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Perception of health : a phenomenological study of the meaning of health to Indo-Canadians Thompson, Robyn D. 1989

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PERCEPTION OF HEALTH: ft PHENOMENOLOGICAL STUDY OF THE, MEANING TO INDO-CANADIANS OF HEALTH BY ROBYN D. THOMPSON B.Sc. (Biology), University of Vi c t o r i a , 1976 B.S.N., University of B r i t i s h Columbia, 1982 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in FACULTY OF GRADUATE STUDIES The School of Nursing We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH November 1989 (c) Robyn D. Thompson, COLUMBIA 1989 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada Date DE-6 (2/88) i i ABSTRACT PERCEPTION OF HEALTH: THE MEANING OF HEALTH TO INDO-CANADIANS Th i s study was designed to i n v e s t i g a t e the meaning of h e a l t h to Indo-Canadians. Given the i n c r e a s i n g l y m u l t i c u l t u r a l nature of Canadian s o c i e t y and the n u r s i n g p r o f e s s i o n ' s growing r e c o g n i t i o n of the importance of c r o s s - c u l t u r a l knowledge, t h i s area of i n v e s t i g a t i o n i s both t i m e l y and r e l e v a n t . The explanatory model of Arthur Kleinman (1978a,b, 1980, 1984) was the framework which guided the r e s e a r c h e r to adopt the phenomenological method to conduct t h i s q u a l i t a t i v e study. The phenomenological method i s h i g h l y s u i t a b l e f o r enquiry i n t o the pe r c e p t i o n and e x p l a n a t i o n of the h e a l t h phenomenon. A p i l o t study conducted p r i o r to the a c t u a l r e s e a r c h a s s i s t e d the f o r m u l a t i o n of s u i t a b l e q u e s t i o n s to e l i c i t in-depth d e s c r i p t i o n of the h e a l t h phenomenon from i n d i v i d u a l s of t h i s c u l t u r a l group. S e m i - s t r u c t u r e d i n t e r v i e w s were conducted with eight p a r t i c i p a n t s contacted through an informal network of c o l l e a g u e s and acquaintances. T h e o r e t i c a l sampling techniques determined the f i n a l sample s i z e . P a r t i c i p a n t s were f i r s t g e n e r a t i o n Indo-Canadians of the Hindu f a i t h between the ages of 28 and 56, who had r e s i d e d i n Canada f o r 6 1/2 to 21 years at the time of the study. Most p a r t i c i p a n t s were i n t h e i r mid-40's and had l i v e d i n Canada f o r about 12 years. Data c o l l e c t e d from a t o t a l of 15 i n t e r v i e w s with the 8 p a r t i c i p a n t s were analyzed a c c o r d i n g to the technique of constant comparative a n a l y s i s . Common themes and c a t a g o r i e s a r i s i n g from the data formed a f i n a l a n a l y t i c framework which organized the p r e s e n t a t i o n of r e s e a r c h data, and represented the e s s e n t i a l meaning of h e a l t h f o r the Indo-Canadians who p a r t i c i p a t e d in t h i s st udy. Although the r e s e a r c h e r ' s o r i g i n a l i n t e n t was to i n v e s t i g a t e the i n f l u e n c e which c u l t u r e e x e r t s on p e r c e p t i o n of h e a l t h , socio-economic circumstance and e d u c a t i o n a l background were important f a c t o r s i n the c o n s t r u c t i o n of p a r t i c i p a n t ' s h e a l t h accounts. D e f i n i t i o n of h e a l t h emerged as a c o n s t r u c t which i s s t r u c t u r e d by c u l t u r e , and i n t i m a t e l y r e l a t e d to s o c i a l m i l i e u . P a r t i c i p a n t s d e s c r i b e d h e a l t h as a m u l t i d i m e n s i o n a l , h o l i s t i c phenomenon where the body and mind are i n s e p a r a b l e . Health was c o n c e p t u a l i z e d p r i m a r i l y as "doing normal a c t i v i t i e s " . The mind was d e s c r i b e d as the most important f a c t o r i n f l u e n c i n g h e a l t h . The f i n d i n g s of t h i s study have important i m p l i c a t i o n s f o r the n u r s i n g p r o f e s s i o n . In terms of n u r s i n g p r a c t i c e , the f i n d i n g s support i n c r e a s i n g use of c r o s s - c u l t u r a l theory to guide n u r s i n g p r a c t i c e . For c u l t u r a l l y r e l e v a n t n u r s i n g care to become a r e a l i t y , i t i s c r u c i a l that nurses rec o g n i z e h e a l t h as a c o n s t r u c t d e f i n e d d i f f e r e n t l y w i t h i n d i f f e r e n t s o c i o - c u 1 t u r a l c o n t e x t s . T h i s r e s e a r c h supports c u r r e n t moves to i n c o r p o r a t e c r o s s - c u l t u r a l theory i n t o undergraduate and graduate n u r s i n g c u r r i c u l a . F i n a l l y , in terms of n u r s i n g research, the f i n d i n g s of t h i s study advocate on-going i n v e s t i g a t i o n of the explanatory i v models of h e a l t h and s i c k n e s s held by the Indo-Canadian community and other c u l t u r a l groups making up the Canadian mosaic. Table of Contents A b s t r a c t i i Table of Contents . v L i s t of F i g u r e s ix Acknowledgements x CHAPTER 1: INTRODUCTION 1 Background to the Problem . 1 T r a n s c u l t u r a l S t u d i e s 3 The S i g n i f i c a n c e of S t u d i e s on Indo-Canadians 5 L i t e r a t u r e and Research on Indo-Canadians: a S c a r c i t y 6 Lack of L i t e r a t u r e on the Hindu Community 7 C o n c e p t u a l i z a t i o n of the Problem 7 Use of Kleinman's Framework w i t h i n The D i s c i p l i n e of Nursing 11 Problem Statement 12 S i g n i f i c a n c e of the Study 12 S c i e n t i f i c S i g n i f i c a n c e 12 P r a c t i c a l S i g n i f i c a n c e 13 Purpose of the Study 14 Research Question 14 T h e o r e t i c a l and Methodological P e r s p e c t i v e s of the Study 15 I n t r o d u c t i o n to the Methodology 15 D e f i n i t i o n of Terms 18 T h e o r e t i c a l D e f i n i t i o n 18 O p e r a t i o n a l D e f i n i t i o n 18 Assumptions . . 18 L i m i t a t i o n s 19 Summary 19 CHAPTER 2: REVIEW OF SELECTED LITERATURE 21 L i t e r a t u r e on Health and I l l n e s s 22 T h e o r e t i c a l P e r s p e c t i v e s on Health 24 D e r i v a t i o n of the Word "Health" 24 P e r s p e c t i v e s found in Sociology, Philosophy and Theology 25 T r a d i t i o n a l Biomedical P e r s p e c t i v e s ... 27 S o c i o - C u l t u r a l P e r s p e c t i v e s w i t h i n the Health Care D i s c i p l i n e s 28 v i C r o s s - c u l t u r a l nursing views 29 Health and I l l n e s s : T r a d i t i o n a l B e l i e f s h e l d i n India 33 L i t e r a t u r e on I n d i v i d u a l s from India ^ 35 Indo-Canadians 36 Summary 38 CHAPTER 3: METHODOLOGY 41 S e l e c t i o n of P a r t i c i p a n t s 41 T h e o r e t i c a l Sampling 41 C r i t e r i a f o r S e l e c t i o n 43 Ra t i o n a l e f o r C r i t e r i a 43 S e l e c t i o n Procedure 44 The P i l o t Study 46 P i l o t Study: Re s u l t s 47 C h a r a c t e r i s t i c s of the Sample . 47 Data C o l l e c t i o n 49 Data C o l l e c t i o n : The Procedure 50 D e t a i l s of the Interviews and C o n s t r u c t i o n of Accounts 51 F i e l d Notes 52 P r o t e c t i o n of Human Rights 52 Informed Consent 52 C o n f i d e n t i a l i t y 53 Data A n a l y s i s 53 R e l i a b i l i t y and V a l i d i t y of Data 56 Summary 57 CHAPTER 4: PERCEPTION OF HEALTH: THE MEANING OF HEALTH TO INDO-CANADIANS 58 H e a l t h : The Most Important Thing in L i f e 62 Doing Normal A c t i v i t i e s 63 What Normal A c t i v i t i e s are 64 The Three Phases of the Health Experience: Complete Health - P a r t i a l Health - Sickness 68 Complete Health 71 Body and Mind Together: The T o t a l Unit i n Balance and Harmony 72 Doing Happily, Doing Well 75 Doing h a p p i l y 75 Doing well 76 Energy and r e s i s t a n c e 78 Independence and c o n t r o l 81 P a r t i a l Health 88 Can do with E f f o r t , But not Well . 90 Decreased energy and r e s i s t a n c e ... 91 v i i D e c r e a s e d i n d e p e n d e n c e and c o n t r o l 93 Temporary and Bothersome 96 S i c k n e s s 99 Cannot do, Cannot f u l f i l l R e s p o n s i b i l i t i e s 101 Low e n e r g y and r e s i s t a n c e 103 Dependency and l a c k o f c o n t r o l .... 106 Permanent, S e r i o u s and Worrisome 108 R e t u r n t o H e a l t h , o r C h r o n i c D i s e a s e and Death 112 I n f l u e n c e s on t h e S t a t e o f H e a l t h 114 The M i n d : Body-Mind I n t e r a c t i o n 114 Worry 116 P o s i t i v e M e n t a l A t t i t u d e 120 E x t e r n a l F a c t o r s 128 D i e t and E x e r c i s e 129 D i e t 129 E x e r c i s e 134 S l e e p and C l e a n l i n e s s 135 Use o f M e d i c i n e s 136 M a i n t a i n i n g R o u t i n e 137 Summary 139 CHAPTER 5: DISCUSSION OF THE FINDINGS 142 The E x p l a n a t o r y Model Framework 143 D o i n g Normal A c t i v i t i e s : N o r m alcy and H e a l t h 144 The S o c i o - C u l t u r a l C o n s t r u c t i o n o f Normal A c t i v i t i e s 144 F a m i l y , D u t i e s and R e s p o n s i b i l i t i e s i n I n d o - C a n a d i a n S o c i e t y 145 The S o c i o - C u l t u r a l C o n s t r u c t i o n o f N o r m a l i t y and N o r m a l i z a t i o n i n H e a l t h 148 N o r m a l i z a t i o n 153 C o n c e p t u a l i z a t i o n s o f H e a l t h 156 The H e a l t h - S i c k n e s s Continuum 156 I n d o - C a n a d i a n and O t h e r E t h n i c C a n a d i a n P e r s p e c t i v e s 159 F o u r C o n c e p t i o n s o f H e a l t h 161 H o l i s m : Body and Mind T o g e t h e r 166 F a c t o r s I n f l u e n c i n g H e a l t h 167 The Mind and H e a l t h 168 Mind, t h e Immune System and R e s i s t a n c e .. 