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- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
The culture-centred approach offered in this book argues that communication theorizing ought to locate culture at the centre of the communication process such that the theories are contextually embedded and co-constructed through dialogue with the cultural participants. The discussions in the book situate health communication within local contexts by looking at identities, meanings and experiences of health among community members, and locating them in the realm of the structures that constitute health. The culturecentred approach foregrounds the voices of cultural members in the co-constructions of health risks and in the articulation of health problems facing communities. Ultimately, the book provides theoretical and practical suggestions for developing a culture-centred understanding of health communication processes.
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Veröffentlichungsjahr: 2015
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Table of Contents
Cover
Title
Copyright
Dedication
List of Figures
List of Boxes
Glossary
Acknowledgments
Introduction
Culture-Centered Approach to Health Communication
Roots of Culture-Centered Health Communication
Characteristics of the Culture-Centered Approach
Conclusion
1: Culture in Health Communication
Historical Overview
Models of Health Communication
Culture in Health Communication
Applying Culture in Health Communication
Conclusion
2: The Culture-Centered Approach to Health Communication
Interrogating the Dominant Paradigm
Health Communication
Critiques of the Dominant Paradigm
The Culture-Centered Approach
Characteristics of the Culture-Centered Approach
Conclusion
3: Theoretical Approaches to the Study of Culture
Communication and Culture
Approaches to the Study of Culture
Similarities and Differences between Cultural Approaches
Practices of Culture
Conclusion
4: Culture, Identity, and Health
Identity and Health
Narratives of Health
Narrative, Culture and Structure
Conclusion
5: Pathways of Curing and Healing
The Dominant Framework: Biomedical Knowledge
The Culture-Centered Critique of the Biomedical Model
Spirituality and Health
Alternative Systems
Socio-Structural Contexts of Healing and Curing
Polymorphism
Conclusion
6: Culture and Marginalization
Marginalization
Communicative Enactment of Marginalization
Conclusion
7: Health Experiences in Marginalized Sectors
Experiences at the Margins
Structures of Violence
Markers of Marginalization
Marginalization in a Global Context
Imperialism and Disease
Postcolonial Experiences
Positions of Subalternity
Conclusion
8: Culture, Social Capital, and Health
The Community as an Organizing Framework
Public Sphere and Health
Social Capital and Health
Culture and Social Capital
A Culture-Centered Approach to Community Organizing
Conclusion
9: Culture and Resistance
Communicating Resistance
Resistance and Social Change
Culture in Resistance
Conclusion
10: Health, Culture, and Globalization
Introduction: Defining Globalization
Globalization and Health
Communicating Globally about Health
Global Resistance and Activism
Conclusion
11: Culture as Praxis
Culture-Centered Praxis: The Case of SHIP
Culture as a Concept: From Theory to Research to Praxis
Culture in Social Change
Conclusion
References
Index
End User License Agreement
List of Illustrations
Introduction
Fig. I.1 The culture-centered approach to health communication
Fig. I.2 A meeting of peer educators in Africa
1: Culture in Health Communication
Fig. 1.1 A tuberculosis (TB) patient in a clinic run by Médecins sans Frontières in Sudan
Fig. 1.2 A Dalit woman with a flower attends the 2006 Vanangana conference in Chitrakoot
3: Theoretical Approaches to the Study of Culture
Fig. 3.1 Approaches to the study of culture
Fig. 3.2 A mother holds her sick child waiting for treatment
Fig. 3.3 A child with malaria being comforted by his parents
4: Culture, Identity, and Health
Fig. 4.1 The role of identities in physician–patient relationship negotiation
5: Pathways of Curing and Healing
Fig. 5.1 A shamanic ritual in the taiga near Shadan
Fig. 5.2 Healing session in the Mama Olangi hospital
Fig. 5.3 A polymorphic approach to healthcare decision-making
6: Culture and Marginalization
Fig. 6.1 Hunger in Kalahandi, India
Fig. 6.2 Prisoners in Manaus prison, Brazil
7: Health Experiences in Marginalized Sectors
Fig. 7.1 Malnourished child in a feeding center in Uganda
Fig. 7.2 Prisoner abuse in Abu Ghraib
8: Culture, Social Capital, and Health
Fig. 8.1 The relationship between structure, culture, agency, and community
Guide
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Table of Contents
Begin Reading
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Communicating Health
MOHAN J. DUTTA
Copyright © Mohan J. Dutta 2008
The right of Mohan J. Dutta to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First published in 2008 by Polity Press
Polity Press65 Bridge StreetCambridge CB2 1UR, UK
Polity Press350 Main StreetMalden, MA 02148, USA
All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
ISBN-13: 978-07456-3491-3ISBN-13: 978-07456-3492-0 (pb)
A catalogue record for this book is available from the British Library.
The publisher has used its best endeavours to ensure that the URLs for external websites referred to in this book are correct and active at the time of going to press. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate.
Every effort has been made to trace all copyright holders, but if any have been inadvertently overlooked the publishers will be pleased to include any necessary credits in any subsequent reprint or edition.
