy). ognising that health is not simply about the absence of Consistent with this, subjective health judgements were physical disease, to promote mental health and wellbeing. more tied to health behaviour in ‘healthier’ individuals They seek to gain an additional two ‘healthy life years’ in (Benyamini et al., 2003). everyone living in their member states. Although some people have been shown to find it hard to distinguish health from an absence of illness, health is generally viewed as a state of equilibrium across various Lay theories of health aspects of the person, encompassing physical, psycho- Health and wellbeing are clearly important at a policy logical, emotional and social wellbeing (e.g. Herzlich, level; however if a fuller understanding of health and ill- 1973). Bennett (2000: 67) considers these representations ness is to be attained, it is necessary to find out what of health to distinguish between health as ‘being’, i.e. if people think health and illness are. The simplest way of not ill, then healthy; ‘having’, i.e. health as a positive doing this is to ask them! resource or reserve; and ‘doing’, i.e. health as represented In a now classic study exploring lay perceptions of by physical fitness or function (as seen in Benyamini health, Bauman (1961) asked ‘What does being healthy et al.’s study above). Bauman’s respondents appear to mean?’. She found that people with diagnoses of quite have focused more on the ‘being’ healthy and ‘doing’ serious illness made three main types of response aspects, which may be in part because ‘having’ health as whereby being healthy was: a resource was not prominent in the minds of her patient sample. It does seem that health is considered differently 1. considered as a ‘general sense of wellbeing’; when it is no longer present, i.e. it is considered to be 2. identified with ‘the absence of symptoms of disease’; good when nothing is wrong (perhaps more commonly 3. seen in ‘the things that a person who is physically fit thought in older people) and when a person is behaving is able to do’. in a health-protective manner (perhaps more commonly thought in younger people). Bauman argued that these three types of response Another classic, but more representative picture of reveal health to be related to: the health concept was perhaps obtained from a large, feeling questionnaire-based Health and Lifestyles Survey of symptom orientation 9,003 members of the general public, of whom 5,352 also completed assessment seven years later (Cox, Huppert performance. and Whichellow, 1993). This survey asked respondents to: However it was noted that study respondents in this Think of someone you know who is very healthy. study did not answer in discrete categories, with nearly half of the sample providing two of the above response Define who you are thinking of (friend/relative etc. – types, and 12 per cent using all three types. This high- do not need specific name). lights the multifaceted way in which we may think Note how old they are. about health. In addition, Bauman’s sample consisted of Consider what makes you call them healthy. those with quite serious illness. We now know that cur- Consider what it is like when you are healthy. rent health status influences subjective views of health and reports of what ‘health is’. For example, among almost 500 elderly people asked to rate factors in order health behaviour of importance to their subjective health judgements, behaviour performed by an individual, regardless the most important factors related to physical function- of their health status, as a means of protecting, ing and vitality (being able to do what you need/want promoting or maintaining health, e.g. diet to do). However, the current health status of the sample 16 CHAPTER 1 WHAT IS HEALTH? About 15 per cent could not think of anyone who was Health as psychosocial wellbeing: health defined in ‘very healthy’, and about 10 per cent could not describe terms of a person’s mental state; e.g. being in harmony, what it was like for them to ‘feel healthy’. This inability to feeling proud, or, more specifically, enjoying others. describe what it is like to feel healthy was particularly evi- Health as function: the idea of health as the ability dent in young males, who believed health to be a norm, a to perform one’s duties or meet role expectations, background condition so taken for granted that they could i.e. being able to do what you want when you want not put it into words. By comparison, a smaller group without being handicapped in any way by ill health or of mostly older women could not answer for exactly the physical limitation (relates back to the WHO concept opposite reason – they had been in poor health for so long of handicap, now described as participation/participa- that either they could not remember what it was like to tory restriction, described earlier, and see Figure 1.3). feel well or they were expressing a pessimism about their condition to the interviewer (Radley 1994: 39). Such findings suggest that health concepts are perhaps The categories of health identified from the survey even more complex than initially thought, with evidence findings were: that the presence of health is considered as something more than physical, i.e. as something encompassing Health as not ill: i.e. no symptoms, no visits to doctor, psychosocial wellbeing. Categories generally seem to fit therefore I am