168 P o s i t i v e M e n t a l A t t i t u d e 170 F a m i l y : a m o d e r a t o r o f l i f e s t r e s s 171 O t h e r F a c t o r s A f f e c t i n g H e a l t h 172 M a i n t e n a n c e o f R o u t i n e 174 D i e t and E x e r c i s e 175 v i i i Use of Medicines 177 Summary 179 CHAPTER 6: SUMMARY, CONCLUSIONS AND IMPLICATIONS OF THE STUDY 182 Summary and Co n c l u s i o n s of the Study 182 Summary 182 Conc l u s i o n s 188 I m p l i c a t i o n s of the Study 189 Im p l i c a t i o n s f o r Nursing P r a c t i c e 189 Im p l i c a t i o n s f o r Nursing Education 191 Im p l i c a t i o n s f o r Nursing Research 192 B i b l i o g r a p h y ... 195 Appendices 210 Appendix A - Information r e g a r d i n g the Study and Consent to Contact Form 211 Appendix B - Consent Form 213 Appendix C - I n i t i a l T r i g g e r Questions 214 Appendix D - F i n a l T r i g g e r Questions 215 Appendix E - C e r t i f i c a t e of Approval f o r the Study ... 216 Appendix F - Health Images in c l u d e d in the Health D e s c r i p t i o n s of P a r t i c i p a n t s in t h i s Study (Adapted a f t e r Woods and Coworkers, 1988) ....... 217 L i s t of F i g u r e s i x F i g u r e 1. The Explanatory Model. Kleinman's c o n c e p t u a l i z a t i o n of the h e a l t h care system 8 F i g u r e 2. Components of the Framework 60 F i g u r e 3. Schematic D e s c r i p t i o n of the Framework 61 from the P a r t i c i p a n t s ' P e r s p e c t i v e F i g u r e 4: The Four F a c t o r s i n each Phase of the Health Experience 78 X Acknowledgements I am indebted to my t h e s i s committee, Dr. Joan Anderson (chairperson) and P r o f e s s o r Donelda E l l i s , f o r t h e i r on-going support and i n v a l u a b l e guidance dur i n g the conduct of t h i s r e s e a r c h and p r e p a r a t i o n of the t h e s i s . I thank them both f o r so generously o f f e r i n g t h e i r e x p e r t i s e and knowledge, and i n i t i a t i n g me i n t o the joys and depths of phenomenology. S p e c i a l acknowledgement goes to Dr. Joan Anderson f o r i n s p i r i n g me with her undying enthusiasm and commitment to q u a l i t a t i v e r e s e a r c h . I am deeply g r a t e f u l to my dear and l o v i n g parents, f a m i l y and f r i e n d s f o r t h e i r f a i t h i n me, and the c o n s i s t e n t encouragement they gave me durin g the p r e p a r a t i o n of t h i s work. A f f e c t i o n a t e mention goes to G. and G. - f o r a l l the smiles and hugs when I needed them most, and f o r h e l p i n g me l e a r n about computers. The eight study p a r t i c i p a n t s deserve p a r t i c u l a r thanks. Welcoming me i n t o t h e i r homes, they generously gave many hours of t h e i r time. By sharing t h e i r unique p e r s p e c t i v e s on the h e a l t h experience they made t h i s study p o s s i b l e . My thanks a l s o extend to a l l those who helped by e n l i s t i n g study p a r t i c i p a n t s . F i n a l l y , I am s i n c e r e l y g r a t e f u l to H.H.S.C., the one without whom t h i s work would not have been s u c c e s s f u l l y completed - f o r h i s b l e s s i n g s and love which s u s t a i n e d me throughout the months of w r i t i n g . T h i s work i s de d i c a t e d to him. 1 CHAPTER 1: INTRODUCTION Background to the Problem Canada today i s an e t h n i c a l l y d i v e r s e " c u l t u r a l mosaic" with c u l t u r a l groups maintaining t h e i r d i s t i n c t i d e n t i t i e s and remaining as d i s t i n c t u n i t s w i t h i n the s o c i a l framework (Palmer, 1975, p. 2). Asian immigrants c o n s t i t u t e a s i g n i f i c a n t p o r t i o n of the country's growing p o p u l a t i o n . Each year more Asians a r r i v e in Canada from v a r i o u s c o u n t r i e s . Since 1970, Asian immigrants have made up 32% of the t o t a l immigrant p o p u l a t i o n (Canada Year Book, 1985; Current Demographic A n a l y s i s , 1983). I n d i v i d u a l s from the Indian c o n t i n e n t c o n t r i b u t e markedly to t h i s Asian immigrant flow. Between the years 1976 and 1981, the number of persons in Canada who r e p o r t e d Indo-Pakistani languages as t h e i r mother tongue doubled. In 1981, 16.1% of the Canadian p o p u l a t i o n r e p o r t e d having been born outside of Canada and 7.6% of the p o p u l a t i o n r e p o r t e d c u l t u r a l h e r i t a g e stemming from more than one e t h n i c group (Canada Year Book, 1985; Current Demographic A n a l y s i s , 1983). In 1986, approximately 4 m i l l i o n Canadians r e p o r t e d having been born o u t s i d e of Canada. Of t h i s group, 3.354 re p o r t e d having come from India, and 14% r e p o r t e d having come from A s i a in g e n e r a l . For the same year, 2.9 m i l l i o n persons, or 11% of the t o t a l Canadian po p u l a t i o n , r e p o r t e d having a mother tongue other than E n g l i s h or French; 634,000 persons in t h i s group i n d i c a t e d a mother tongue of Asian or Middle E a s t e r n o r i g i n (Canada Year Book, 1988; P r o f i l e of E t h n i c Groups, S t a t i s t i c s Canada, 1988). 2 It i s p r e d i c t e d that there w i l l be an increase in the immigration r a t e to 150,000 annua l l y by the year 1994 (Canada Year Book, 1985). Immigration thus appears to be a f a c t o r which w i l l exert s i g n i f i c a n t i n f l u e n c e i n shaping Canadian s o c i e t y in the f u t u r e . The r e a l i t y of ongoing and i n c r e a s i n g immigration in the years ahead a f f e c t s Canada's h e a l t h s e r v i c e s as well as the p o p u l a t i o n composition (Splane, 1984). In order to e f f e c t i v e l y meet the needs of the p o p u l a t i o n , the Canadian h e a l t h care system i s c h a l l e n g e d to adopt a m u l t i c u l t u r a l p e r s p e c t i v e . The s t r u c t u r e and philosophy of Canada's h e a l t h care system d i r e c t l y a f f e c t s the p r a c t i c e of h e a l t h care p r o f e s s i o n a l s and the p r o v i s i o n of h e a l t h care to c l i e n t s . Recent government documents, such as the La Londe Report (1974) and Epp's Framework f o r Health Promotion (1986), have proposed equity of h e a l t h f o r a l l as t h e i r goal. These two documents, however, propose a h e a l t h care scheme s t r u c t u r e d l a r g e l y from the p e r s p e c t i v e of white middle c l a s s s o c i e t y . They a l s o appear to not adequately a p p r e c i a t e the f a c t that h e a l t h i s determined by the c u l t u r a l and s o c i a l context in which i t i s embedded (Coburn, D'Arcy, Torrance & New, 1987). A p p r e c i a t i o n of the unique p e r s p e c t i v e s on h e a l t h h e l d by the v a r i o u s c u l t u r a l groups making up Canadian s o c i e t y i s v i t a l f o r s u c c e s s f u l r e a l i z a t i o n of the f e d e r a l government's v i s i o n of h e a l t h f o r a l l . Mechanisms and s t r a t e g i e s f o r h e a l t h promotion (Epp, 1986) can be f r u i t f u l only when c r o s s - c u l t u r a l viewpoints are acknowledged. In a m u l t i c u l t u r a l s o c i e t y such as Canada, which has f o r m a l l y 3 advocated a p o l i c y of c u l t u r a l p l u r a l i s m , r e c o g n i t i o n of the impact which e t h n o c u l t u r a l f a c t o r s have on the d e f i n i t i o n and experience of h e a l t h and i l l n e s s i s e s s e n t i a l . fit present, h e a l t h care p r o f e s s i o n a l s remain l a r g e l y ignorant of, or i n d i f f e r e n t to, c r o s s - c u l t u r a l d i f f e r e n c e s among c l i e n t s (Dobson, 1983; L e i n i n g e r , 1984). The Canadian h e a l t h care system i t s e l f o ften f a i l s to meet the needs of i n d i v i d u a l s whose e t h n o c u l t u r a l background d i f f e r s from that of the mainstream p o p u l a t i o n (Anderson, 1985b). T r a n s c u l t u r a l s t u d i e s explore the d i f f e r e n t p e r s p e c t i v e s on h e a l t h and h e a l t h care held by i n d i v i d u a l s of v a r y i n g s o c i o - c u l t u r a l backgrounds. C r o s s - c u l t u r a l nursing l i t e r a t u r e emphasizes the need f o r increased knowledge i n the area of c u l t u r a l l y determined p e r s p e c t i v e s on h e a l t h and i l l n e s s . T r a n s c u l t u r a l S t u d i e s As Canadian s o c i e t y becomes i n c r e a s i n g l y m u l t i c u l t u r a l i