For further information on Polity, visit our website: www.polity.co.uk
To Ma and Baba
List of Figures
I.1 The culture-centered approach to health communication
I.2 A meeting of peer educators in Africa
1.1 A tuberculosis (TB) patient in a clinic run by Médecins sans Frontières in Sudan
1.2 A Dalit woman with a flower attends the 2006 Vanangana conference in Chitrakoot
3.1 Approaches to the study of culture
3.2 A mother holds her sick child waiting for treatment
3.3 A child with malaria being comforted by his parents
4.1 The role of identities in physician–patient relationship negotiation
5.1 A shamanic ritual in the taiga near Shadan
5.2 Healing session in the Mama Olangi hospital
5.3 A polymorphic approach to healthcare decision-making
6.1 Hunger in Kalahandi, India
6.2 Prisoners in Manaus prison, Brazil
7.1 Malnourished child in a feeding center in Uganda
7.2 Prisoner abuse in Abu Ghraib
8.1 The relationship between structure, culture, agency, and community
List of Boxes
I.1 The story of Dr Maria Rodriguez
1.1 The story of Suzanne
1.2 The story of Ibasa
2.1 The story of Minoti
2.2 The story of Sarah
3.1 The story of Carmen
3.2 The story of Louise
4.1 The story of Jake
4.2 The story of Cecilia
4.3 The story of Amy
5.1 The story of Basanti
5.2 The story of Jennifer
5.3 The story of Vanessa
5.4 The story of Meina
6.1 The story of Roberto
6.2 The story of Fan Wang
7.1 The story of Sarah
7.2 The story of Jim
7.3 The story of Rodney
7.4 The story of Kini
8.1 The story of Sarah
8.2 The story of Bob
9.1 The story of Radheshyam
9.2 The story of Illeana
10.1 The story of Sumirah
11.1 The story of Doug
Glossary
Biomedical
The most widely accepted model of healthcare that underlies the theories and practices of modern medicine.
Dominant
The dominant approach in this book refers to the widely circulated health communication research and application that is based on mainstream ideas of what it means to be healthy and what are the best ways to address health problems informed by the biomedical model.
Dyad
Two-person communication setting for interpersonal exchanges.
Epidemiology
The study of distribution of disease patterns and the underlying reasons that govern these patterns.
Epistemology
Part of philosophy which deals with knowledge and knowing.
Eurocentric
Ways of thinking which are rooted in European value systems and European ways of knowing the world. Eurocentrism is connected to the Enlightenment project, which used the universal rationality of science to dominate over other ways of knowing.
Globalization
Globalization refers to the global movement of economic commodities and communication across nation-states.
Heteroglossia
The multiplicity of different worldviews and knowledge systems that co-exist.
Identity
The sense of self of an individual; the way he/she sees himself/ herself.
Ideology
The stories and ideas through which dominant social actors maintain their control over the marginalized sectors of the world.
Marginalization
The condition of being situated at the peripheries of mainstream society, without access to basic resources.
Medicalizing
The medicalizing ideology looks at a disease as a problem that can be solved only through medicines and surgical treatments. In other words, the biomedical model is seen as the only viable solution to disease and illness.
Macro
The occurrence of phenomena at social level and the explanations that account for these large-scale patterns.
Micro
The occurrence of phenomena at individual, dyadic and small group levels.
Mobilization
Collective communicative processes which bring the community together in its resistance to dominant structures.
Narrative
The process of making a story and the story itself which is generated in the process.
Patriarchy
Hierarchical organization of the social structures which privileges masculine norms and ideals and rewards masculine values.
Polymorphism
The idea that multiple approaches and ways of knowing are complementary.
Redistributive justice
Form of justice which addresses resource inequalities by seeking to redistribute economic resources within the social system.
Resistance
Those processes that challenge the dominant structures and the control exerted by them.
Social capital
Concept which refers to cohesiveness within a community and taps into features of social organization such as community participation, and norms of reciprocity, and trust in others, which facilitate mutually beneficial cooperation.
Acknowledgments
We become who we are owing to the sacrifices which continuous generations of ancestors have made in order for us to be able to have a voice. This book is about rewriting a history of health communication from a viewpoint which is personal as well as political. I have learned early on, from my joint family who nurtured me to life, that what is personal is also political, and that politics is integral to the academic journey. I have learned from my family to speak from my heart, and to stand up in resistance to narratives of convenience. It is due to my family that I had sufficient faith in my voice as to want to speak, and sufficient commitment as to keep listening to what my own voice said. Hence this book is an homage to the voices of my family, community and culture that speak through me.
A big thank you goes to my teachers, who taught me the language through which I can now speak. Without you, I wouldn’t know where to begin, where to end, or where to hang my thoughts in-between.
I thank my colleague Patrice Buzzanell, who has mentored me generously during my formative years and has taught me the value of grace even as one engages in criticism. I also thank my colleagues Howard and Beverly Sypher, and Steve Wilson, for their friendship and for making Purdue an exciting place to work in, both intellectually and professionally.
Heather Zoller and Kimberly Kline have been invaluable collaborators on this journey, as they continued to ask critical questions in their own work and to provide points of entry for dialogue. My colleague and mentor Barbara Sharf has been, for me, an amazing role model as well as an immense source of support: she has read an earlier version of this manuscript and provided detailed feedback, in spite of her very busy schedule. I would also like to thank my friend Teri Thompson for the faith she placed in me even before I had acquired my credentials, for her continued support in the rigorous pursuit of health communication scholarship, and, not least, for her kindness and contaminating sense of optimism.
Without the visions of Collins Airhihenbuwa this book would not have been possible. Collins, thank you for igniting the spark in a young graduate student, almost a decade ago, to interrogate Eurocentric hegemony in health communication discourse. In those early days of graduate school – when I felt so unsettled by what seemed like the inherent racism of health communication programs that talked about development – your work gave me a language through which I could understand my feelings and emotions and give them a voice. Through your example, you have taught me the importance of continuing this work, which challenges our understandings of culture and the values that drive us to do what we do as health communicators.