healthy. with dimensions of ‘being’ and ‘doing’ and in ‘health as Health as reserve: i.e. come from strong family; not ill’ and seem to be fairly robust (at least in Western recovered quickly from operation. culture; see later section for culture differences). Health as behaviour: i.e. usually applied to others It also appears that subjective evaluations are typi- rather than self; e.g. they are healthy because they look cally reached through comparison with others, and in after themselves, exercise, etc. Health as physical fitness and vitality: used more often by younger respondents and often in reference to a psychosocial male – male health concept more commonly tied to an approach that seeks to merge a psychological ‘feeling fit’, whereas females had a concept of ‘feel- (more micro- and individually oriented) approach ing full of energy’ and rooted health more in the social with a social approach (macro-, more community- world in terms of being lively and having good rela- and interaction-oriented), for example, to health tionships with others. Health condition (disorder or disease) Body structure and Activity Participation functions (functional (disability) (impairments) limitations) Personal Environmental factors factors Figure 1.3 The international classification of functioning, disability and health. Source: WHO (2002b).  INDIVIDUAL, CULTURAL AND LIFESPAN PERSPECTIVES ON HEALTH 17 this way one’s concept of what health is, or is not, can from lung, colon and prostate cancers in men, and breast be shaped. For example, Kaplan and Baron-Epel (2003) and colorectal cancers in women, and reductions in drink- found that young Israelis reporting suboptimal health did ing and smoking incidence also among young adults (see not compare themselves with people of the same age, Chapter 3 ☛). whereas many older people in suboptimal health did com- It is clear that health policy acknowledges the evi- pare themselves with similar aged peers. This suggests denced relationship between people’s behaviour, life- that people try to get the best out of their evaluations – a styles and their health (broadly defined). What has often young person will tend to perceive their peers as gener- been less explicitly acknowledged and addressed are the ally healthy, so if they feel that they are not healthy, they socio-economic and cultural influences on health, ill- will be less likely to draw this comparison. In contrast, ness and health decisions which is why we have, ever older people in poorer health are more likely to compare since this textbook first emerged in 2006, dedicated a full themselves with same-aged peers, who may also have chapter to these important influences to build this aware- normatively poorer health, thus their own health status ness (see Chapter 2 ☛). More recently the focus has seems less unusual. Asking a person to consider what it in fact shifted to policies that recognise the social deter- is that they would consider as ‘being healthy’ inevitably minants of health and illness as well as the individual will lead people into making these types of comparison. determinants, for example in the UK the Health Founda- Health is a relative state of being. tion introduced a ‘healthy lives strategy’ in 2017 (Health Foundation, 2017) that prioritises health as an asset rather than ill health as a burden and in doing do seeks to pro- World Health Organization mote social policies that promote health lifestyles. This definition of health fits with the Public Health England campaign for Better Health 2020 and 2021 (Public Health England, 2021) (see The dimensions of health described in the preceding par- Chapters 3 and 4 ☛). agraphs are reflected in the WHO (1947) definition of Other more context-aware definitions of health do health as a ‘state of complete physical, mental and social exist, for example Bircher (2005) defines health as ‘a wellbeing and... not merely the absence of disease or dynamic state of well-being characterized by a physical infirmity’. Some have questioned whether the WHO use and mental potential, which satisfies the demands of life of the term ‘complete’ in relation to physical wellbeing is commensurate with age, culture, and personal respon- unrealistic given the changing population age and preva- sibility’. This view places the individual centrally in lence of chronic disease and the likelihood that most of the experience of health and illness whereas the WHO us will have some symptomatology as we age (Huber definition does not. Individual beliefs play a major role et al. 2011). That aside, the definition saw individuals as in the experience of health, illness, and disability. Fur- ideally deserving of a positive state, an overall feeling of thermore health should not be seen in one dimension or wellbeing, fully functioning and has helped shape global in black or white, but instead as something experienced health targets ever since and many national policy docu- on a continuum from optimal wellness, through minor ments with their own specific targets. In general, as stated and major illness, to death, as described by Antonovsky earlier in this chapter, these have, and will, set targets (1987). The fascination for many health psychologists is for reductions in deaths from the leading disease causes how people respond differently to experiences along this (i.e. heart disease, lung disease, strokes, cancer etc.) or