n nature, i t becomes imperative f o r the nu r s i n g p r o f e s s i o n to adopt a t r a n s c u l t u r a l p e r s p e c t i v e . T r a n s c u l t u r a l h e a l t h care i s both a growing r e a l i t y and a f u t u r e n e c e s s i t y , which c l e a r l y s i g n i f i e s c r o s s - c u l t u r a l study as an important focus f o r nursing r e s e a r c h (Splane, 1984). A sound understanding of the "concept of c u l t u r e " i s e s s e n t i a l f o r p r o v i s i o n of c u l t u r a l l y r e l e v a n t n u r s i n g care (Dobson, 1983). Nurses who provide care to c l i e n t s from v a r i o u s c u l t u r a l and e t h n i c groups need to be cognizant of f a c t o r s which f a c i l i t a t e or impede t h e r a p e u t i c i n t e r a c t i o n between the nurse and the c l i e n t . T r a d i t i o n a l l y educated w i t h i n a u n i c u l t u r a l , 4 biomedical p e r s p e c t i v e , nurses often f i n d that t h e i r own p e r c e p t i o n of h e a l t h and i l l n e s s , and u n d e r l y i n g b e l i e f s , values and l i f e s t y l e s , d i f f e r markedly from those of the c l i e n t . T h i s u n i c u l t u r a l o r i e n t a t i o n on the part of the nurse, t o g e t h e r with a s s o c i a t e d a t t i t u d e s of ethnocentrism and c u l t u r a l i m p o s i t i o n , act as b a r r i e r s to p r o v i s i o n of t h e r a p e u t i c n u r s i n g care and negate the v a l i d i t y of the c l i e n t ' s unique e t h n o c u l t u r a l p e r s p e c t i v e and experience ( L e i n i n g e r , 1984). According to L e i n i n g e r , i n d i v i d u a l s in s o c i e t y are demanding c u l t u r a l l y r e l e v a n t h e a l t h care and s e r v i c e s which acknowledge t h e i r unique s o c i a l and c u l t u r a l m i l i e u . She s t a t e s : They are beginning to speak of " c u l t u r a l r i g h t s ' and expect to be looked at w i t h i n t h e i r own c u l t u r a l p a t t e r n s . The n u r s i n g p r o f e s s i o n must act q u i c k l y i f i t i s to prevent a gap from developing between consumers' e x p e c t a t i o n s and nurses' a b i l i t y to d e l i v e r the s e r v i c e s they demand. (1984, p. 42) It thus c l e a r l y behooves the n u r s i n g p r o f e s s i o n to gain a b e t t e r understanding of the c l i e n t ' s unique e t h n o c u l t u r a l p e r s p e c t i v e in order to provide e f f e c t i v e n u r s i n g care to i n d i v i d u a l s from v a r i o u s c u l t u r a l and e t h n i c backgrounds. Knowledge of i n d i v i d u a l s u b j e c t i v e experience and p e r c e p t i o n of h e a l t h i s an e s s e n t i a l component of t r a n s c u l t u r a l n u r s i n g p r a c t i c e . Knowledge of the meaning which i n d i v i d u a l s a s s i g n to the s t a t e of h e a l t h promotes the a p p r e c i a t i o n of the c l i e n t as a unique human being. T h i s human-to-human r e l a t i o n s h i p , based upon r e c o g n i t i o n of i n d i v i d u a l uniqueness and worth, i s fundamental to 5 the philosophy of n u r s i n g (Travelbee, 1971). Health i s a s o c i o - c u l t u r a l c o n s t r u c t r a t h e r than a given s t a t e , and i s thus i n s e p a r a b l e from the e t h n o s o c i o c u l t u r a 1 context in which i t i s grounded (Anderson, 1985b). The nurse r e q u i r e s t r a n s c u l t u r a l knowledge to guide nursing p r a c t i c e so that c u l t u r a l l y r e l e v a n t n u r s i n g care can be provided to c l i e n t s . The S i g n i f i c a n c e of S t u d i e s on Indo-Canadians B r i t i s h Columbia has the second l a r g e s t Indo-Canadian p o p u l a t i o n i n Canada, second only to Ontario. In 1981, 43,065, or 37% of the country's t o t a l Indo-Canadian p o p u l a t i o n r e s i d e d in B r i t i s h Columbia (Johnson, 1984). 1986 f i g u r e s showed a small decrease i n numbers, with 39,780 i n d i v i d u a l s i n B r i t i s h Columbia r e p o r t i n g India as t h e i r country of o r i g i n (Summary T a b u l a t i o n s , S t a t i s t i c s Canada, 1986). Despite t h i s r e p o r t e d numerical d e c l i n e , i n d i v i d u a l s from India remain one of the major immigrant groups i n the province, ranking a f t e r immigrants from Europe, the Netherlands and China. Over the f i r s t s i x months of 1988, 1,890 i n d i v i d u a l s from In d i a came to B r i t i s h Columbia; numbers of immigrants recorded f o r a l l other c u l t u r a l groups, except those from Hong Kong, were s i g n i f i c a n t l y l e s s over the same pe r i o d (Employment and Immigration Canada, 1988; Appendum to the D a i l y , S t a t i s t i c s Canada, 1988). The Indo-Canadian community in B r i t i s h Columbia i s predominately Sikh, with fewer Hindus and P a k i s t a n i s . T h i s predominance of Sikhs i n the province's Indo-Canadian community i s a p a t t e r n not r e f l e c t e d w i t h i n the Canadian p o p u l a t i o n as a whole 6 (Johnson, 1984; P o p u l a t i o n by E t h n i c O r i g i n , S t a t i s t i c s Canada, 1986). In view of the s i g n i f i c a n t number of i n d i v i d u a l s of Indian o r i g i n c u r r e n t l y a r r i v i n g i n Canada, and the c u l t u r a l l y d i s t i n c t nature of the Indo-Canadian community, s t u d i e s f o c u s i n g on Indo-Canadians are c l e a r l y r e l e v a n t i n themselves. Moreover, given the Canadian h e a l t h care system's mandate to meet the needs of the country's p o p u l a t i o n , i n v e s t i g a t i o n of the d i s t i n c t c u l t u r a l p e r s p e c t i v e of h e a l t h held by Indo-Canadians i s t i m e l y and p e r t i n e n t . L i t e r a t u r e and Research on Indo-Canadians a P. S c a r c i t y Over the years, v a r i o u s accounts have been p u b l i s h e d of the immigration of i n d i v i d u a l s from India i n t o Canada and t h e i r experience of b u i l d i n g a new l i f e in Canadian s o c i e t y . Many of these works were publi s h e d in the e a r l y 1900's ( B r i t i s h Columbia P u b l i c S e r v i c e B u l l e t i n , 1928; Broad, 1913). Authors over recent years have focused p r i m a r i l y on immigration i s s u e s , s t a t i s t i c s , h i s t o r i c a l accounts and s o c i o — psycho 1 o g i c a l f a c t o r s a s s o c i a t e d with the Indo-Canadian community (Buchignani, 1977, 1980; F i l t e a u , 1980; Naidoo, 1980, 1981, 1984; Wood, 1980, 1984). Other authors, such as Goa, Coward and Neufeldt (1984) have focused on t h i s group's r e l i g i o u s t r a d i t i o n s . Very l i t t l e theory has addressed the h e a l t h care concerns of Indo-Canadians. Of the l i t e r a t u r e a v a i l a b l e i n t h i s category, s t u d i e s p r e s e n t i n g a c t u a l r e s e a r c h f i n d i n g s are scarce. Nursing has begun to s e r i o u s l y examine h e a l t h care w i t h i n the 7 t r a n s c u l t u r a l context. Anderson's work on the h e a l t h of Indo-Canadian and Greek women immigrants (1985a, 1987) and the recent study conducted by Majumdar and Carpio (1988) are exemplary n u r s i n g r e s e a r c h s t u d i e s in t h i s area. Most i n v e s t i g a t i o n s c a r r i e d out by r e s e a r c h e r s i n other h e a l t h p r o f e s s i o n s deal with case s t u d i e s of i l l n e s s e s found in the Indo-Canadian community, such as mal a r i a (Ough, 1976), f i l a r i a l c h y l u r i a (Smith, 1971) and trachoma (Detels, Alexander & Dhir, 1966). Lack of L i t e r a t u r e on the Hindu Community The l a r g e m a j o r i t y of l i t e r a t u r e p e r t a i n i n g to Indo-Canadians c o n c e n t r a t e s on the Sikh community. S t r u s e r (1985) researched the experience of c h i l d b i r t h amongst Sikh women from the Punjab. D e t e l s et a l . (1966), i n t h e i r p r e v i o u s l y noted study on trachoma, looked e x c l u s i v e l y at Punjabi Sikhs in B r i t i s h Columbia. Recent s t u d i e s on the i r o n s t a t u s (Bindra & Gibson, 1986) and vitamin D st a t u s (Gibson, Bindra, Nizan & Draper, 1986) of immigrants from India a l s o focused on samples drawn from the Sikh community. S o c i o l o g i c a l and h i s t o r i c a l l i t e r a t u r e on the Indo-Canadians gives evidence of a s i m i l a r bias towards study of the Sikh community over the Hindu community (Broad, 1913; Buchignani, 1977; Naidoo, 1980). C o n c e p t u a l i z a t i o n of the Problem The conceptual framework f o r t h i s study i s the explanatory model of Arthur Kleinman (1978a,b, 1980, 1984). The conceptual framework r e p r e s e n t s the r e s e a r c h e r ' s mind set, or the p e r s p e c t i v e a from which the t o t a l r e s e a r c h process i s viewed. The res e a r c h q u e s t i o n i s c o n s i d e r e d to be generated from the conceptual framework i t s e l f , and supported by the framework duri n g the r e s e a r c h process. As an o r g a n i z i n g framework, Kleinman's model guides the a c t u a l conduct of f i e l d work and the development of the r e s e a r c h e r ' s t h e o r e t i c a l p e r s p e c t i v e as data are c o l l e c t e d and analyzed. S o c i o c u l t u r a l Systems Medical POPULAR C u l t u r a l System(s) FOLK Care System(s) of Health Care System(s) (PROFESSIONAL) ( I n d i v i d u a l and Family Based) F i g u r e 1: The Explanatory Model. Kleinman's c o n c e p t u a l i z a t i o n of the h e a l t h care system (Kleinman, 1978a, p. 422). Kleinman's explanatory model f i n d i n g s , and views h e a l t h and hea i s based upon c r o s s - c u l t u r a l 1th care as c u l t u r a l systems. 