Ambar, Iccha, Induk, Mahuya, and Rebecca – each one of you has contributed to this journey of discovery in ways that are profound. You have challenged me to think and rethink my work in new ways, and you have created new possibilities for the culture-centered approach. You have never shied away from engaging reflexively in work, although sometimes that task was painful. You have asked the difficult questions and walked along with me as we have grown together in our conversations, seeking to find the answers. The stuff of this book is very much a product of those late night talks and chats over coffee. I have full confidence that, as the next generation of culture-centered scholars, you will take this body of work to places that I haven’t yet dreamt of, that you will continue to challenge this line of work with your critical eye and always keep open the possibilities of reflexivity. A special note of thanks goes to Ambar, for reading preliminary drafts of this manuscript and for sharing your insights. A big thank you goes also to my students who have enrolled in the “Culture and health” and “Culture and resistance” graduate seminars, where we debated many of these ideas.
I would like to thank my editor at Polity, Andrea Drugan, for showing faith in the value of this project and for providing invaluable feedback and detailed copyedits.
My grandmother, Nana, taught me to value life and to be committed to whatever I think is important in life. It is through you, Nan, that I came to appreciate the value of learning and to understand that learning is a journey that never ends – so that the best kind of scholarship is the one which never ceases to ask questions.
Finally, I dedicate this book to Baba and Ma. Baba, your dreams have taught me to dream. Your belief in me has given me the courage to put together this work, and to pursue those stories that speak to me from my heart. You taught me to value a good debate, to be politically engaged, and to make that politics a part of my academic commitment. Ma, your patience, love, and endless faith in my work made me believe that I could someday write a book. Both of you continue to be the pillars on which I stand.
Introduction
In recent years, the concept of culture has received increasing attention in health communication (Airhihenbuwa 1995; Brislin 1993; Dutta-Bergman 2004a, 2004b, 2005a, 2005b; Resnicow, Braithwaite, Dilorio, and Glanz 2002). The call to respond to the varied needs of multicultural societies is evident in the large amounts of funds available for multicultural interventions, and the growth in the number of multicultural health communication programs that seek to serve the needs of multicultural communities. These programs are being designed with the goals of being culturally sensitive, of responding to the diverse cultures in the global context, and of meeting a felt cultural need (Resnicow, Braithwaite, Dilorio and Glanz 2002). Furthermore, globalization processes have foregrounded the relevance of articulating the concept of culture in the context of health communication programs by questioning the universal narratives of healthcare embedded within the biomedical model (Airhihenbuwa 1995; Dutta-Bergman 2004a, 2004b, 2005a, 2005b; Dutta 2007; Dutta and Basu 2007; Dutta and Basnyat, in press). The locally situated nature of health communication processes has become particularly relevant in the context of a growing awareness of the diverse ways in which meanings of health and illness are constituted in diverse societies and cultures. As the grand narratives of health have been ruptured in the backdrop of an increasing realization that the biomedical model provides a limited viewpoint for engaging in issues of global health, there is also an increasing awareness of the need to open up the spaces of health communication to the voices of cultural communities.
Surveying the scope of the field, a new scholar might observe that health communication has become increasingly sensitized to the need to address these cultural shifts in the world. It might seem that the ways in which we traditionally conceptualize health and practice health communication have paved the way for a more humanizing approach by creating spaces for the discussion of cultures and for culture-specific health solutions. This book examines the response of health communication work to culture and suggests criteria for historically situating the study of culture in health communication. Its goal is to provide a historical overview of the ways in which culture has been used in health communication scholarship and to offer the culture-centered approach as an entry point for engaging with the culturally situated nature of health communication processes and meanings (Dutta-Bergman 2004a, 2004b). The historical overview of health communication scholarship using the concept of culture offers a trajectory for locating health communication scholarship and for comparing the various approaches to culture-based health communication (Dutta-Bergman 2005a; Dutta 2007). The culture-centered approach is juxtaposed in the backdrop of other approaches to culturally based health communication, demonstrating points of similarity and points of departure among these approaches. This comparison will ultimately equip the reader with both theoretical and methodological tools to examine the multicultural nature of the different approaches to health communication and to apply these tools in healthcare settings.
In discussing the culture-centered approach, the book suggests that the nature of how and what we communicate about health is embedded in our taken-for-granted assumptions about what it means to be healthy, what it means to be ill, and how we approach disease and illness. In suggesting this, the culture-centered approach is set up in opposition to the dominant approach of health communication, which represents the status quo and uses psychological cognitive theories to predict health attitudes and behaviors. The dominant approach is located within the biomedical model, with its focus on constructs and variables lent by this model, and with an emphasis on promoting and studying beliefs, attitudes, and behaviors within its framework. In the widely circulated biomedical model of health communication, health is treated as a universal concept based on Eurocentric understandings of health, disease and its treatment. Within this model, the way we come to see health is intrinsically built upon a Eurocentric ideology that privileges certain assumptions about health and downplays other approaches. The culture-centered approach locates this Eurocentric ideology by underlying the major approaches to health communication, and offers a criticism of the universal appeal of the dominant approaches that are built upon the culturally-situated Eurocentric notions of health and illness. The criticism of the Eurocentric ideology in health communication is based upon (a) criticism of the biomedical model that offers the foundation to much of the existing health communication scholarship (we will see this in greater detail in chapter 5), and (b) criticism of the basic premises of the health communication theories and applications that are widely circulated in the literature on cognitive behavioral principles (we will engage with these criticisms in chapters 1, 2 and 3). This criticism, both of the biomedical ideology underlying health practices and of the cognitive behavioral basis of health communication theorizing, offers openings for engaging culture in health communication scholarship in ways which are meaningful to the experiences of cultural communities hitherto marginalized; it also creates openings for alternative ways of knowing.
