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Revista Sexología y Sociedad. 2013; Vol. 19, No. 1
ISSN 1682-0045
Versión electrónica
ARTÍCULO ORIGINAL
Representations of health in Latin American professionals: A comparative study
Dra. Ramón Rivero Pino
National Center for Sexual Education (CENESEX)
ramonrp@infomed.sld.cu
ABSTRACT
Analysis of an issue of particular relevance for the global society: the need to find more adequate and revolutionary ways to think and implement health professional practices. The scientific idea developed in the article is to find the cultural norms at the root of the representations that professionals have about health and how to modify them for the purpose of human emancipation, and personal and social dignifiedness. The general objective is to search for a critical and revolutionary scientific approach—from a theoretical and methodological perspective—in the study of health practices, which will foster the capabilities and skills of health professionals and personnel, their personal and professional development, as well as that of those who benefit from their activity, having a positive impact in the socialization process of new generations. The methodology used was community self-development, developed at the Community Study Center of the Marta Abreu Central University of Las Villas in Cuba. Results show insufficient critical awareness in the professionals of the selected sample, regarding traditional health approaches, the existence of a set of health-related discomfort expressing, on the one hand, shortages of health services provided in different countries and, on the other, daily problems people face. As a result of the research, some proposals were put forward.
Key words: health, health concepts, health professional interventionIntroduction
Studies conducted by many social scientists on people´s daily reasoning and categories spontaneously used to cope with reality, have allowed us to gradually get acquainted with the laws and logic governing social thinking, that is, the kind of thinking we use, as members of a society and a culture, to forge our perception of peoples, things, realities and events comprising our world.
The relevance of these studies is crystal clear: we decode the conditions surrounding the construction of social thinking, which is characteristic of human beings, as well as its functioning mechanisms and the structure it adopts, so as to be capable of explaining their reactions, conducts and psychology.
The need to understand these forms of «daily» thinking –term used to differentiate it from, let´s say, the scientific or religious thinking, is not new; many theories have come closer to this term. However, the approach to the theory of social representations has the advantage of equally combining cognitive and social dimensions in the construction of reality.
The concept of collective representation was originally put forward by E. Durkheim in 1951 (1) and then reformulated in 1961 by Sergue Moscovici (2) in his study on the insertion of the psychoanalytic theory into public opinion. In his work, he shows the process we follow to familiarize ourselves with the universe of new issues, events and facts that are constantly taking place in our contemporary world and which are conveyed through mass media, informal conversations and fortuitous encounters, thus becoming objects of our knowledge and reality.
Social representations are just one part of social knowledge, one part of the common sense knowledge.
At the content level, social representation includes first-order legitimating concepts, that is, a knowledge dealing with everything that exists (what it is) and explaining how to act (what to do). At a very simple level, it incorporates second-order legitimizations (why). These are very simple and explanatory models especially designed for social action. Above all, they legitimize what to do with a very simple why, being the first aspect essential. Social representation is not just a mere reflection of ideologies, but a reproduction and activation of the tools of common sense knowledge applied to a concrete situation and with a strategic view of social action (3).
The study of social representations allows us to know how legitimizations of ideology and, particularly, of science diffuse together to become the legitimization of daily knowledge for most people; that is, this diffusion and re-interpretation of both the ideological and, particularly, scientific knowledge play an important role in the construction of social representations.
Social representations constitute an expression of our thinking, which is neither formalized nor institutionalized. However, not all beliefs are social representations. Social representations focus on social objects (groups, roles, institutions); they are shared and made by a group; they serve for intra- and inter-group communication; they classify, explain and assess, from the functional viewpoint, social objects from the common sense discourse and belief, an interaction-oriented knowledge.
In this process, the evaluation dimension prevails, associated with an affective dimension. Thus, what essentially distinguishes social representation from cognitive representation is the affective evaluation among groups. This affective evaluation made by social representation is quite stable and remains, even when cognition on social objects changes. This is a central element in social representations.