9 The model c o n c e p t u a l i z e s three i n t e r a c t i n g s t r u c t u r a l domains, or spheres, of h e a l t h c a r e : popular, f o l k and p r o f e s s i o n a l . These " h e a l t h and h e a l t h c a r e - r e l a t e d aspects are c u l t u r a l l y c o n s t i t u t e d ... d i s t i n c t i v e and o v e r l a p p i n g " . They represent the e s s e n t i a l components which s t r u c t u r e the i n d i v i d u a l ' s explanatory model f o r viewing h e a l t h and i l l n e s s (Kleinman & Chrisman, 1983, p. 570-571) . Kleinman's c u l t u r a l system model addresses the discrepancy between lay and p r o f e s s i o n a l p e r s p e c t i v e s , or views, on the i l l n e s s experience. Sickness i s experienced and r e a c t e d to w i t h i n the three s t r u c t u r a l spheres. Each of these domains of h e a l t h care r e p r e s e n t s "a s o c i o c u l t u r a l system with i t s own b e l i e f s , values and norms and i t s own explanatory model of h e a l t h and i l l n e s s " . The popular domain encompasses f a m i l y , s o c i a l network and community. The f o l k domain i n c l u d e s n o n - p r o f e s s i o n a l h e a l e r s , and the p r o f e s s i o n a l domain r e p r e s e n t s h e a l t h p r o f e s s i o n a l s who base c l i n i c a l p r a c t i c e upon complex p r o f e s s i o n a l h e a l t h c u l t u r e s (Anderson, 1985b, p. 237). Although d i s e a s e and i l l n e s s are themselves explanatory models, Kleinman and c o l l e a g u e s c l e a r l y d i s t i n g u i s h between the two concepts. I l l n e s s i s d e f i n e d as the "human experience of s i c k n e s s " or the "personal, i n t e r p e r s o n a l and c u l t u r a l r e a c t i o n s to d i s e a s e and d i s c o m f o r t " . Disease, in c o n t r a s t , i s considered as the " m a l f u n c t i o n i n g of b i o l o g i c and p s y c h o p h y s i o l o g i c processes i n the i n d i v i d u a l " . The i l l n e s s experience i s i n f l u e n c e d by c u l t u r e , being " c u l t u r a l l y shaped in the sense that how we 10 p e r c e i v e , experience and cope with d i s e a s e i s based on our e x p l a n a t i o n s of s i c k n e s s , e x p l a n a t i o n s s p e c i f i c to the s o c i a l p o s i t i o n s we occupy and the systems of meaning we employ" (Kleinman, Eisenberg & Good, 1978, p. 251-252). Kleinman speaks of the c u l t u r a l c o n s t r u c t i o n of c l i n i c a l r e a l i t y , wherein c1ient—hea1th care p r o f e s s i o n a l i n t e r a c t i o n s represent t r a n s a c t i o n s between explanatory models. The p a t i e n t ' s explanatory model i s c u l t u r a l l y shaped and i l l u s t r a t e s the b e l i e f s which the i n d i v i d u a l holds about h i s " i l l n e s s , the personal and s o c i a l meaning he attaches to h i s d i s o r d e r , h i s e x p l a n a t i o n s ... and h i s t h e r a p e u t i c g o a l s " (Kleinman et a l . , 1978). Kleinman (1984) d e s c r i b e s the "meaning c o n t e x t s " of i l l n e s s and care. In t h i s study the r e s e a r c h e r may a p p r o p r i a t e l y r e f e r to the meaning context of h e a l t h . Kleinman and Chrisman (1983), r e f e r r i n g to the experience of i l l n e s s as a c u l t u r a l or symbolic r e a l i t y , propose that "emotion, c o g n i t i o n , motivation, behavior and s o c i a l i n t e r a c t i o n are made meaningful i n p a r t i c u l a r c u l t u r a l c o n t e x t s " (p. 569). Such c u l t u r a l p e r s p e c t i v e s c o n s t r u c t the i n d i v i d u a l ' s personal c u l t u r a l l y - s p e c i f i c explanatory model f o r viewing the world. Although Kleinman's explanatory model has been used p r i m a r i l y f o r viewing the experience of i l l n e s s , the framework i s a l s o well s u i t e d to c o n s i d e r a t i o n of i n d i v i d u a l experience of h e a l t h (A. Kleinman, personal communication, February 18, 1989). As i n the i l l n e s s experience, the way i n d i v i d u a l s p e r c e i v e h e a l t h and a s s i g n meaning to h e a l t h i s s t r u c t u r e d by the e t h n i c and c u l t u r a l f a c t o r s 11 inherent in each of the three domains. The r e s e a r c h e r proposes that the experience of h e a l t h , l i k e the experience of i l l n e s s , i s c u l t u r a l l y determined and based upon i n d i v i d u a l e x p l a n a t i o n s of we 11-be ing. Use of Kleinman 1s Framework w i t h i n the D i s c i p l i n e of Nursing Kleinman's explanatory model has been employed in recent n u r s i n g r e s e a r c h (Anderson, 1981a, 1985b; Anderson & Chung, 1982) as a framework f o r viewing the s o c i o - c u l t u r a l context of h e a l t h and i l l n e s s . Anderson's work i l l u s t r a t e s the p o t e n t i a l of Kleinman's theory f o r guiding and supporting r e s e a r c h w i t h i n the nur s i n g p r o f e s s i o n , and a s s i s t i n g enquiry i n t o phenomena of concern to n u r s i n g p r a c t i c e . In her d i s c u s s i o n on the relev a n c e of c o n s i d e r i n g h e a l t h and i l l n e s s as s o c i o - c u l t u r a l c o n s t r u c t s , Anderson makes the f o l l o w i n g statement r e g a r d i n g the c l i n i c a l d i r e c t i o n provided by a nur s i n g framework based upon Kleinman's theory: The q u e s t i o n that a r i s e s i s the extent to which biomedical models of c l i n i c a l p r a c t i c e that overlook the sociocu1tura1 context i n which h e a l t h and i l l n e s s experiences are grounded are r e s p o n s i v e to the needs of c l i e n t s i n the Canadian h e a l t h care system .... A framework f o r n u r s i n g care which focuses on the m u l t i p l e determinants which shape the c l i e n t ' s experience of 'health' and ' i l l n e s s ' i s c r i t i c a l i f adequate care i s to be provided to the many e t h n o c u l t u r a l groups that make up the Canadian mosaic. (1985b, p. 234-235) The d i s t i n c t r e s e a r c h problem addressed in t h i s study evolved 12 from t h e f o r e g o i n g c o n s i d e r a t i o n o f h e a l t h as a m u l t i d i m e n s i o n a l , c u l t u r a l l y and s o c i a l l y g r o unded phenomenon, and t h e r e c o g n i t i o n t h a t h e a l t h c a r e p r o f e s s i o n a l s need t o become aware o f t h e v a l i d i t y and u n i q u e n e s s o f t h e i n d i v i d u a l h e a l t h e x p e r i e n c e and t h e s o c i a l c o n t e x t o f t h a t e x p e r i e n c e . P r o b l e m S t a t e m e n t The p e r c e p t i o n o f h e a l t h h e l d by I n d o - C a n a d i a n s i s not a d e q u a t e l y u n d e r s t o o d by t h e m a j o r i t y o f h e a l t h c a r e p r o f e s s i o n a l s . T h e r e may be a d i s c r e p a n c y between t h e h e a l t h p e r s p e c t i v e e n t e r t a i n e d by h e a l t h c a r e p r o f e s s i o n a l s and t h a t o f t h e c l i e n t . When such a d i s c r e p a n c y e x i s t s i t i s u n l i k e l y t h a t c u l t u r a l l y r e l e v a n t c a r e w i l l ensue. T h e r a p e u t i c n u r s i n g c a r e c a n n o t be p r o v i d e d u n l e s s t h e c l i e n t ' s u n i q u e c u l t u r a l p e r s p e c t i v e o f h e a l t h i s a p p r e c i a t e d and used t o g u i d e n u r s i n g p r a c t i c e . P r e v i o u s s t u d i e s do not a p p e a r t o have e x c l u s i v e l y f o c u s e d on what h e a l t h means t o H i n d u I n d o - C a n a d i a n s . S i g n i f i c a n c e o f t h e S t u d y  S c i e n t i f i c S i g n i f i c a n c e R e s e a r c h i s n e c e s s a r y f o r t h e p r o f e s s i o n a l i z a t i o n o f n u r s i n g ( F a w c e t t , I 9 6 0 ) . T h i s s t u d y on t h e meaning o f h e a l t h t o I n d o -C a n a d i a n s c o n t r i b u t e s t o t h e d e v e l o p m e n t o f t r a n s c u l t u r a l n u r s i n g t h e o r y and f u r t h e r s t h e c u l t i v a t i o n o f a u n i q u e body o f n u r s i n g knowledge. K l e i n m a n (1984) c i t e s c r o s s - c u l t u r a l r e s e a r c h as h i g h l y s i g n i f i c a n t i n t h e o n - g o i n g work t o b u i l d a t h e o r y on t h e 13 u n i v e r s a l and c u l t u r e - s p e c i f i c aspects of h e a l t h care. Coburn et a l . (1987) recognize the need f o r r e s e a r c h on the