Therefore, in this book, the culture-centered approach is introduced as an alternative lens for understanding health communication. This approach is value-centered and is built on the notion that the various ways of understanding and negotiating the meanings of health are embedded within cultural contexts and the values deeply connected with them. Thus knowledge is embedded within value systems. These systems often remain hidden from the language of universal rationality in health communication scholarship; the culture-centered approach draws our attention to them. This approach questions the very values which underlie the universal logic of the biomedical model and of the cognitive–behavioral model, bringing out the hidden agendas embedded in the top-down frameworks underlying health communication and providing a critical entry point for interrogating them. As it does this, its emphasis is on looking at the erasure of the voice of those communities which have traditionally been rendered silent through treatment as subjects of health communication interventions doled out by the experts. Alternatively, the culture-centered approach proposes to build health communication theories and practices from the vantage point of cultural members, foregrounding their voices in the articulation of problems, the prioritization of problems, and the development of health solutions. The emphasis therefore is on creating opportunities for dialogue that bring out meanings of health articulated through the voices of cultural communities otherwise marginalized and silenced.
Ultimately, the goal of this book is to lay out the foundations for discussing the culture-centered approach and to create openings for its discussion in health communication. Chapter 1 introduces the reader to the concept of culture in health communication and provides a historical overview of the ways in which culture has been incorporated in health communication theory, research, and application. It examines the history of culture in health communication, studies the different models of health communication in the context of culture, compares the different strands of culture-based health communication work, and explores the applications of culture in health communication. Chapter 2 builds on the Introduction to discuss further the culture-centered approach to health communication by locating it in the backdrop of the dominant approach to health communication scholarship. After laying out the foundations and characteristics of the dominant approach to health communication, it explains the basic tenets of the culture-centered approach, which is followed by a discussion of its various applications in health communication theory, research, and practice. Chapter 3 examines and compares the theoretical foundations of the different approaches to the study of culture.
Chapter 4 offers a culture-centered overview of the relationship between culture, identity, and health. It suggests that this relationship is a complex and dynamic, so that the identities of cultural members play important roles in constituting health experiences of cultural members. Chapter 5 locates health and illness experiences in the different realms of healing and curing, thus making the dominant biomedical framework of healthcare into a culturally situated model and comparing it with other approaches to health and healing.
In chapter 6 we will engage with the topic of cultural marginalization and study the ways in which cultures are marginalized in health communication discourse and practices. More specifically, we will focus on what it means to be marginalized and on the kind of material and discursive conditions which create positions at the margins. We will further build on the topic of marginalization in chapter 7, to look at the health experiences of specific marginalized sectors. We will conclude the chapter by discussing marginalization in postcolonial and subaltern contexts.
Chapter 8 connects the culture-centered approach in health communication to the realm of the community. The emphasis on social capital examines the community-building and community-sustaining aspects of health communication, and connects the practice of culture-centered health communication to the sphere of community-organizing. Building on the notion of community-organizing, chapter 9 studies the ways in which resistance is enacted in culturally situated communities, and chapter 10 examines health communication processes in the area of globalization. Finally, chapter 11 demonstrates the pragmatic applications that might develop from the culture-centered approach.
Throughout the book, the culture-centered approach is used as a sensitizing lens for looking at the concept of culture and at the ways health communication scholarship has responded to culture. This approach will offer the foundation and criteria for investigating the various conceptualizations of culture in health communication and the various applications of health communication which have emerged from these conceptualizations. The rest of the introduction will provide a brief overview of the culture-centered approach, walking you through its basic principles. The goal of doing it is to equip you with a basic understanding of the approach, which should be used in reading the subsequent chapters. We will return to the discussion of the culture-centered approach in greater depth in chapter 2.
Culture-Centered Approach to Health Communication
What is the culture-centered approach to health communication? What are the basic tenets of the culture-centered approach to health communication? What does it mean to engage in culture-centered health communication scholarship? What are the characteristics of culture-centered health communication applications? The culture-centered approach is an emerging approach to health communication which questions the constructions of culture in traditional health communication theories and applications, examines how the latter have systematically erased the cultural voices of marginalized communities in their constructions of health, and builds dialogical spaces for engaging with these voices (Dutta 2006, 2007; Dutta-Bergman 2004a, 2004b). With its emphasis on interrogating the erasures in health communication discourse and application, the culture-centered approach primarily focuses on understanding health meanings and experiences in marginalized settings.
Fig. I.1 The culture-centered approach to health communication
Fig. I.2 A meeting of peer educators in Africa. They educate young people about health issues, especially HIV and AIDS
© Giacomo Pirozzi @ Panos Pictures
As figure I.1 indicates, the culture-centered approach is built upon three key concepts and the interactions betweeen them: structure, culture, and agency). The intersection of structure, culture, and agency creates openings for listening to the voices of marginalized communities, constructing discursive spaces which interrogate the erasures in marginalized settings and offer opportunities for co-constructing the voices of those who have traditionally been silenced by engaging them in dialogue.
Structure
Structure, in this context, refers to those aspects of social organization that constrain and enable the capacity of cultural participants to seek out health choices and engage in health-related behaviors. Structures include elements such as medical services, transportation services, food, and shelter, which are essential to the healthcare of cultural members. Structure also refers to the ways the healthcare system is organized and its services are delivered, and to the organization of healthcare organizations. Structure is simultaneously constraining and enabling. On the one hand, it limits the opportunity for securing healthcare in marginalized contexts by determining the range of healthcare choices that are available or unavailable to cultural members; on the other hand, it creates opportunities for change by challenging the frameworks within which health is constructed. Structures are deeply connected with the material resources available to individuals and to the communities within which they live, and play out in the realm of the day-to-day healthcare choices in marginalized communities. Marginalized communities are those communities that have limited access to healthcare resources and to the various communication platforms which discuss healthcare policies and disseminate information on health. The emphasis on structure favors the orientation of the culture-centered approach toward the development of health communication theories and applications which are directed at marginalized healthcare settings (more on this in a later section). The role of structure in the realm of health communication is typically played out in the form of culturally situated health practices.