continuum and how health psychology can help identify more explicitly targeted the associated behaviours (see factors that might help to optimise health or reduce the Chapters 3 and 4 ☛). For example in the Netherlands negative impact of illness. (‘A longer and healthier life’, Ministry of Health, 2003) the targets were disease incidence reductions, whereas in Belgium the targets were more behavioural: reducing Cross-cultural perspectives smoking behaviour, fat intake, fatal accidents, increasing uptake of vaccination programmes and increasing health on health screening in the over-50s. Progress has been made over What is considered to be ‘normal’ health varies across the past 20 years or so with reductions seen in mortality cultures and as a result of the economic, political and 18 CHAPTER 1 WHAT IS HEALTH? cultural climate of the era in which a person lives. Cul- considered a punishment for past sins within the family tures vary in their health belief systems, health attribu- (Katbamna et al., 2004; Mackenzie, 2006). Such belief tions and health practices. Think of how pregnancy is systems can have profound effects on living with ill- treated in most Western civilisations (i.e. medicalised) ness or, indeed, caring for someone with an illness or as opposed to many developing regions (naturalised). disability – in Ghana, children with disability may be The stigma of physical disability, mental illness, or of viewed as non-human ‘spirit-children’, although thank- dementia, among African, South Asian communities, fully related infanticide is thought to be low (Grischow and some Eastern European groups, may have conse- et al., 2018). quences for the family which would not be considered In addition to beliefs of spiritual influences on health, in Caucasian families: for example, having a sibling studies of some African regions consider that the com- or a child with a disability, or a relative with dementia munity or family work together for the wellbeing of all. or depression, may affect siblings’ marriage chances This collectivist approach to staying healthy and avoid- or the social standing of the family (Ahmad, 2000; ing illness differs from our individualistic approach to Grischow et al., 2018; Mackenzie, 2006). Such beliefs, health (consider how long the passive smoking evidence often related to negative attributions of illness causal- was ignored, or more recently, arguments played out ity and blame, can influence disclosure of symptoms on social media and in policy around imposing mask- and health-seeking behaviour (Vaughn et al., 2009) (see wearing to protect others from potential coronavirus Chapter 9 ☛). transmission). Generally speaking, Western European Westernised views of health differ in various ways cultures are found to be more individualistic, with Eastern from conceptualisations of health in non-Westernised and African cultures exhibiting more holistic and col- civilisations. In an early work, Chalmers (1996) astutely lectivist approaches to health. For example, in a study of noted that Westerners divide the mind, body and soul in terms of allocation of care between psychologists and psychiatrists, medical professions and the clergy, whereas in some African cultures, these three ‘elements of human collectivist nature’ are integrated in terms of how a person views a cultural philosophy that emphasises the individual them, and in how they are cared for. This holistic view is as part of a wider unit and places emphasis similar to that found in Eastern and in Aboriginal Australian on duties above rights, with actions motivated cultures (e.g. Swami et al. 2009) where the social (e.g. by interconnectedness, reciprocity and group membership, rather than individual needs and wants social and community norms and rituals) as well as the biological, the spiritual and the interpersonal, are integral individualistic to explaining health and illness states. a cultural philosophy that places responsibility at Spiritual wellbeing as an aspect of health has gained the feet of the individual and emphasises rights above duties; thus behaviour is often driven credence following inclusion in many quality of life by individual needs and wants rather than by assessments (see Chapter 14 ☛), and, although faith community needs or wants or God’s reward may sometimes be perceived as sup- porting health, attributing one’s health to a satisfied coronavirus ancestor may nonetheless raise a few eyebrows if stated one of a group of RNA viruses that cause a variety of diseases – most recently SARS-CoV-2 virus has aloud. Negative supernatural forces such as ‘hexes’ or caused COVID-19 disease (SARS: severe acute the ‘evil eye’ sometimes share the blame for illness respiratory syndrome) and disability. For example, Grischow and colleagues’ holistic review of stigma and disability in Ghana (Grischow root word ‘wholeness’; holistic approaches are et al., 2018) reveals evidence that a child’s disability concerned with the whole being and its wellbeing, may be perceived as a punishment for parental wrongs, rather than addressing the purely physical or and among Hindus and Sikhs, in particular, it has been observable. reported that disability and even dementia may also be  INDIVIDUAL, CULTURAL AND LIFESPAN PERSPECTIVES ON HEALTH 19 preventive behaviour to avoid endemic tropical disease relating to maintaining balance between poles of ‘hot’ in Malawians, the