h e a l t h p e r s p e c t i v e s of lay Canadians, e s p e c i a l l y amongst e t h n i c populat ions. L e i n i n g e r has r e c e n t l y commented on the s i g n i f i c a n c e of t r a n s c u l t u r a l theory as a major component of nursing's unique body of knowledge. The author emphasizes the p o s i t i o n that t r a n s c u l t u r a l theory i s "one of the most important and r e l e v a n t t h e o r i e s of n u r s i n g " (1985a, p. 209). Echoing L e i n i n g e r ' s sentiments, deChesnay (1983) s t a t e s that c r o s s - c u l t u r a l r e s e a r c h strengthens the d i s c i p l i n e ' s theory base. This study e f f e c t i v e l y b u i l d s upon e a r l i e r n ursing r e s e a r c h focused i n the area of c u l t u r e , e t h n i c i t y and h e a l t h care, and c o n t r i b u t e s to c o n s o l i d a t i o n of q u a l i t a t i v e c r o s s - c u l t u r a l study as a major focus of n u r s i n g r e s e a r c h . The t i m e l i n e s s of t h i s study i s supported by Anderson's suggestion that f u t u r e r e s e a r c h might e f f e c t i v e l y examine the " c l i e n t ' s s u b j e c t i v e experiences of h e a l t h and i l l n e s s " . She s p e c i f i c a l l y poses the r e s e a r c h q u e s t i o n "what i s the meaning of h e a l t h " as a t o p i c r e l e v a n t f o r n u r s i n g r e s e a r c h (1985b, p. 238-240). Other nurse r e s e a r c h e r s have c i t e d i n v e s t i g a t i o n of the h e a l t h experience as an important focus f o r n u r s i n g enquiry (Munhall & O i l e r , 1986; Smith, 1986). P r a c t i c a l S i g n i f i c a n c e Theory generated from c r o s s - c u l t u r a l r e s e a r c h guides h e a l t h care p r o f e s s i o n a l s i n the p r o v i s i o n of q u a l i t y p a t i e n t care. By 14 g u i d i n g p r a c t i c e , c r o s s - c u l t u r a l s t u d y b e n e f i t s b o t h t h e n u r s i n g p r o f e s s i o n and t h e c l i e n t . Knowledge about c u l t u r a l l y s p e c i f i c b e l i e f s r e g a r d i n g h e a l t h and i l l n e s s , and a s s o c i a t e d e x p e c t a t i o n s a bout c a r e , c o n t r i b u t e s t o t h e p r o v i s i o n o f c u l t u r a l l y r e l e v a n t n u r s i n g c a r e (deChesnay, 1983). L e i n i n g e r (1985a) f i r m l y p r o p o s e s t h a t t r a n s c u l t u r a l t h e o r y i s r e l e v a n t t o n u r s i n g p r a c t i c e , s t a t i n g t h a t n u r s i n g must be b a s e d on t r a n s c u l t u r a l c a r e knowledge and s k i l l . S p l a n e , i n h e r 1983 k e y n o t e a d d r e s s a t t h e C a n a d i a n C o n f e r e n c e o f S c h o o l s o f N u r s i n g , e m p h a s i z e d t h e need f o r t r a n s c u l t u r a l h e a l t h c a r e . S p l a n e s t a t e s t h a t t h e r e i s an i m p e r a t i v e r e q u i r e m e n t f o r " h e a l t h p e r s o n n e l who u n d e r s t a n d d i f f e r e n t c u l t u r a l v a l u e s , b e l i e f s and p r a c t i c e s " (1983, p. 6 ) . By becoming more aware o f t h e c u l t u r a l l y - g r o u n d e d e x p e r i e n c e o f h e a l t h , n u r s e s w i l l be a b l e t o p r o v i d e b e t t e r and more s a t i s f y i n g n u r s i n g c a r e t o c l i e n t s . Such a c o n s o l i d a t i o n o f c r o s s - c u l t u r a l n u r s i n g t h e o r y and p r a c t i c e i s i m p e r a t i v e i f t h e n u r s i n g p r o f e s s i o n i s t o e f f e c t i v e l y meet t h e c h a l l e n g e s o f t h e f u t u r e as s o c i e t y becomes i n c r e a s i n g l y m u l t i c u l t u r a l i n n a t u r e . Purpose of the Study The p u r p o s e o f t h i s p h e n o m e n o l o g i c a l s t u d y was t o i n v e s t i g a t e t h e meaning o f h e a l t h t o I n d o - C a n a d i a n s . Research Question In t h i s r e s e a r c h t h e f o l l o w i n g q u e s t i o n was a d d r e s s e d : "What 15 i s the meaning of h e a l t h to Indo-Canadians"? T h e o r e t i c a l and Methodological P e r s p e c t i v e s of the Study I n t r o d u c t i o n to the Methodology Kleinman's (1978a,b, 1980, 1984) explanatory model provides a s u i t a b l e framework f o r enquiry i n t o i n d i v i d u a l p e r c e p t i o n of the phenomenon of h e a l t h . T h i s study focused on the lay experience of h e a l t h w i t h i n the popular domain, or sphere, of the model. Kleinman's framework d i r e c t e d the r e s e a r c h e r to design a phenomenological study which i n v e s t i g a t e d i n d i v i d u a l p e r c e p t i o n of h e a l t h , i n order to e l i c i t in-depth d e s c r i p t i o n of the explanatory models u n d e r l y i n g t h i s experience. The phenomenological r e s e a r c h design supported by the chosen framework i s the a p p r o p r i a t e q u a l i t a t i v e method f o r d e s c r i p t i o n of the i n d i v i d u a l h e a l t h experience from the a c t o r ' s personal p e r s p e c t i v e (Knaack, 1984). Q u a l i t a t i v e approaches are g a i n i n g i n c r e a s e d acceptance among n u r s i n g r e s e a r c h e r s as e f f e c t i v e f o r studying phenomena of concern to n u r s i n g p r a c t i c e . Among q u a l i t a t i v e methods, the phenomenological approach i n p a r t i c u l a r i s w e ll s u i t e d to c l i n i c a l n u r s i n g r e s e a r c h where the aim i s to understand i n d i v i d u a l p e r c e p t i o n and experience. A growing number of n u r s i n g r e s e a r c h e r s u t i l i z e the phenomenological approach and support i t s r e l e v a n c e (Anderson, 1985a, 1987; Anderson & Chung, 1982; Anderson & Lynam, 1987; Davis, 1978; Lynch-Sauer, 1985; Munhall, 1982, 1986a,b; O i l e r , 1982; Parse, Coyne & Smith, 1985; Ray, 1985; Reimen, 1986; Smith, 1986). 16 Phenomenology i s a p h i l o s o p h i c a l p e r s p e c t i v e , or way of viewing the world and c o n c e p t u a l i z i n g r e a l i t y , as w e l l as an approach to enquiry i n t o phenomena ( O i l e r , 1982). As an i n d u c t i v e , d e s c r i p t i v e r e s e a r c h method f o c u s i n g on the whole i n d i v i d u a l (Omery, 1983), phenomenology seeks to "uncover ground s t r u c t u r e s " of phenomena (Lynch-Sauer, 1985). It values both the "in n e r experience and outer behavior of a subject as viewed by both the r e s e a r c h e r and the p a r t i c i p a n t s " , aiming "to formulate a model f o r the study of human behavior at the l e v e l of everyday s o c i a l o r g a n i z a t i o n ... (focusing) on the s u b j e c t i v e experience of persons in everyday l i f e " (Anderson & Chung, 1982, p. 42). In the phenomenological method, the s u b j e c t ' s responses c o n s t i t u t e the data of the study (Parse, Coyne & Smith, 1985). The r e s e a r c h e r and p a r t i c i p a n t j o i n t l y explore the meaning of phenomena, c o n s t r u c t i n g a d e s c r i p t i o n of the fundamental nature of the experience. C o n c e n t r a t i n g on the s u b j e c t ' s experience, " r a t h e r than c o n c e n t r a t i n g s o l e l y on the s u b j e c t s or on o b j e c t s " , phenomenology attempts to "see human experience in the complexity of i t s content" (Munhall & O i l e r , 1986, p. 57). As Straus (1966) e x p l a i n s , phenomenology focuses on the l i v e d moment, and re c o g n i z e s the v a l i d i t y of each person's unique experience of world s i t u a t i o n s . Thus, from the phenomenological p e r s p e c t i v e , o b j e c t i v e study of human experience i s viewed as s t r i p p i n g r e a l i t y of i t s primary, fundamental aspects. Research i s conducted from the emic p e r s p e c t i v e of the subject (Morse, 1987), aiming to see knowledge d i r e c t l y through immediate human 17 experience (Davis, 1978). Knaack (1984), r e f e r r i n g to the work of G i o r g i (1975) and Keen (1975), o u t l i n e s the b a s i c assumptions of phenomenology as f o i l o w s : 1) f a i t h f u l n e s s to the phenomenon as i t e x i s t s ; 2) the importance of experience w i t h i n the world as we l i v e i t ; 3) u t i l i z a t i o n of a d e s c r i p t i v e approach; 4) d e s c r i p t i o n of the s i t u a t i o n from the p e r s p e c t i v e of the subj e c t ; 5) c o n s i d e r a t i o n of the " l i v e d s i t u a t i o n " as the b a s i c r e s e a r c h unit ; 6) "a b i o g r a p h i c a l emphasis because a l l human phenomena are temporal, h i s t o r i c a l and p e r s o n a l " ; 7) aim to be " p r e s u p p o s i t i o n 1ess d e s c r i p t i o n " ; and 8) emphasis on a "search f o r meaning" (p. 109). These b a s i c assumptions, or e s s e n t i a l b u i l d i n g blocks u n d e r l y i n g the phenomenological method, support exhaustive d e s c r i p t i o n of the phenomenon of h e a l t h as i t i s l i v e d by i n d i v i d u a l s w i t h i n the context of t h e i r unique e t h n o s o c i o c u l t u r a l environment. Grounded in the r e c o g n i t i o n that context gives meaning to personal experience, phenomenological d e s c r i p t i o n e f f e c t i v e l y communicates i n s i g h t i n t o the human experience of h e a l t h . In c o n t r a s t to the t r a d i t i o n a l s c i e n t i f i c method of p o s i t i v i s t i c enquiry, which focuses on and gives u l t i m a t e r e a l i t y to the o b j e c t i v e world, phenomenology focuses on the s u b j e c t i v e world of the i n d i v i d u a l . Shaped by the i n d i v i d u a l ' s d i s t i n c t i v e c u l t u r a l , 18 s o c i a l and h i s t o r i c a l background, t h i s s u b j e c t i v e world i s unique f o r each person. D e f i n i t i o n of Terms T h e o r e t i c a l D e f i n i t i o n 1) C u l t u r e : r e f e r s to "the learned, shared, and t r a n s m i t t e d values, b e l i e f s , norms and lif e w a y p r a c t i c e s of a p a r t i c u l a r group that guides t h i n k i n g , d e c i s i o n s and a c t i o n s i n a patterned way" ( L e i n i n g e r , 1985, p. 209). 