Box I.1 The story of Dr Maria Rodriguez
Dr Maria Rodriguez struggled with poverty as she grew up; her family barely had the money to make ends meet. Although Dr Rodriguez remembers a great deal of those days of struggle, she also has very fond memories of her trips to the church and of growing up in a closely knit family. As a second generation immigrant from Colombia, she also has vivid memories of her childhood and of the values that her grandmother taught her. She learned to respect her family and to recognize how important family is in one’s life. As a medical student and, later, as a family medicine practitioner, Dr Rodriguez had a difficult time in understanding all the rules in the hospital system that limited the access family members had to patients, to interactions with physicians and to information about patients. She struggled with this sense of deep-rooted individualism in the medical system, as it clashed with her sense of family and of its role in the medical experience.
How would you interpret Dr Rodriguez’s story from a culture-centered approach? What are the key elements of the culture-centered approach that play out in the narrative presented here? How do you suggest that culture, structure, and agency play out in Dr Rodriguez’s experience?
Culture
The concept of culture, as embodied in the culture-centered approach, refers to the local contexts within which health meanings are constituted and negotiated (more on the various meanings and interpretations of culture in chapter 3). The emphasis here is on looking at the constitutive and dynamic nature of culture. In other words, culture provides the communicative framework for health meanings such that the ways in which community members come to understand health and illness are embedded within cultural beliefs, values, and practices. These beliefs, values, and practices are also contextual, and health meanings become localized within these contexts. It is this contextual nature of health meanings that contributes to the dynamic nature of culture, suggesting that cultural meanings continually shift. Culture is constituted by the day-to-day practices of its members as they come to develop their interpretations of health and illness and to engage in these day-to-day practices. Furthermore, cultural meanings provide the locally situated scripts through which structures influence the health choices of cultural participants.
Agency
Agency refers to the capacity of cultural members to enact their choices and to participate actively in negotiating the structures within which they find themselves. In other words, the concept of agency reflects the active processes through which individuals, groups, and communities participate in a variety of actions which directly challenge the structures that constrain their lives, and, simultaneously, work with the structures in finding healthful options. From a health communication standpoint, agency taps into the ability of individuals and of their communities to be active participants in determining health agendas and in formulating solutions to a variety of health problems, as these are perceived by the community. The emphasis, therefore, shifts to the community as an entry point for the articulation of knowledge. Participatory spaces are created and sustained that allow health communicators the opportunity to engage with the agency of cultural participants.
Interactions between structure, culture, and agency
The three concepts of structure, culture, and agency are intertwined. Structures within social systems are played out through the culturally situated contexts in communities. In other words, structural features gain meaning through the contexts of the local culture, thus creating a site for the articulation and sharing of meanings. Structural constraints become meaningful through the lived experiences of cultural members and through the sharing of these lived experiences. For instance, the structures that limit healthcare access in inner city United States are made meaningful through the culturally situated stories of residents in the inner cities as they discuss their daily lives and the struggles embodied in them (Abraham 1993). Simultaneously, culture offers the substratum for structure, such that structures are both reified and challenged through the cultural meaning systems that are in circulation within the culture. It is through the articulation of new meanings that cultures create points of social change. For instance, it is when cultural members in a marginalized context start sharing their stories of deprivation that greater awareness is created and opportunities are introduced for changes in the healthcare infrastructures (Wang and Burris 1994).
Agency is enacted in the lives of individuals and communities as they struggle with the structural constraints they face. Given the emphasis of the culture-centered approach on marginalized settings, much of the discussion of the approach relates to the lack of basic resources and economic capacities in these contexts. Agency offers an opportunity to situate the lives of marginalized individuals, groups and communities in the realm of their active engagement in living with, and challenging, the structures that constrain their lives. In other words, agency becomes meaningful in its relationship with the structures within which healthcare experiences are embedded. Members of marginalized communities continually interact with the structures within which they live, simultaneously working within these structures and participating in avenues that seek to change them. Ultimately, agency offers the opportunity for social change by challenging the structures that limit the healthcare capacities in marginalized communities.
It is in the realm of culturally situated meanings and actions that individuals enact their agency. In other words, culture provides the conduit through which agency is realized. The language for engaging in the discourses of health and the meanings of health that become possible are constituted in the domain of culture. It is through the culturally situated symbols that individuals communicate with each other, interact with the social structures, and come to organize collectively to address the structures. The interactions that individuals have with social structures are made meaningful through the lens of culture; therefore it is through the symbols that circulate in the culture that individuals enact their agency. Similarly, the ways in which individuals go about their daily practices of health are rendered meaningful through the symbols that circulate in the culture. Agency also offers an opportunity for changing culturally situated meanings as it is through their uses of discourse that individuals, groups and communities challenge the dominant cultural meanings and create new openings. Now that we have discussed the culture-centered approach and its basic configuration, the next section will discuss its roots, together with some of the concepts which are central to the ways we discuss and use it in health communication.
Roots of Culture-Centered Health Communication
The culture-centered approach draws much of its theoretical, methodological and application-based focus from critical theory, cultural studies, postcolonial theory and subaltern studies (see Dutta-Bergman 2004a, 2004b; Dutta 2007; Lupton 1994). Therefore the questions asked by the culture-centered approach, and the key concepts that inform it, draw from these disciplinary roots of the approach, which are represented by the four areas of study.
Critical theory
The culture-centered approach to health communication draws much of its impetus from critical theory. With its emphasis on questioning the ways in which knowledge gets articulated and talked about, the culture-centered approach locates knowledge in the realm of the concepts of power and control. It argues that the content of knowledge claims are embedded within the practices of powerful actors in social systems that have access to the spaces of knowledge. In this sense, knowledge is situated in the realm of the interests of powerful social actors, and the focus of critical theory is on examining how knowledge is used so as to ensure the control held by these dominant social actors.