In relation to the study of social representations on health we can point out the following:
From the theoretical point of view, the use of social representations allows us to get acquainted with the ways and processes involved in the construction of social thinking through which we build our reality and, in this specific case, in response to its content, the ways in which health is seen by specific groups in our society. Social representations are created by reflexive groups (4), whose members, in their systematic practice, collectively design rules, justifications, beliefs and conducts which are relevant to the group. The study can be conducted in three different dimensions, namely, knowing the field covered by representations under study and their central core, knowing the «figurative core», as well as knowing the information level handled by subjects. This will give us the possibility of knowing the origin of that information, its quality and quantity. In the attitudinal dimension, knowing the willingness expressed by individuals over represented objects. This latter dimension is the one providing more information for an applied study, since it can allow us not only to understand what it reflects, but also the attitude towards it.
From the practical point of view, the application of these studies is highly useful. Representations can materialize the ideological contents masking reality so, if we want to unmask the ideologizing role of shared health beliefs, we can do it by providing analytical elements leading to the collective construction of a new knowledge.
Regarding the object of our analysis, this is both possible and necessary. Let´s remember how health conceptualization and its functions have evolved to the same extent in which economic conditions have been transformed. As ideology is a reflection of the economic basis, it is quite easy to understand why the society´s opinion on health, at every historical moment, has been influenced by the prevailing social and economic interests.
The way we propose can be used to achieve a better integration of health professionals, since the way in which they represent their roles will have a direct impact in their individual and collective identification, behavior and satisfaction.
Health issues have been developed by scholars on social representations. This theoretical and methodological approach has become one of the main tools to understand these processes. Science is increasingly closer to people. In this regard, the contributions of social representation can be very valuable. On the one hand, as a way to get acquainted with that common sense thinking and, on the other hand, as a guiding mechanism for health professionals in that demanding relationship between health providers and users.
Uwe Flick was the first providing clues on the importance of this conceptual framework when analyzing public health processes. Acknowledging its importance, Flick stated: (unofficial translation)
[…] Today, the specific relevance of social representations as a health-illness approach derives from the general development of a health conceptualization and understanding not only as an individual issue. The concepts of public health and health promotion for specific social groups require a conception of people´s ideas about health and illness capable of taking into consideration the social influences acting upon them, and understanding the daily knowledge as a socially constructed knowledge [5].
However, today´s assessment of this issue leads us to affirm, in accordance with Daniel Gonzalo Eslava Albarracín and María Cecilia Puntel de Almeida (6), that the general production scene, concerning the object of this article, in indexed magazines of international scientific prestige, shows that, despite being an important theme to understand certain phenomena (demanding processes and health care, persistence of popular practices and beliefs, and interaction of different cultural forms in the healing and/or treatment process), both production and development are still limited, at least as far as the internationally recognized academic work is concerned. Obviously, English-language production prevails over the poor Spanish-language production. The United States holds the publishing hegemony; psychology is the knowledge sphere recording the greatest production; and the prevailing topic is closely related to social aspects, with qualitative-type works accounting for almost the entire production, and descriptive studies being the most referenced ones. The most outstanding issues are those associated with AIDS, geriatrics, pediatrics and, within them, the significance of some of their pathologies or the experience of living with them.
In light of the foregoing, it is evident that social representation of health has been poorly treated in professional groups and that comparative studies in our region are nonexistent.
Comparative Study
Between 2004 and 2011, this article´s author conducted a post-doctoral research on issues such as family, gender and health which included exchanges with Argentinean professionals from Santiago del Estero and Rosario provinces (2004), Mexican professionals from Ciudad Juárez (2006 and 2007), Ecuadorian professionals from Loja, Zamora Chinchipe and Guayaquil provinces (2009, 2010 and 2011) and Cuban professionals from Villa Clara, Matanzas, Santiago de Cuba, Ciego de Ávila and Havana provinces (2008-2011). They were doctors, psychologists, teachers and social workers who work with families and provided the information that was later on subjected to comparison. This is a comparative study of social representations of professionals from those countries on the abovementioned issues which allowed us to learn the common reflections made by participants in the group processes conducted.
Methodology
As a whole, the sample selected was made up by 13 reflexive groups, namely, three from Argentina (two from Santiago del Estero and one from Rosario), two from Mexico, three from Ecuador (one from each province) and five from Cuba (one per province). The groups were randomly constituted following an invitation to reflect on the previously mentioned issues. As a whole, 360 professionals (207 women and 153 men) participated in this encounter.
The group processes were part of a general community-work strategy (7) which included five stages:
The first stage is called initial exchange with the subject requiring professional action. The objectives of this first stage are: a) to know the demanding subject´s perception of his/her general characteristics, problems requiring a prioritized solution and the most affected scenarios; b) to hypothetically formulate the underlying contradictions concerning the problems stated by the demanding subject; and c) to agree on the initial plan for professional action.