2) E t h n i c : r e f e r s to "a s o c i a l group w i t h i n a c u l t u r a l and s o c i a l system that claims or i s accorded s p e c i a l s t a t u s on the b a s i s of complex, of t e n v a r i a b l e t r a i t s i n c l u d i n g r e l i g i o u s , l i n g u i s t i c , a n c e s t r a l , or p h y s i c a l c h a r a c t e r i s t i c s " (Spector, 1976, p. 76). 3) E t h n i c i t y : r e f e r s to "the c o n d i t i o n of belonging to a p a r t i c u l a r e t h n i c group; e t h n i c p r i d e " (Spector, 1979, p. 76). O p e r a t i o n a l D e f i n i t i o n 1) Indo-Canadian: f o r t h i s study the term r e f e r s to an i n d i v i d u a l r e s i d i n g in Canada, who was born i n India and f o l l o w s the Hindu re 1i g i on. 2) H e a l t h : r e f e r s to what was d e f i n e d by i n d i v i d u a l s in t h i s st udy. ftssumpt i ons The assumptions, or b a s i c concepts and p r i n c i p l e s which were taken f o r t r u e in t h i s study, are as f o l l o w s : 1) That the members of the s e l e c t e d sample were able to provide a s u b j e c t i v e r e p o r t of t h e i r i n d i v i d u a l p e r c e p t i o n of h e a l t h ; 2) That the ve r b a l r e p o r t obtained from the study p a r t i c i p a n t s was 19 t r u e to t h e i r p e r c e p t i o n s of h e a l t h ; 3) That the p e r c e p t i o n and experience of health/meaning of h e a l t h v a r i e s c r o s s - c u l t u r a l l y ; 4) That h e a l t h i s a s t a t e which can be d e s c r i b e d by verbal r e p o r t . L i m i t a t i o n s The f o l l o w i n g l i m i t a t i o n s f o r the study were i d e n t i f i e d : 1) Sample: The sample had to be E n g l i s h speaking i n order f o r the r e s e a r c h e r to be able to conduct a l l of the i n t e r v i e w s h e r s e l f . I n d i v i d u a l s who could not communicate i n E n g l i s h were t h e r e f o r e excluded from the study; consequently, the meaning which h e a l t h holds f o r t h i s group was not i n v e s t i g a t e d . 2) Data: The presence of f a m i l y members at c e r t a i n p o i n t s d u r i n g some of the i n t e r v i e w s may have i n f l u e n c e d the p a r t i c i p a n t ' s v e r b a l r e p o r t . The major i t y of in t e r v i e w s , however, were und i st urbed. Summary In t h i s i n t r o d u c t o r y chapter, the background to the problem was presented. The explanatory model of Arthur Kleinman was d e s c r i b e d and i d e n t i f i e d as the conceptual framework supporting t h i s r e s e a r c h . The s c i e n t i f i c and p r a c t i c a l s i g n i f i c a n c e of the cu r r e n t study were noted. The problem statement and purpose of the study were s t a t e d and di s c u s s e d , along with the re s e a r c h q u e s t i o n which d i r e c t e d the a c t u a l r e s e a r c h design. The t h e o r e t i c a l and methodological p e r s p e c t i v e s of the study were advanced, d e t a i l i n g the phenomenological approach and 20 p r o v i d i n g t h e o r e t i c a l and o p e r a t i o n a l d e f i n i t i o n of s e l e c t e d terms. The u n d e r l y i n g assumptions and recognized l i m i t a t i o n s of the study have been d e s c r i b e d in c o n c l u s i o n . The r e s e a r c h e r emphasized the need f o r understanding s u b j e c t i v e experience of h e a l t h and i l l n e s s as the b a s i s f o r p r o v i s i o n of e f f e c t i v e , c u l t u r a l l y r e l e v a n t h e a l t h care to i n d i v i d u a l s w i t h i n Canada's m u l t i c u l t u r a l s o c i e t y . T h i s study was designed to explore the unique p e r c e p t i o n of h e a l t h h e l d by Indo-Canadians. The methodology used in t h i s r e s e a r c h w i l l be examined in depth in chapter three. The f o l l o w i n g chapter w i l l present an overview of s e l e c t e d l i t e r a t u r e germane to the problem and purpose of the c u r r e n t study. This l i t e r a t u r e review w i l l d i s c u s s the o r i g i n of the word " h e a l t h " and v a r i o u s p e r s p e c t i v e s on h e a l t h and i l l n e s s found w i t h i n the d i f f e r e n t d i s c i p l i n e s . L i t e r a t u r e and r e s e a r c h on the Indo-Canadian community, together with an account of India's t r a d i t i o n a l b e l i e f systems r e g a r d i n g h e a l t h and i l l n e s s , w i l l a l s o be i n c l u d e d i n the subsequent d i s c u s s i o n . CHAPTER 2: REVIEW OF SELECTED LITERATURE The f o l l o w i n g l i t e r a t u r e review provides the background f o r viewing the c u r r e n t study on the meaning of h e a l t h . The review i s d i v i d e d i n t o three s e c t i o n s . In the f i r s t , an overview of e x i s t i n g h e a l t h l i t e r a t u r e presents the c o n c e p t u a l i z a t i o n of h e a l t h o f f e r e d by v a r i o u s d i s c i p l i n e s , and examines how each p e r s p e c t i v e c o n t r i b u t e s to d e s c r i p t i o n and understanding of the phenomenon of h e a l t h . Reference to the o r i g i n of the word " h e a l t h " provides v a l u a b l e i n s i g h t i n t o the l i n k between h e a l t h and concepts of holism, and suggests that the word f o r h e a l t h found in each language may be d e r i v e d from a fundamentally d i f f e r e n t concept of the phenomenon. The l i t e r a t u r e shows that h e a l t h i s being i n c r e a s i n g l y r e c o g n i z e d as a s u b j e c t i v e phenomenon with c h a r a c t e r i s t i c s that vary a c c o r d i n g to s o c i o - c u l t u r a l context. C r o s s - c u l t u r a l n u r s i n g l i t e r a t u r e and r e s e a r c h form a major focus of t h i s d i s c u s s i o n because of t h e i r p a r t i c u l a r r e l e v a n c e to the c u r r e n t study, emphasizing h e a l t h as a s o c i o - c u l t u r a l c o n s t r u c t and e x p l a i n i n g why i t was important to i n v e s t i g a t e the meaning of h e a l t h to Indo-Canadians. The d e s c r i p t i o n of India's t r a d i t i o n a l b e l i e f s on h e a l t h and i l l n e s s presented i n the second s e c t i o n of t h i s chapter, provides a d d i t i o n a l background f o r viewing the Indo-Canadian p e r s p e c t i v e on the h e a l t h phenomenon. The t h i r d s e c t i o n reviews p e r t i n e n t l i t e r a t u r e on i n d i v i d u a l s from India. Chapter one presented the 2E background to the problem in d e t a i l and d i s c u s s e d the relevance of s t u d i e s f o c u s i n g on the Indo-Canadian community, the l i t e r a t u r e on Indo-Canadians reviewed in t h i s s e c t i o n f u r t h e r s u b s t a n t i a t e s the need f o r r e s e a r c h on the h e a l t h p e r s p e c t i v e s of t h i s c u l t u r a l group. Although n u r s i n g r e s e a r c h e r s are showing i n c r e a s i n g i n t e r e s t in h e a l t h as a focus of i n v e s t i g a t i o n , c r o s s - c u l t u r a l s t u d i e s remain r e l a t i v e l y few in number. As the subsequent review shows, in f o r m a t i o n on the h e a l t h of I n d o - C a n a d i a n s . i s l i m i t e d , and s t u d i e s s p e c i f i c a l l y i n v e s t i g a t i n g the meaning of h e a l t h to Indo-Canadians are v i r t u a l l y n on-existent. L i t e r a t u r e on Health and I l l n e s s Much has been w r i t t e n on d i s e a s e and i l l n e s s . The c u l t u r a l b e l i e f s a s s o c i a t e d with p e r c e p t i o n s of i l l n e s s have a l s o been d e a l t with q u i t e e x t e n s i v e l y i n the l i t e r a t u r e . There i s l i t t l e l i t e r a t u r e a v a i l a b l e however, d i s c u s s i n g the concept of h e a l t h and the ways in which i n d i v i d u a l s p e r c e i v e and experience the h e a l t h s t a t e . Even l e s s i n f o r m a t i o n e x i s t s d e a l i n g s p e c i f i c a l l y with i n d i v i d u a l experience of h e a l t h as a s o c i o - c u l t u r a l c o n s t r u c t , and the