Furthermore, drawing upon Marxist theory, critical theorists study the role of social structures in constraining the life experiences of the underprivileged classes. The critical lens focuses on studying the relationship between fundamental economic resources and the distribution of power within social systems. From this standpoint, knowledge is seen as a tool which is used for the purposes of controlling and managing the underprivileged social classes so that they may continue to supply the labor for capitalist economies, which in turn, serves as the basis for the profit secured by the owners of the capital.
The contents of knowledge claims are tied to the ways in which knowledge claims are made and to the positions of power from which they are made. Therefore the culture-centered approach locates knowledge as the subject of inquiry. As a first point of entry into talking about health communication, it looks at the ways in which knowledge claims are intrinsically tied to the positions from which they are made. To this extent, the culture-centered approach investigates the claims made in dominant health communication approaches and the ways in which these claims serve those in positions of power, thus primarily starting as a deconstructive exercise.
In addition to engaging with the concept of power, the culture-centered approach also draws upon the two concepts of ideology and hegemony in critical theory. Ideology reflects the taken-for-granted assumptions that help maintain the power structures; and hegemony refers to the ways in which the dominant actors retain their status of dominance without having to use coercive measures. In health communication, ideology and hegemony are intrinsic to the control exerted by the dominant social actors on the positions at the margins. The ideology of individual lifestyles, for instance, locates individual behaviors at the root of health problems without attending to the surrounding social and structural features of the environment that constrain the possibilities of health (Lupton 1994). Health campaigns are funded and implemented to curb the smoking habits of individuals, but they do not touch on the problem of regulating the tobacco industry and the marketing strategies used by it. Furthermore, transnational capital maintains its dominant status through hegemonic processes that ensure that global policies supporting the free market economy are supported, simultaneously sustaining conditions of poverty and inaccess to resources, which are often fostered by these unhealthy global policies (Kim, Millen, Irwin and Gershman 2000).
Drawing from critical theory, culture-centered health communication scholarship is engaged with questions of power, ideology, hegemony and control in the discourses and practices of healthcare (Dutta-Bergman 2004a, 2004b). It examines such discourses in terms of their maintaining the control of powerful social actors. From a critical standpoint, the goal of the culture-centered approach is to look at the dominant values in healthcare systems – values which underlie the ways in which these systems maintain the control of the powerful actors. Through the exploration of ideology and hegemony, attention is drawn to the health communication processes that maintain the privileges of the powerful social actors in healthcare systems and simultaneously exploit the poor, the working classes, women, racial minorities, and communities from the global South. The emphasis of the culture-centered approach on the concepts of ideology and hegemony are further complemented by the emphasis of cultural studies on the social constructions of knowledge and practices.
Cultural studies
Building on the questions of ideology and hegemony presented in critical theory, the domain of cultural studies is interested in how knowledge is socially constructed by powerful social actors. Aligned with the goals of critical theory, it keeps the focus still on power structures and the modes of their being maintained through the social constructions of discourse. A cultural studies approach to communicative practices locates these practices within the realm of power and studies how meanings are created and circulated in order to serve the interests of powerful social actors. That meanings are situated in the realm of cultural contexts drives much of the scholarship in cultural studies.
The culture-centered approach draws from cultural studies scholarship, with its emphasis on the social constructions of discourse and on the culturally situated nature of health narratives. On the one hand, this type of approach studies the social construction of meanings played out through the ideological devices employed by the dominant actors within social systems; on the other hand, it studies culturally situated health meanings and discursively explores the way these meanings are socially constructed by the local actors. For instance, a cultural-studies examination of the stigma of living with HIV/AIDS builds on the social construction of stigma and the ways in which meanings of stigma get attached to HIV/AIDS (Farmer 1999). The emphasis therefore is on agency and on the constitution of agency through the participants of the culture.
Postcolonial theory
Drawing from Said’s influential work on Orientalism, postcolonial scholars are interested in interrogating the colonial agendas of knowledge structures. In other words, postcolonial scholarship explores how the dominant knowledge configurations serve colonial interests. From a health communication standpoint, a postcolonial approach interrogates the dominant health discourses that circulate globally. The interest here is to explore the dichotomies of the First and Third World, the North and the South, the West and the rest; and to see how these dichotomies play out in selecting who gets to decide the health agendas, who participates in the communicative processes leading up to it, and who gets to configure the communicative strategies for healthcare interventions. Simultaneously, based on a postcolonial lens, the culture-centered approach explores the communicative strategies through which points of dominance are created through the dichotomous categories of “primitive” and “modern” within the healthcare system. Questioning the values underlying this dichotomy exposes the political economy of health communication interventions that seek to maintain the dominant status of the North through the presentation of discourse which privileges it and locates the South in terms of absences tied to its so-called primitiveness, thus necessitating interventions carried out by the North. The categorization of the South/Third/Underdeveloped as “primitive” helps to maintain the privilege of the North/First/Developed world by creating and fostering conditions of dependence and need (Dutta-Bergman 2004a, 2004b; Dutta and Basnyat, in press; Escobar 1995).
Subaltern studies
As a discipline of inquiry, subaltern studies is interested in interrogating the erasures in the dominant configurations of knowledge (Beverly 2004; Guha 1988). Originally emerging from the ranks of historians, subaltern scholars were interested in what is absent from the mainstream articulations of history. With an emphasis on writing history from below, they asked how the writing of history and its products served the interests of the colonial powers and national elites. In doing so, they turned the lens on the dominant epistemic structures and questioned the underlying privileges of the elite that are maintained by these structures.