At this stage, the key objective is to achieve an adequate communication between the professional and the subject requiring professional action. This implies the free exchange of clear messages, the legalization of conflicts and the process for establishing frustrations. Likewise, it is extremely important for professionals to be aware of the difference between demand and need, for not all demands constitute a real need because, occasionally, when the real causes of their discomfort are unknown, subjects resort to demands masking the essential elements causing their discomfort: the basic contradictions of such situations. Therefore, establishing the hypothesis of the demand is very important within the process since it contributes, from the very beginning of social work, to empower the critical consciousness of the demanding subject on the real causes of his/her demand.
The second stage of this process is known as the scenario exploration. The main objective of this stage is to collect the empirical data associated with problems faced by demanding subjects and confront them with the demand stated so as to gather all elements that will allow us to organize and plan future intervention steps or stages. The techniques used to collect these empirical data are, namely, analysis of documents, participatory observation and individual and group interviews. Of course, these are not the only ones that could be used. The techniques to be used depend on the intervention level and the specific characteristics of the object.
During this stage, a highly significant element to bear in mind is the starting theoretical references, since they should also be confronted with the empirical data collected. Certainly, this allows professionals to formulate the theoretical indicators that, according to his/her appreciation will be used to organize the methodological proposal for intervention. Then, the participatory diagnostic matrix can be established on the basis of these indicators.
This matrix is a sort of scheme synthesizing, from a certain organization, the information collected so far by the professional to continue with the intervention process. Its basic elements are: problems (negative situations directly affecting the demanding subject), priorities (the criterion used to define them is the analysis of each problem in relation to future impacts or effects), determining factors (characterization and identification of key elements associated with the origin of problems), potential actions (concrete activities contributing to solutions; they can be immediate actions as, for example, technical assistance, political management, community work agreements, campaigns with the population, or projects or studies as political decisions and inter-institutional agreements), resources (means that could help to improve or solve the problems stated), municipal and communal contributions (identification of contributions that communal organizations and municipal institutions can make), responsible (definition of the individual in charge of coordinating actions), and implementation period (starting date and date of termination of activities).
The third stage is the diagnostic and search for solutions. As indicated by its name, the main objectives include diagnosing problems to be solved by the demanding subject and facilitating the correcting process. This takes place at the same time through different ways but, especially, through group spaces for reflection.
This special feature provides the diagnostic and search for solution process with a great realism and transforming strength, since the situations subjected to analysis and reflection within correcting spaces are closely associated with the main causes of the discomfort suffered by the demanding subject without a critical consciousness. As a result of this, the autonomy, intelligence, prominence and real participation of the demanding subject are empowered when overcoming his/her own and surrounding contradictions.
The fourth stage is evaluation and the fifth stage is systematization.
Intervention Program
The intervention program included a title, objectives, contents and techniques. Contents provided an answer to the selected indicators. These indicators were verified through intervention practices, either expressed or not in the groups, though they were a reference to be considered. What was important was that the intervention program content promoted reflections and learning on issues unknown to participants, despite the fact that they constituted essential causes for discomfort and conflicts.
The techniques used in the intervention program promoted critical reflection. In this regard, we preferred the experience-oriented techniques, as dramatizations.
The program had as many sessions as selected indicators, namely, three. Sessions did not exceed the two-hour work and the maximum number of participants per group was 25.
During the working process, the groups made their own life projects on problems analyzed and they were considered, in accordance with this methodology, the tangible product of the professional intervention conducted. The self-development or social transformation projects comprise actions defined by the groups in order to achieve objectives which could meet their needs. They are to be materialized at a certain time and space and distinguished by being a community effort.
The basic topics dealt with by the groups included:
• social representations of health,
• most frequent discomforts found among health providers,
• potential solutions identified by the groups.
Once these elements were identified, the data collected was processed in the following way: Elements provided by reflection groups were documented in records of textual discourse (silences, reiterative interventions), pre-verbal (what participants were doing while the coordinator or others were talking), main emerging situations (moments of tension, confusion, and occasional thematic or dynamic task boycott of the session), thematic notes (new topics) and transfer and counter-transfer (to highlight a type of demand and introjection of what was respectively projected). These data served to analyze group processes in thematic and dynamic aspects.