social actions to prevent infection (e.g. and ‘cold’. In Eastern cultures illness or misfortune is clearing reed beds) were adhered to more consistently commonly attributed to predestination; African Ameri- than the personal preventive actions (e.g. bathing in piped cans and Latinos are more likely than White Americans water or taking one’s dose of chloroquine) (Morrison et to attribute illness causes externally (e.g. to the will of al. 1999). Collectivist cultures emphasise group needs God) (e.g. Vaughn et al., 2009). and find meaning through links with others and one’s Clearly, therefore, to maximise effectiveness of health community to a greater degree than individualistic ones promotion efforts, it is important to acknowledge the exist- which emphasise the uniqueness and autonomy of its ence and effects of such different underlying belief sys- members i.e. promote and validate ‘independent selfs’ tems and resultant behaviours (see Chapters 6 and 7 ☛). (Morrison et al. 1999: 367). This belief in a community It is also worth noting that variations exist within as well of individuals working together for the good of all can as between, cultures, especially where there may have however lead to problems if a person is ill or disabled and been exposure to multiple cultural influences for example considered unable to contribute, with consequent stigma, as reported by Wong et al. (2011) from studies in Singa- disenfranchisement and sometimes even the experience pore where both Asian and Western influences coexist of personal harm (Grischow et al. 2018). but have differential effects on subjective wellbeing rat- Cultures that promote an interdependent self are more ings. In the Western world, the perceived value of alter- likely to view health in terms of social functioning rather native remedies for health maintenance or treatment of than simply personal functioning, fitness, etc. For exam- symptoms is seen in the growth of alternative medicine ple classic studies by George Bishop and colleagues (e.g. and complementary therapy industries; however, Western Bishop and Teng, 1992; Quah and Bishop 1996) noted medicine dominates. In contrast, in non-Western coun- that Chinese Singaporean adults view health as a har- tries a mixture of Western and non-medical/traditional monious state where the internal and external systems medicine can often be found. For example in Malaysia, are in balance, and, on occasions where they become while Western-style medicine is dominant, traditional imbalanced, health is compromised. Yin – the positive medicine practice by ‘bomohs’ (faith healers) is avail- energy – needs to be kept in balance with the yang – the able (Swami et al., 2009). Similarly among some Abo- negative energy (also considered to be female!). Other riginal tribes spiritual beliefs in illness causation coexist Asian cultures, e.g. the Vietnamese, use mystical beliefs with the use of Western medicines for symptom control (Devanesen, 2000), with traditional medicine and heal- ing processes consistent with cultural and spiritual beliefs still used by some in the treatment of cancer (Shahid et al., 2010). These examples illustrate that the biomedical view is acknowledged and assimilated within different cul- tures’ belief systems, and show that, while access to and understanding of Western medicines’ methods and efficacy grows, better understanding of culturally rele- vant cognitions regarding illness and health behaviour is needed (see Kitayama and Cohen, 2007; Vaughn et al., 2009). We also need more research which considers the role religion plays in health across and within cultures. Swami et al. (2009) for example, in their study of 721 Malaysian adults, found that Muslim participants had Photo 1.2 Visiting a herbalist to choose individually tailored higher beliefs in religious factors and fate as influences remedies. on recovering from illness than did Buddhist or Catholic Source: Marcus Chung/E+/Getty Images. participants and they were also more likely to believe 20 CHAPTER 1 WHAT IS HEALTH? that their likelihood of becoming ill was uncontrollable. think of childhood asthma, juvenile arthritis, or diabetes, As we will discuss in a later chapter (Chapter 9 ☛), for example. If health professionals are to promote the responses to symptoms, including the use of healthcare physical, psychological, social and emotional wellbeing either traditional or Western, will in part be determined of their patient or client whatever their age, then some by the nature and strength of such cultural values and reli- understanding of ‘typical’ cognitive and psychosocial gious beliefs. Illness discourse will reflect the dominant development will be helpful in cases where illness may conceptualisations of individual cultures and religions, have disrupted this. The subsequent section introduces and, in turn, how people think about health and illness lifespan issues in relation to health perceptions, but it is will shape expectations, behaviour, and use of health recommended that interested readers also consult a devel- promotion and healthcare resources. Chapter 2 ☛ opmental health psychology text for fuller coverage (e.g. will describe the social inequalities in health and address Turner-Cobb, 2014). further cultural and social economic influence, but one issue worth noting here is that of social exclusion, Developmental theories defined by Macleod et al. (2016). Poor health has been confirmed as both a predictor and as an outcome of The developmental process is a function of the interaction social exclusion based on data from four waves of data between three factors: from Understanding Society, the UK Household Longi- 1. Learning: a relatively permanent change in knowl- tudinal Study (Sacker et al, 2017). Those from minority edge, skill or ability as a result of experience. cultures, and also those of older age, are more likely to 2. Experience: what we do, see, hear, feel, think. be socially excluded. 