meaning which i n d i v i d u a l s from va r i o u s c u l t u r a l backgrounds a s s i g n to h e a l t h . Enquiry i n t o the nature of h e a l t h i s f a c i l i t a t e d by c o n s i d e r a t i o n of i l l n e s s as a c o n t r a s t i n g concept. Viewing h e a l t h w i t h i n the h e a l t h - i l l n e s s context i s t h e r e f o r e p e r t i n e n t to t h i s d i s c u s s i o n , s i n c e understanding what h e a l t h " i s not" a s s i s t s 23 d e s c r i p t i o n of what h e a l t h " i s " . Health and i l l n e s s are t r a d i t i o n a l l y viewed w i t h i n the context of the medical model. Consequently, over the l a s t decade i l l n e s s and h e a l t h have been viewed as opposite e n t i t i e s , with h e a l t h d e s c r i b e d in negative terms as a s t a t e where di s e a s e i s absent (Guttmacher, 1978). Recent h o l i s t i c h e a l t h l i t e r a t u r e in c o n t r a s t , advocates h e a l t h as a p o s i t i v e s t a t e of wholeness ( B l a t t n e r , 1981; Flynn, 198(3; Goldwag, 1979; P e l l e t i e r , 1979; S a r k i s & Skoner, 1987). Each d i s c i p l i n e views the human being s l i g h t l y d i f f e r e n t l y . In a d d i t i o n , d i f f e r i n g t h e o r e t i c a l p e r s p e c t i v e s e x i s t w i t h i n a given d i s c i p l i n e . Various d i s t i n c t p e r s p e c t i v e s on the d e f i n i t i o n of h e a l t h and i l l n e s s are t h e r e f o r e found in the l i t e r a t u r e . For example, h e a l t h i s c o n c e p t u a l i z e d as a goal (Duhl, 1976), a response (Murray & Zentner, 1975), a wealth or resource (Fuchs, 1976), a process ( G r e i f i n g e r & Grossman, 1977), a task ( I l l i c h , 1976), a d i a g n o s i s (Sebag, 1979), a moral o b l i g a t i o n or r e s p o n s i b i l i t y ( S i d e r & Clements, 1984), a s t a t e ( T e r r i s , 1975), and a s o c i a l s t a t u s (Twaddle, 1974, 1982). These c o n c e p t u a l i z a t i o n s of h e a l t h vary i n t h e i r e x p l i c i t n e s s of d e f i n i t i o n and c i r c u m s c r i p t i o n of parameters. The f o l l o w i n g d i s c u s s i o n presents some of the t h e o r e t i c a l p e r s p e c t i v e s on h e a l t h found i n the l i t e r a t u r e , to provide a general account of cu r r e n t d e s c r i p t i o n s of the phenomenon of h e a l t h . Examination of the d e r i v a t i o n of the word " h e a l t h " i n t r o d u c e s the s e c t i o n . 24 T h e o r e t i c a l P e r s p e c t i v e s on Health P. b r i e f account of the d e r i v a t i o n of the word " h e a l t h " l i n k s h e a l t h with the concept of holism, and i d e n t i f i e s c u l t u r e and s o c i a l environment as i n t e g r a l aspects of i n d i v i d u a l wholeness. In a d d i t i o n , t h i s e t y m o l o g i c a l account suggests that each language's word f o r h e a l t h may represent a d i f f e r e n t fundamental c o n c e p t u a l i z a t i o n of the phenomenon. D e r i v a t i o n of the Word "Health" It i s proposed that the word " h e a l t h " has been d e r i v e d from the concept of wholeness ( K e l l e r , 1981). I n v e s t i g a t i n g the h i s t o r i c a l development of the word " h e a l t h " , K e l l e r , provides support f o r the p o s i t i o n that h e a l t h i s a p o s i t i v e s t a t e of being encompassing a l l aspects of man's p e r s o n a l i t y . She d e s c r i b e s the o r i g i n a t i o n of the term " h e a l t h " as f o l l o w s : "'Whole' was d e r i v e d from 'hole' or 'hale' i n Middle E n g l i s h and from ' h a l l ' i n Old E n g l i s h (hal - h o l e / h a l e - whole - h e a l t h ) " (1981, p. 44). The word f o r h e a l t h i n S a n s k r i t (the c l a s s i c a l language from which Hindi i s derived) provides a d i f f e r e n t angle on the l i t e r a l meaning of the word " h e a l t h " . The S a n s k r i t word f o r h e a l t h , "svastah", may be t r a n s l a t e d v a r i o u s l y as " s e l f - a b i d i n g ; being in one's n a t u r a l s t a t e ; contented; and healthy i n body and mind" (Monier-Wi11iams, 1976, p. 1277). These accounts of the d e r i v a t i o n and meaning of the word " h e a l t h " support h o l i s t i c h e a l t h p e r s p e c t i v e s on the human being. According to t h i s h o l i s t i c viewpoint, the i n d i v i d u a l i s "a whole p s y c h o - p h y s i o - s o c i o - c u l t u r a l - s p i r i t u a l being" r e l a t e d to h i s / h e r 25 t o t a l environment (Dorsey & Jackson, 1976, p. 77). P e r s p e c t i v e s found i n S o c i o l o g y . Philosophy and Theology As noted, the concept of h e a l t h i s c o n s t r u c t e d from various t h e o r e t i c a l p e r s p e c t i v e s . The work of Parsons (1979) and Twaddle (1974; 1982) represent two s i g n i f i c a n t , c o n t r a s t i n g s o c i o l o g i c a l v i ewpo i n t s. Parsons (1979), a f o r e f a t h e r of medical s o c i o l o g y , d e s c r i b e s h e a l t h as a s o c i a l norm, and s i c k n e s s as a form of s o c i a l l y deviant behaviour. While r e c o g n i z i n g the " c u l t u r a l r e l a t i v i t y " of h e a l t h and s i c k n e s s , Parsons p e r c e i v e s them as i n s e p a r a b l e from notio n s of s o c i a l r o l e , s o c i a l c o n t r o l and conformity. Twaddle (1974; 1982) champions a s o c i o l o g y of h e a l t h c h a r a c t e r i z e d by a socio-cu1tura1, r a t h e r than a b i o p s y c h o 1 o g i c a l , focus. In l i n e with s o c i o l o g y ' s c u r r e n t emphasis on the "meaning" and "grounding" of i n d i v i d u a l experience, Twaddle advocates a p p r e c i a t i o n of the context of l i f e events. He proposes that s m a l l e r u n i t s "need to be understood in the context of l a r g e r ones" (1982, p. 347). Health and i l l n e s s are consequently conceived of as s o c i a l s t a t u s e s c o n s t r u c t e d a c c o r d i n g to personal context, and thus r e l a t e d to socio-economic circumstance, e t h n i c i t y and s i t u a t i o n a l f a c t o r s . According to Twaddle, the c l i e n t i n today's h e a l t h care system experiences not only problems of communication, but a l s o an i n c r e a s i n g sense of a l i e n a t i o n r e l a t e d to economic and c l a s s d i f f e r e n c e s as well as c l i n i c a l and o r g a n i z a t i o n a l f a c t o r s . C a l l a h a n (1982), Beauchamp (1982), Boorse (1982) and Capra 26 (1983) o f f e r some p h i l o s o p h i c a l p e r s p e c t i v e s on the c h a r a c t e r i s t i c s of h e a l t h . Beauchamp notes three prominent and competing approaches to the v i s i o n of h e a l t h . He suggests that h e a l t h may be seen as "a s t a t e of complete p h y s i c a l , mental and s o c i a l w e l l - b e i n g " as s t a t e d in the d e f i n i t i o n of the World Health O r g a n i z a t i o n (WHO); as encompassing only the p h y s i c a l and mental dimensions of the i n d i v i d u a l ; or as a s t a t e of " p h y s i c a l w e l l -being without any s i g n i f i c a n t impairment (Beauchamp, 1982, p. 44). Ca l l a h a n (1982) argues against the WHO d e f i n i t i o n of h e a l t h , and proposes that h e a l t h i s a " s t a t e of p h y s i c a l w e l l - b e i n g " which need not encompass "mental" w e l l - b e i n g (p. 53). Boorse (1982) argues that h e a l t h i s n o r m a l i t y in the sense of " n a t u r a l f u n c t i o n a l o r g a n i z a t i o n of the s p e c i e s " , and di s e a s e i s d e v i a t i o n from the organism's n a t u r a l f u n c t i o n i n g (p.68). Capra (1983), the p h y s i c i s t turned philosopher, speaks of h e a l t h as a " s u b j e c t i v e experience whose q u a l i t y can be known i n t u i t i v e l y " but never q u a n t i f i e d . Emphasizing the need to attempt d e f i n i t i o n of h e a l t h , Capra proposes that " d i f f e r e n t models of l i v i n g organisms w i l l lead to d i f f e r e n t d e f i n i t i o n s of h e a l t h " . Health i s viewed as an i n t e g r a l part of l i m i t e d , approximate models "that m i r r o r a web of r e l a t i o n s h i p s among m u l t i p l e aspects of the complex and f l u i d phenomenon of l i f e " . Capra summarizes h i s p e r s p e c t i v e as f o l l o w s : Once the r e l a t i v i t y and s u b j e c t i v e nature of the concept of h e a l t h i s perceived, i t a l s o becomes c l e a r that the experience of h e a l t h and i l l n e s s i s s t r o n g l y inf1uenced 4by 27 the c u l t u r a l content in which i t occurs. What i s healthy and s i c k , normal and abnormal, sane and insane, v a r i e s from c u l t u r e to c u l t u r e . (1983, p. 320-321) The v i s i o n of h e a l t h proposed by Capra r e c o g n i z e s the s u b j e c t i v i t y of h e a l t h and acknowledges the r o l e of c u l t u r e in d e f i n i t i o n of the concept. The t h e o l o g i a n , T i l l i c h (1961), poses the view