The analysis of collected data was conducted through its coding (the breaking down of recording or thematic units into sense units and the search for indicators worth analyzing), and was then categorized and construed.
Results
Daily life discomfort expressed through dramatizations performed by Argentinean, Mexican and Ecuadorian groups, which served as an exploring basis for social representations of health, included the following essential elements: the contradictions between the attitude of health professionals and the needs of the population, the economic shortages hindering health management of the most needed, and the welfare approach of health care, among others, while Cubans paid more attention to lack of formal education of people in public spaces, parents not aware of their children´s daily life, conflicts among professionals (in every sphere), and individual and collective subjects requiring their services.
In this regard, in the case of the Argentineans, Mexicans and Ecuadorians, explanations given for these discomforts included: lack of sanitary education; poor planning and organization of health services; individualism in the search for solutions; non-compliance of the role to be played by primary health care units (welfares); absence of an interdisciplinary work by health teams; poor or absent networking resulting in a lack of efforts; health awareness-raising only in the presence of an illness; hegemonic and omnipotent role played by doctors; external, political and institutional pressures affecting good services; low wages of health professionals and technicians; deterioration of the system due to people´s silence; and excessive drug consumption.
Cuban professionals focused their analysis on those situations faced by people during the performance of different social roles. Their main concerns were associated with economic shortages and poor functional effectiveness of institutes in charge of socializing the personality; that is, on the one hand, the reflection focused on underdeveloped conditions limiting health processes and, on the other hand, the incompetence of institutional entities as health providers.
Two aspects stand out from the reflections made by both Cuban and foreign professionals: the criticism of the established status quo and the passive citizenship in terms of solutions.
The following question encouraged the critical thinking of participants: should dramatization characters be considered sick persons? A large number of participants answered affirmatively; others were doubtful and began rephrasing their arguments under a different view.
Beliefs shared by all groups manifested a well-structured figurative core. Those who answered affirmatively stated that these persons are not biologically sick but socially sick which, in the case of Argentinians, Mexicans and Ecuadorians, was associated with the search for external solutions, the State. The Cuban groups emphasized the economic hardships; the performance of institutions and its impact on the people´s cultural and spiritual life, in terms of the limited development of civic and moral values; the existence of a double standard; the negligence or incapacity to find answers, for example, to familial difficulties.
As can be observed, while it is true that professionals take into account the biological, psychological and social aspects when dealing with the health status of a community or social group, they do not consider human capabilities as a solution or the potential development aspects to which the population systematically resorts, to a greater or lesser extent, to organize their life and find a way to live or survive. The professional perspective does not bear in mind population´s capabilities as a major resource to plan, organize, control and evaluate health processes. It focuses on the negative aspects as a basis to begin working on the pathology, from the disease and a welfare approach.
The verified essential field and core of social representations, without elements from the traditional biologically-oriented health approach for it was focused on social aspects, showed the health-illness relationship in a dichotomic fashion. Likewise, health reasoning, understood as the complete biological and psychosocial welfare, was an element shaping that set of ideas shared by groups.
Health concepts have evolved from a biologically-oriented approach to a more social approach, which is a significant advance. The conceptualization of social determinants in health which excludes the traditional cause-effect articulation in classic epidemiology has significantly contributed to this end. However, despite being an advance, this viewpoint has the distinct epistemological problem of assuming the existence of a universal consensus on the meaning of key defining terms, namely: health, welfare and population. This universality is deprived from politics and history, since it evades the question of who defines these terms. Therefore, it essentially eludes the epistemological problem of power.
Another problem associated with representations is that, despite the importance currently attached to the individual´s health care responsibility, the active role, starting from health institutional practices, is still played by health professionals, not by the citizens. Obviously, this epistemological viewpoint does not take into account the community as a health subject or the health as a social construction.
An important aspect associated with this issue is the impotence and frustration of health professionals or technicians when acting under the idea that health is a full welfare state. This was acknowledged by participants in the different groups from the four countries.
While group reflections progressed, new and significant elements, playing an important role in the collective construction of a new health approach, stemmed out. These elements included: understanding the static nature of health traditional definition; the value of culture and education in training and human capacity building for emancipation; the need to go beyond the sanitary and prevention health approach and resort to higher health management levels; acknowledgement and legitimization of community self-management capacity in health; overcoming sectorial orientation in health management; and strengthening the link among different subsystems within the National Health System. Particularly, the following criteria were shared in the Argentinean, Mexican and Ecuadorian groups: unraveling the ideologizing content of using health, as well as its human and material resources, as the central issue for political interests; defining a coherent sanitary policy including clear-cut goals, mechanisms and resources; achieving a better performance by health teams; and to promote patriotism and education on the citizens’ rights aiming at self-management capacity building.