3. Maturation: thought, behaviour or physical growth, attributed to a genetically determined sequence of Lifespan, ageing and beliefs development and ageing rather than to experience. about health and illness Psychological wellbeing, social and emotional health social exclusion are affected by illness, disability, treatments and hospi- a multidimensional process through which talisation, which can be experienced at any age. While individuals become disengaged from mainstream growing older may be associated with decreased func- society, depriving people of the rights, resources tioning and increased disability or dependence, it is not and services available to the majority of course only older people who live with chronic illness: STOP and THINK problem, with abusers seen as deviant, to a disease, with alcohol dependent patients treated in clinics. Simi- Conclusions reported in textbooks such as this are only larly smoking, once viewed as a glamorous, even desir- based on what is reported in the research (i.e. in sur- able behaviour (1930s–1980s), is now more commonly vey responses). As noted by a large European statistics viewed as socially undesirable and indicative of a weak reporting body (Health at a Glance, OECD/EU, 2018, will – perhaps reflecting this, the smoking prevalence p. 98): ‘Cross-country differences in perceived health has declined. Furthermore, what is normal (or deviant) status can be difficult to interpret because social and and what is defined as sick (reflecting illness) in a given cultural factors may affect responses.’ The way in which culture can have consequences for how others respond: certain behaviours are viewed can vary across cultures, consider how societal responses to illicit drug use have and also shift over time and this may affect self-reporting. ranged from prohibition through criminalisation to an ill- For example, mainstream views of alcohol dependence have shifted from it being viewed as a legal and moral ness requiring treatment (see Chapter 3 ☛ ).  INDIVIDUAL, CULTURAL AND LIFESPAN PERSPECTIVES ON HEALTH 21 An early maturational framework for understanding adult development – young adulthood, middle adulthood, cognitive development (Piaget, 1930, 1970) provides a maturity). Each stage varies across different dimensions, good basis for understanding the developmental course of including: concepts regarding health, illness and health procedures. cognitive and intellectual functioning; Piaget proposed a staged structure to which, he consid- ered, all individuals follow in sequence as below: language and communication skills; the understanding of illness; 1. Sensorimotor (birth–2 years): an infant understands the world through sensations and movement, and healthcare and maintenance behaviour. moves from reflexive to voluntary action, but lacks Each of these dimensions is important to the health symbolic thought. psychologist and to healthcare practitioners. Deficits or 2. Preoperational (2–7 years): symbolic thought devel- limitations in cognitive functioning (due to age, acci- ops, enabling imagination and intellectual devel- dent or illness) may, for example, influence the extent to opment through the emergence of simple logical which an individual can understand or execute medical thinking, play and language, although preoperational instructions, report their symptoms or emotions or even children are generally egocentric. have their healthcare needs assessed. Children’s acquisi- 3. Concrete operational (7–11 years): logical thought tion of language is fundamental to their development as develops; can perform mental operations (e.g. men- it enables interaction in their social world and thus social tal arithmetic) and manipulate objects to enable development (Vygotsky, as reported in Daniels, 1996). problem-solving; others’ perspectives can also be Communication deficits or limited language skills can understood. impair a person’s willingness to place themselves in social situations, or impede their ability to express their pain or 4. Formal operational (age 12 to adulthood): abstract distress to health professionals or family members. Intel- thought and imagination develop as does deductive lectual development further affects the understanding an reasoning, metacognition and introspection. Not eve- individual has of their symptoms or their illness which is ryone may attain this level. also crucial to their healthcare-seeking behaviour and to Piaget’s work was influential in terms of providing their adherence with any healthcare intervention. Finally, an overarching structure within which to view cogni- behaviour, specifically health-risk or health-enhancing tive development although it has been noted that he may behaviour, also varies across the lifespan and influences have underestimated children’s capacities and also the one’s perceived