Constructing bodies of knowledge: examining the discursive sites through which individuals come to understand what "health" means

How individuals perceive and understand health will impact the health behaviours that they engage in, how they engage with the healthcare system, and how they perceive themselves on a spectrum of healthfulness. Perceptions of health are developed within specific contexts, such that individuals’ understanding of what constitutes a state of health is shaped within the culture in which they are situated. The present study used semi-structured interviews to examine how individuals conceptualize health and health status, and through discourse analysis examined how culture and gender intersect to influence personal discourses of health. There were three main themes that emerged consistently within both lay and health-related participant groups around defining health and ill-health: Health as an absence of illness, Mechanistic conceptions of health (food and nutrition, obesity/overweight as unhealthy), and Holistic notions of health (psychological well-being, stress, and the role of environment on health). Lay persons have had greater access to biomedical discourse and medical professionals participate in social discourse, so the agreement between groups would be expected. Analyses by gender demonstrated that while males and females tended to use similar words to describe health, males appeared to use more active language references “activity” and “ability” more frequently than female participants. These research findings reflect a proliferation of biomedical discourse at the cultural level, in which the locus of control for health is located within the individual and their behaviours. UNDERSTANDING HEALTH PERCEPTIONS 5 Constructing Bodies of Knowledge: Examining the Discursive Sites Through Which Individuals’ Come to Understand What “Health” Means. There is a great deal of research being conducted in the field of health and medicine that is aimed at understanding how to better deliver healthcare, to decrease costs, and to improve the health status of individuals and the population (Entwistle, Firnigl, Ryan, Francis, & Kinghorn, 2012; Kongstvedt, 2013). This research is important and constructive, but there is a gap in its applicability; enhancing expert knowledge and applying it to strengthen our current healthcare system is certainly desirable, but an integral piece is often missing, and that is the perspective of those the system is meant to benefit – the consumers of healthcare services. In order to effectively deliver health services, it is important to understand how those who utilize these services perceive health, so that the delivery may be as efficacious as possible. It is also important to understand how those who deliver healthcare services perceive and understand health concepts so that there may be continuity between expert and layperson, doctor and patient. Because perceptions and knowledge are consistently evolving, continued research in the area of perception of health is integral to maintaining an understanding of how both laypersons and medical personnel perceive and understand health phenomena. Research in the social and medical sciences regarding lay perceptions of health have most often focused on lay beliefs in relation to specific illnesses or disease, for example, beliefs about alcoholism, obesity, breast cancer, diabetes etc. (Cavanagh, Taylor, Keim, Clutter, & Geraghty, 2008; Kilpatrick, Ohannessian, & Bartholemew, 1999), rather than individuals’ general beliefs about health. Furthermore, studies within the field of psychology that have examined lay individuals’ general beliefs about health and the social construction of health are 20 years old or more and according to Lupton (1995) tend to undervalue humanistic, critical, and interpretive approaches to understanding UNDERSTANDING HEALTH PERCEPTIONS 6 health and health behaviours (e.g., Connelly, Philbrick, Smith, Kaiser, & Wymer, 1989; Kirscht, 1972; Weinstein, 1984). Since these studies were conducted, ideas about health and health care have shifted. For example, health care consumers within Canada have available to them greater options – options outside of the biomedical model, such as more holistic, and Eastern models of health care services (Hughner & Kleine, 2004). Furthermore, understandings of health are inevitably tied into cultural mores, and these have also shifted over the past few decades. In understanding what is considered to be ‘healthy’ and the behaviours that individuals consequently engage in to attain a state of health, health researchers will then be better prepared to address effective healthcare delivery. Examining perceptions of health held by individuals and informed by their social contexts may also elucidate the manners in which individuals think about what constitutes a state of health, health practices, and may inform more effective public health advocacy and the dissemination of relevant information to individuals. Therefore, the purpose of the present study is to examine the perceptions held by healthrelated professionals as well as lay persons to determine the ways in which individuals internalize messages about health from their contextual surroundings, how these perceptions are reflected in beliefs about health and healthfulness, and the myriad of ways in which individuals’ place in culture (their experiences, their age, their gender, their ethnicity, and so on) intersect to impact how health is perceived. The concept of constructions of health and the intersectionality of personal, biomedical, and cultural discourses will first be explored through the lens of social constructionist theory. Intersectional approaches aim to understand the person in relation to their varying sites of power and oppression within social contexts that vary across space and time and how these impact individual experience; it is concerned with recognizing and understanding the complex manners in which social locations and power structures shape the lived experiences of UNDERSTANDING HEALTH PERCEPTIONS 7 humans (Hankivsky, 2014). Because of the emphasis on body size that is seen in research, media, and cultural discourses of health (Fox, Ward, & O’Rourke, 2004; Rail, 2008), the present study will examine the ways in which perceptions of health are related to the evaluations of appearance and body size. We construct our knowledge of the world through our experiences and the discourses to which we are exposed (Burr, 2003), so social constructionist theory was applied to make sense of the ways in which people come to know about health. For the present study, qualitative methods were employed; semi-structured interviews were conducted with students in health-related professions and lay individuals in which questions focused on personal conceptions of health (how one defines health, what constitutes a state of health or illness), and how they conceptualize and engage in health services (to determine if there are gendered and cultural differences in accessing health care, understanding health, or caring for one’s health, and if a state of health means something different to individuals according to gender). These inquiries are informed by previous research that suggests that women consult their general practitioners more than do men; that medicalization of female bodies has increased conceptions of the female body as needing medical intervention; and that within medical interactions, women tend to receive more time and attention than do men (Hunt, Adamson, and Galdas, 2012). However, Hunt, Adamson, and Galdaas (2012) assert that the gendered differences in health behaviours are much more complex. Healthcare utilization also changes over the lifespan and by region (Roy & Chaudhuri, 2012). Social Constructionism In order to examine constructions of health and the perceptions individuals hold, it is important to consider the context in which these ideas are held. This context influences individual and cultural perceptions. Social constructionism is a theoretical paradigm that applies a critical UNDERSTANDING HEALTH PERCEPTIONS 8 lens to knowledge and knowledge production; it provides a structure for critiquing and examining the taken-for-granted manners in which the world is understood, challenges the presumed objectivity of science, and opposes essentialist ideologies. Social constructionist theory posits that the categorical delineations that we use to understand natural phenomena do not exist in any real or fundamental way; they do not refer to real divisions in nature (Burr, 2003; Foucault, 1979). For example, the dichotomotized gender binary of males and females is not inherently ‘real’, but a category that was constructed as a manner of comprehending our world. These categories that we apply to natural phenomena are located culturally and historically, so that they are specific to time and place. This becomes evident in the alterations that conceptions undergo across time, alterations that do not reflect any actual changes in the entities being constructed but are contingent upon and reflective of shifts in cultural mores and social processes (Gergen, 1985). Knowledge production and specific manners of understanding the world are dependent upon where in the world one is, and the social and economic clime of that culture and time (Burr, 2003). Not only is knowledge culturally specific and historically relative, it is inevitably a product of that culture. Therefore, those who have been socialized differently and whose conceptual backgrounds differ, live, at least partly, in a different world with different objects (Liebrucks, 2001). Four key concepts presented in the social constructionist literature which will be pertinent to this research study are knowledge production, language, discourse, and power. These inform an understanding of how perceptions of health are produced. Knowledge production. Knowledge, then, is an artifact of the culture in which it is produced, a product of social interactions (Berger & Luckmann, 1966; Danziger,