Finally, with regard to this problem, groups got to the bottom of community participation as a key element to empower people´s health self-management. Likewise, the Argentinean, Mexican and Ecuadorian groups considered the following essential issues as obstacles to achieve a true popular involvement: a) high illiteracy levels, especially in rural areas; b) customs and traditions against the elemental precepts of basic health care as, for example, the counterproductive use of herbs to treat ailments; c) alcoholism, drug addiction and individualism –those who have resources but are not willing to work collectively; d) omnipotence and elitism characterizing the work of some doctors and health technicians and others; e) political struggle that alienates and divides; f) sanitary agents working as political agents; g) political campaign promises; h) lack of access to health centers due to bad road conditions; i) lack of inputs; j) lack of control at the different health levels; k) poor human resources in health.
In turn, Cubans focused on: a) improving comprehensive health care structure, processes and outcomes; b) increasing personal competence and performance in Primary Health Care (PHC) through technical consultancy, training and improvement; c) promoting research on PHC in keeping with problems identified in the health-status analysis; d) strengthening the transfer and counter-transfer at the three health care levels; e) raising the people´s satisfaction with services provided, thus contributing to local and sustainable human development, and to a comprehensive identification and solution of problems with the involvement of different social actors; f) raising the health workers´ satisfaction.
Likewise, professionals from the four countries acknowledged the existing contextual potentialities to promote PHC processes. Argentineans, Mexicans and Ecuadorians referred to the presence of sanitary agents and nurses in the communities; the good relations existing between health agents and community residents; solidarity among neighbors; sanitary education of part of the population; the holding of social events to obtain resources; the authority, credibility and training of the health staff; the positive results achieved in those places with good health care services and attitude displayed by health teams; the incorporation of self-care to the popular culture; and the existing positive experiences associated with the working link between doctors and healers.
Regarding the Cuban experience, these potentialities included the high level training and education of the population; the existence of a community health and infrastructure capable of meeting the real needs of the population; and the official willingness to support the people´s interests.
The final stage of each group processes was characterized by a set of proposals put forward by participants. It is worthwhile mentioning the level of involvement achieved in the process by all professionals.
Conclusions
The research promoted a diagnostic on social representations related to health by the groups participating in the inquiring process allowing us to attest the prevalence of a non-historical and welfare conception dichotomizing health and illness processes.
As a result of this working process, the groups attained:
• A more comprehensive understanding of health associated with the involvement and cooperation of the population.
• An understanding of the rigid patterns instilled from a specific and socially established order in daily life which are inter-generationally transmitted without being aware of the damage they might cause in training future generations.
• The visualization of social factors that widen social representations regarding the professional role played in the health care field which, in our society, legitimizes traditional stereotypes in the exercise of this role.
• An understanding of the elements that should be included in an intervention strategy (in community health) with a self-development approach.
Besides, the study provided an understanding of the importance of broadening the analysis of this issue in the international scientific literature, especially in Cuban publications.
Referencias
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2. Moscovici S. La psicología social en los umbrales del siglo xxi. Alelón 1991; 3 (número especial).
3. Páez D, et al. Pensamiento, individuo y sociedad. Madrid: Editorial Fundamentos; 1987.
4. Elejabarrieta F, Wagner W. Representaciones sociales. Manual de psicología social.Barcelona; 1993.
5. Flick U. Social representations of health-illness. [Editorial]. Papers of Social Representations 1995; 4(1):1.
6. Eslava Albarracín DG, Puntel de Almeida MC. Representaciones sociales de salud y enfermedad: investigando el estado del arte. Cienc. Enferm 2002; 8(2), doi:10 .4067/S0717-95532002000200007.
7. Rivero Pino R, et al. El autodesarrollo comunitario. Crítica a las mediaciones sociales recurrentes para la emancipación humana. Santa Clara: Editorial Feijoo; 2004.
Fecha de recepción de original: 1 de mayo 2013
Fecha de aprobación para su publicación: 7 de junio 2013
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