and/or actual risk of illness. Cognitive, role complex adult language and communication play in a communicative and behavioural aspects with relevance child’s development. In this regard and of more relevance to health and illness experience are extensively covered here, is work that more specifically addresses children’s in this textbook but we cannot assume that explanations developing beliefs, understanding and expression of or models of adult thoughts, feelings or behaviour can health and illness constructs. be applied to children, given normative cognitive devel- Erik Erikson (Erikson 1959; Erikson et al. 1986) opment, or to adolescents, given variations in the sali- described eight major life stages (five related to child- ence of social influence (Holmbeck, 2002). We present hood development – infancy, early childhood, pre- some further details of child development as relevant to school, school age, adolescence, and three related to health and illness concepts here using Piagetian stages as a broad framework. Sensorimotor and preoperational egocentric stage children self-centred, such as in the preoperational stage (age 2–7 years) of children, when they see things Little work with infants at the sensorimotor stage is pos- only from their own perspective (cf. Piaget) sible in terms of identifying health and illness cogni- tions, as language is very limited. At the preoperational 22 CHAPTER 1 WHAT IS HEALTH? stage, children develop linguistically and cognitively, still unable to distinguish between mind and body until and symbolic thought means that they develop aware- around age 11. ness of how they can affect the external world through Illness concept imitation and learning, although they remain very ego- Bibace and Walsh found explanations of illness among centric. In preoperational children, health and illness 8 to 11 year olds to be more concrete and based on a are considered in black and white, i.e. as two opposing causal sequence: states rather than as existing on a continuum. Children are slow to see or adopt other people’s viewpoints or Contamination: i.e. children understand that illness perspectives i.e. they lack a ‘theory of mind’, which is can have multiple symptoms, and they recognise that crucial if one is to empathise with others. Thus a preop- germs, or even their own behaviour, can cause illness: erational child is not very sympathetic to an ill family e.g. ‘You get a cold if you get sneezed on, and it gets member, not understanding why this might mean they into your body’. receive less attention. Internalisation: i.e. illness is within the body, and the Illness concept process by which symptoms occur is partially under- It is important that children learn over time some respon- stood. The cause of a cold may come from outside sibility for maintaining their own health; however, few germs that are inhaled or swallowed and enter the studies have examined children’s conception of health bloodstream. These children can differentiate between which would be likely to influence their health behaviour. body organs and function and can understand specific, Research has however examined the developing illness simple information about their illness. concept. Bibace and Walsh’s (1980) findings from chil- In this concrete operational stage, medical staff are dren aged 3–13 years suggested that an illness concept still seen as having absolute authority, but children can develops gradually. Children were asked questions about also see the role of personal action as returning them to illness knowledge – ‘What is a cold?’; experience – ‘Were health. Children can now begin to weigh up the pros and you ever sick?’; attributions – ‘How does someone get a cons of actions and medical staff actions might be criti- cold?’; and recovery – ‘How does someone get better?’ cised/avoided: e.g. reluctance to give blood, accusations Responses revealed a progression of understanding and of hurting unnecessarily. Importantly children here can attribution for causes of illness, and six developmentally be encouraged to take some personal control over their ordered descriptions of how illness is defined, caused and illness or treatment – which can help the child to cope. treated emerged. They also need to be encouraged to express their fears Under-7s generally explained illness on a ‘magical’ and to recognise the importance of communication. Par- level – explanations are based on association: ents need to strike a balance between monitoring a sick Phenomenonism: until around 4 years old, illness was child’s health and behaviour and being overprotective, a sign or sound that the child has at some time asso- as this can detrimentally affect a child’s social, cognitive ciated with illness, but with little grasp of cause and and personal development and may encourage feelings of effect: e.g. a cold is when you sniff a lot. dependency and disability (see Chapter 15 ☛ for further discussion of coping with illness in a family). Contagion: from around age 4, illness was caused by a person or object that is close by, but not necessar- ily touching the child; or it can be attributed to an Adolescence and formal activity that occurred before the illness: e.g.: ‘You get measles from people’. If asked how? ‘Just by walking operational thought near them’. Adolescence is a socially and culturally created concept only a few generations old, and indeed ma