Questioning the absences in mainstream discourse offers opportunities for understanding how discourses are created, re-created, and circulated within social systems. The examination of the privileges and values of the dominant social actors, which are reflected in the ways knowledge is constituted, plays a critical role in defining the terrain for subaltern scholarship. The erasures also provide entry points for rewriting the narratives of knowledge through engagement with the voices of subaltern communities. Dialogues with subaltern communities offer opportunities for further co-constructing the discourses of knowledge through the voices of subaltern communities presented in the co-constructive process. It is worth noting that subaltern scholars seek neither to represent the subaltern nor to become absent from the discursive spaces. Rather, they present themselves as co-participants, reflexively aware of the privilege they embody in the discursive process. It is through the ownership of the privilege that subaltern scholarship enters into a relationship of solidarity with subaltern participants.
With its roots in subaltern scholarship, the culture-centered approach continually asks how dominant discourses of health communication erase the voices of certain groups and communities and create the conditions of subalternity (Dutta 2007; Dutta-Bergman, 2004a, 2004b). It focuses on examining the taken-for-granted assumptions in the dominant theories of health communication and their persistence in undermining the agency of cultural participants. The culture-centered approach claims that the undermining of the agency of subaltern groups is quintessential to the erasures of these groups from the dominant epistemic structures. Knowledge here is intrinsically connected to praxis, as the applications of health communication that are developed in mainstream social systems continue to erase the voices of subaltern communities by consistently categorizing them as the subjects of healthcare interventions. In this sense, the marginalized community or culture is located in a fixed category, imbued with “undesirable” characteristics, and interventions are developed to change the “undesirable” characteristics of the subaltern groups. By interrogating the absences of subaltern voices in healthcare policies, programs and evaluation strategies, the culture-centered approach creates discursive openings for co-constructing narratives of health through dialogue with subaltern communities. It proposes to bring about changes in healthcare policies and the way these policies are presented and represented through the voices of the subaltern participants engaged in dialogue with the culture-centered scholar. In the next section we will study the basic characteristics of the culture-centered approach.
Characteristics of the Culture-Centered Approach
Some of the key concepts that run through the culture-centered approach are the concepts of: (a) “power,” “ideology,” “hegemony,” and “control,” which demonstrate how health communication theories and research projects and applications serve the interests of the dominant social actors; (b) “marginalization,” which reflects upon how conditions of subjugation are created and supported by the dominant practices of health communication; (c) “contexts” within which health experiences are realized and enacted; (d) the “stories” shared by cultural members about their health experiences, as being constituted in the realm of the structures as well as being about the possibilities of challenging these structures, within which health is constituted; and (e) “resistance,” which reflects the ability of individuals, groups, and communities to challenge the dominant structures within which health is constituted, and offers opportunities for creating new discursive and material possibilities.
Power
As discussed earlier, power consists in the social, cultural and communicative practices through which the dominant social actors maintain their control over the social system. Power is deeply connected with the economic necessities of the dominant social actors. Furthermore, access to power is determined by economic access, such that owners of capital have greater power over those who provide the labor to the capitalist system. In order to maintain their power, dominant social actors employ ideological devices which create discursive spaces supportive of the control they hold. As discussed earlier in this chapter, the ability to maintain control over a social system without the use of coercive strategies is referred to as hegemony. The culture-centered approach is concerned with the way the ideology of healthcare serves the positions of power within social systems. It is also in the realm of power that conditions of marginalization are created and sustained.
Marginalization
Marginalization reflects an array of practices through which the social structures limit the resources and opportunities for participation in certain communities and cultures. Therefore, marginalized communities have minimal access to basic healthcare resources and to the mainstream communication platforms on which they could articulate their questions and concerns. Culture-centered theorists point out that mainstream health communication programs create conditions of marginalization by supporting the agendas of the powerful social actors and by simultaneously ignoring the health needs of subaltern communities (Dutta-Bergman 2004a, 2004b, 2005a, 2005b; Dutta and Basu 2007; Dutta and Basnyat, in press). Much of the emphasis of the culture-centered, approach is on studying the intersections between structure, culture, and agency in the realm of the experiences of these marginalized communities.
Context
Context refers to the locally situated nature of healthcare experiences, and is articulated through “thick” descriptions of the lived experiences of cultural members. Context taps into the dynamics and continuously contested nature of health communication such that health experiences become meaningful only when located in the perimeters of local context. Healthcare discourses and practices are continuously rendered meaningful through their engagement of the local contexts within which they become possible. The culture-centered approach engages with the local context through dialogues with the community members, thus bringing out opportunities for listening to the voices of marginalized communities (Dutta-Bergman 2004a, 2004b; Dutta and Basu 2007).
Stories
It is though stories that healthcare scripts are circulated. Stories are built upon shared cultural meanings and offer insights into the ways in which the culture constitutes its meanings of health, approaches health and illness, and engages in healthcare practices. Cultures pass on certain health meanings through a community of participants, and the culturally situated stories provide points of meaning-making to cultural participants (Airhihenbuwa 1995). It is within these communities that stories offer lessons about health, what it means to be healthy, what it means to be ill, and what actions to take in response to illness. It is also through stories that new meanings of health are articulated and change is brought about through the introduction of new possibilities into the discursive space. The culture-centered approach permanently draws our attention to the stories through which culture continues and yet transforms.
Resistance
Resistance reflects an array of communicative practices through which the dominant structures are challenged. In the area of healthcare, marginalized communities resist dominant structures in various ways, which range from the micro-practices of resistance to the macro-practices of resistance. Micro-practices of resistance include practices such as refusal to take medications prescribed by doctors, refusal to get a child immunized, or refusal to take certain preventive measures as prescribed by the dominant paradigm. Macro-practices of resistance include transformative acts which seek to change the social system. Examples include hunger strikes designed to oppose unhealthy global policies, participation in protest marches to discuss the lack of doctors with policy-makers, gheraous at the local hospital etc. (Dutta-Bergman 2004b; Dutta and Basu 2007; Dutta and Pal, in press).
Conclusion
In conclusion, the culture-centered approach offers an avenue for opening up the dominant framework of health communication to communities and contexts that have so far been ignored, rendered silent and been treated simply as subjects of health communication interventions. By examining how we communicate in our traditional health interventions and the linkages between these interventions and the dominant value systems, the approach offers us opportunities to question the inherent biases in our modes of thinking about health and of going about promoting it in communities. In the realm of the media, the culture-centered approach specifically examines the distribution of media structures in subaltern contexts and how the mainstream media marginalize the voices of certain cultures and communities. Furthermore, by engaging in questions of agency, the culture-centered approach creates openings for the voices of those communities that have traditionally been silenced by mainstream media platforms. These points of engagement with subaltern contexts create opportunities for social change in the healthcare system. The culture-centered approach, therefore, is mainly concerned with the possibilities of social change through communication.
In the realm of interpersonal relationships in healthcare, the culture-centered approach offers us opportunities for examining physician–patient relationships and for conceptualizing ways in which such relationships might be informed by notions of culture. It also expands the nature of relationships in healthcare settings by looking at alternative ways of healing and curing. In the area of healthcare organizations, the culture-centered approach creates avenues for looking at how mainstream health organizations marginalize the health experiences of subaltern communities. Furthermore, healthcare organizing challenges the status quo through its emphasis on processes of organizing subaltern communities. It does this with the goal of changing unhealthy social and economic structures which constrain the healthcare experiences of subaltern communities. In mass media contexts, the culture-centered approach deconstructs the dominant mass mediated campaigns targeted at changing target behaviors. It also interrogates the role of global mass media in promoting the ideology of biomedicine.
Throughout the book, we will explore the various ways in which culture informs our manners of talking about health, the health messages we develop, and the healthcare applications we engage in on a daily basis. We will explore the issue of how healthcare identities and relationships are culturally situated; the different cultural approaches to health, illness, and healing; the various ways in which local communities are marginalized in their healthcare experiences; and the possibilities, brought about by the culture-centered approach, for challenging the unhealthy structures surrounding the health of marginalized communities. Ultimately, the goal of the culture-centered approach is to suggest points for a structural transformation which should open up new possibilities for equitable and accessible healthcare. To this end, the book concludes with suggestions for a praxis in health communication based on the culture-centered approach.
Points for reflection
What are the goals of the culture-centered approach? How do these goals inform the ways in which we practice health communication?
Consider the health experiences of Sarah, a 41-year-old single woman with three children living in rural Ohio. Sarah was recently fired from her part-time job, and currently does not have health insurance cover for her medical expenses. Which aspects of the culture-centered approach help you to understand Sarah’s health experiences? How?
You have recently been hired as an outreach worker for a health services clinic promoting condom usage among Hispanic migrant farm workers in Kinnesaw, Kansas. In one of your assigned readings for a class in college on culture and health, you came across the concept of the culture-centered approach. Discuss the ways in which you would incorporate the approach in your work.
What is marginalization? In the context of healthcare, what factors in social systems contribute to marginalization? How? Please discuss in detail the ways in which dominant health communication approaches create conditions at the margins.
What are the ways in which marginalized communities enact their agency? Please discuss.
1Culture in Health Communication
Chapter objectives
In this chapter, we will:
examine the history of culture in health communication
study the different models of health communication
compare the different strands of culture-based health communication work
How did culture emerge as a concept in health communication, and how does culture get used in health communication theories and applications? In our discussions in this chapter, after reviewing the major health communication theories, we will connect our discussion of these theories to the dominant and culture-centered approaches to health communication. As articulated in the introduction, closely aligned with the biomedical model, the dominant approach focuses on utilizing cultural variables to develop more effective health communication solutions (more on this in chapter 2); and the culture-centered approach is a critique of the dominant approach that focuses on the erasure of cultural voices in dominant discourses and seeks to engage with these voices as entry points for dialogue. Locating the current scholarship on culture-based health communication in the realm of its historical roots will offer the foundation for discussing the culture-centered approach to health communication in chapters 2 and 3. Throughout the present chapter, the discussion of the different approaches to health communication will draw upon the critical and cultural underpinnings of the culture-centered approach outlined in the Introduction.
Box 1.1 The story of Suzanne
Suzanne has recently graduated with a PhD in Health Communication from a prestigious US university, and has received a tenure-track position as an assistant professor at a research university. Although she has never really traveled much to other parts of the world, she is very interested in issues of global health. The topic of global health has a great deal of funding potential and Suzanne thinks this would be a great opportunity for her to set up a program of research. She expresses this interest to her Department head and is assigned to teach a course on “Gender, Development, and Health." She has quite a few women who she thinks come from somewhere in the Middle East (she does not know where from exactly . . . both of these students are actually from Pakistan) and feels uncomfortable having them in class because they wear burquas. Being a feminist, she feels that women should not have to cover their heads, and especially not in the US. She is further aggravated by the Middle Eastern women after her Head of Department calls her to his office letting her know that there has been a complaint lodged against her for being culturally insensitive in her classroom by talking about the “primitive cultures” of the Muslim world when she addressed the topic of honor killings in her lecture day on “Gender and Health.” She is quite confident that those women are the ones who probably complained. This infuriates her as she feels that the climate of political correctness in the academy has gone too far - one can’t even address “primitive cultures” and call them for what they are. She further feels that one can’t even discuss the real health problems in the Third World. After all, she only wants to help these women and others like them, who are oppressed by their men. Based on your reading of culture in health communication, how would you interpret Suzanne’s attitude toward her Pakistani students? What do we learn about Suzanne from this encounter? What do we learn about the values of Suzanne and what are the similarities and differences between these values and the values of dominant health communication projects that use the concept of culture?