that h e a l t h i s a multidimensional concept. R e f e r r i n g s p e c i f i c a l l y to the meaning of h e a l t h , T i l l i c h s t a t e s that one must c o n s i d e r a l l "dimensions of l i f e which are u n i t e d i n man" in order to understand the nature of h e a l t h . Concordant with h o l i s t i c h e a l t h p e r s p e c t i v e s , T i l l i c h s t a t e s that the o v e r a l l h e a l t h of an i n d i v i d u a l i s the r e s u l t of the h e a l t h of each dimension of h i s being: mechanical, b i o l o g i c a l , p s y c h o l o g i c a l , s p i r i t u a l and h i s t o r i c a l (p. 93-99). T i l l i c h ' s h i s t o r i c a l dimension acknowledges the i n f l u e n c e which c u l t u r e exerts upon h e a l t h . In the f o l l o w i n g s e c t i o n , some of the explanatory models of h e a l t h and i l l n e s s found in the l i t e r a t u r e of medicine and n u r s i n g are reviewed. T r a d i t i o n a l biomedical p e r s p e c t i v e s , and a number of the s o c i o - c u l t u r a l p e r s p e c t i v e s on h e a l t h and i l l n e s s advanced by the h e a l t h care d i s c i p l i n e s , are presented in t h i s d i s c u s s i o n . These p e r s p e c t i v e s represent the p r o f e s s i o n a l domain in Kleinman's framework. T r a d i t i o n a l Biomedical P e r s p e c t i v e s Medicine t r a d i t i o n a l l y views h e a l t h as a s t a t e where dis e a s e i s absent (Redlick, 1976; Sebag, 1979). From the d i s e a s e o r i e n t e d 28 p e r s p e c t i v e of modern medicine, a healthy i n d i v i d u a l i s i d e n t i f i e d as one with no detected a b n o r m a l i t i e s . Sebag (1979) s t a t e s "when no i r r e g u l a r i t i e s are found, an i n d i v i d u a l i s presumed to be heal t h y " . T h i s focus on h e a l t h i s d e s c r i b e d r a t h e r b l u n t l y by R e d l i c h (1976). He s t a t e s : From a medical point of view, h e a l t h i s the absence of dis e a s e . Once a p a t i e n t i s no longer diseased or, to put i t d i f f e r e n t l y , has reached a c e r t a i n minimal s t a t e of he a l t h , he i s of no f u r t h e r concern to the p h y s i c i a n ... fis no human being i s completely f r e e from d i s e a s e over a l i f e t i m e , there i s no p e r f e c t enduring s t a t e of h e a l t h even at a minimal l e v e l , (p. 270) Health i s viewed as a s t a t e harder to c o n c e p t u a l i z e than di s e a s e (Sebag, 1979), and thus a concept not well understood w i t h i n s o c i e t y i n general. In order to b e t t e r understand h e a l t h , i n v e s t i g a t o r s are f o c u s i n g on s o c i a l environment, c u l t u r e and e t h n i c i t y as v a r i a b l e s which impact upon the d e f i n i t i o n and experience of h e a l t h . S o c i o - C u l t u r a l P e r s p e c t i v e s w i t h i n the Health Care D i s c i p l i n e s Brody (1973) and Blum (1983) present us with a systems concept of the i n d i v i d u a l . Human beings i n t h i s context are seen to possess a h i e r a r c h i c a l s t r u c t u r e w i t h i n t h e i r p e r s o n a l i t y , with each p e r s o n a l i t y l e v e l , or subsystem, c o n t r i b u t i n g to i n d i v i d u a l h e a l t h . Health i s seen as an ongoing process, m a n i f e s t i n g c o n t i n u a l change and a c t i v i t y as the i n d i v i d u a l responds to environmental 29 c h a l l e n g e s . Systems theory, d e s c r i b i n g h e a l t h as a composite of the somatic, p s y c h i c and s o c i a l p e r s o n - l e v e l areas, i s p a r t i c u l a r l y r e l e v a n t to the study of h e a l t h as a c u l t u r a l l y - s p e c i f i c c o n s t r u c t , in that i t acknowledges the importance of the surrounding n a t u r a l and s o c i a l environment in the experience of h e a l t h (Blum, 1983). The theory and r e s e a r c h of Kleinman (1978a,b, 1980, 1984) represent a s i g n i f i c a n t body of knowledge p e r t a i n i n g to h e a l t h and i l l n e s s as concepts c o n s t r u c t e d by s o c i o - c u l t u r a l f a c t o r s . P a t r i c k , Sittampalam, S o m e r v i l l e , C a r t e r and Bergner (1985) are other authors whose re s e a r c h emphasizes the importance of c r o s s - c u l t u r a l comparison of h e a l t h values. Zola, in h i s 1966 r e s e a r c h on the i n t e r p l a y of c u l t u r e and symptoms, found that v a r i o u s e t h n i c groups accept u b i q u i t o u s c o n d i t i o n s d i f f e r e n t l y and p e r c e i v e the same dis e a s e d i f f e r e n t l y due to c u l t u r a l l y s p e c i f i c value systems. He l i n k e d s o c i o - c u l t u r a l background to c o n t r a s t i n g d e f i n i t i o n and response to the same experience. The main p e r s p e c t i v e s and p r i n c i p l e s of c u r r e n t c r o s s - c u l t u r a l n u r s i n g knowledge are presented next. The work of key authors and r e s e a r c h e r s i s d i s c u s s e d . C r o s s - c u l t u r a l n u r s i n g views. L e i n i n g e r ' s monumental work in the f i e l d of t r a n s c u l t u r a l n u r s i n g (1967, 1970a,b, 1977, 1984, 1985a,b; 1988) has c o n t r i b u t e d s i g n i f i c a n t l y to awareness of the need f o r c u l t u r a l l y r e l e v a n t n u r s i n g care. Other nurses have a l s o r e c o g n i z e d the i n f l u e n c e of c u l t u r e on d e f i n i t i o n of h e a l t h and s t r e s s the importance of understanding the p e r c e p t i o n of c l i e n t s 30 from other c u l t u r e s (Branch & Paxton, 1976; Carpio, 1981; Dobson, 1983, 1985; Fong, 1985; Hancock & Perkins, 1985; Mercer, 1981; •rque, Bloch & Monrroy, 1983; Shubin, 1980; Sobralske, 1985; Spector, 1979; Theiderman, 1986; White, 1977). A growing volume of nursing r e s e a r c h supports t h i s c r o s s - c u l t u r a l focus (Anderson, 1981a, 1985a,b, 1987; Anderson & Chung, 1982; Anderson & Lynam, 1987; Majumdar & Carpio, 1988; S t r u s e r , 1985). Examination of the work of a number of these authors expands on the d i s c u s s i o n of c r o s s - c u l t u r a l l i t e r a t u r e presented in the e a r l i e r chapter, and provides an understanding of the c u r r e n t s t a t e of n u r s i n g knowledge in t h i s area. L e i n i n g e r (1970a), advocating a blending of a n t h r o p o l o g i c a l and n u r s i n g p e r s p e c t i v e s , emphasizes the f o l l o w i n g c o n t r i b u t i o n s which anthropology has made to n u r s i n g theory: (1) a " c r o s s - c u l t u r a l and comparative p e r s p e c t i v e of man"; (2) "the c u l t u r e concept"; (3) "the h o l i s t i c and c u l t u r a l context approach in the understanding of man"; (4) "the r e a l i z a t i o n that h e a l t h and i l l n e s s s t a t e s are s t r o n g l y i n f l u e n c e d and often p r i m a r i l y determined by the c u l t u r a l background of an i n d i v i d u a l " (p. 21-22). These p e r s p e c t i v e s are s i g n i f i c a n t to an i n v e s t i g a t i o n of the meaning of h e a l t h from the vantage point of the i n d i v i d u a l l o c a t e d in h i s / h e r unique l i f e context. Hancock and P e r k i n s (1985) have noted that c u l t u r a l values, b e l i e f s and a t t i t u d e s h e a v i l y i n f l u e n c e both the s t a t e of h e a l t h 31 i t s e l f and i n d i v i d u a l p e r c e p t i o n of the s t a t e . White (1977) emphasizes the f a c t that peoples of e t h n i c o r i g i n cannot be viewed as i d e n t i c a l with the mainstream pop u l a t i o n , and underscores the need f o r c r o s s - c u l t u r a l s e n s i t i v i t y . Shubin (1980) advocates that nurses assess the c u l t u r a l f a c t o r s in h e a l t h and recognize the unique p e r s p e c t i v e of the c l i e n t . C arpio (1981), f o c u s i n g s p e c i f i c a l l y on the needs of adolescent immigrants, emphasizes the need f o r c u l t u r a l s e n s i t i v i t y w i t h i n m u l t i c u l t u r a l Canadian s o c i e t y . In her d i s c u s s i o n of c u l t u r a l d i v e r s i t y in h e a l t h and i l l n e s s , Bpector (1979) proposes that nurses need to " f i n d a way of c a r i n g f o r the c l i e n t that matches that c l i e n t ' s p e r c e p t i o n of the h e a l t h problem and treatment of that problem" (p. 75). Spector makes that f o l l o w i n g s i g n i f i c a n t statement: Health and i l l n e s s can be i n t e r p r e t e d and explained in terms of personal experience and e x p e c t a t i o n s . There are many ways in which we can d e f i n e ... h e a l t h or i l l n e s s and determine what these s t a t e s mean ... in our d a i l y l i v e s . We must l e a r n from our own c u l t u r e and e t h n i c backgrounds how to be healthy, how to r e c o g n i z e i l l n e s s , and how to be i l l . Furthermore, the meanings attached to the notions of h e a l t h and i l l n e s s are r e l a t e d to the b a s i c , culture-bound values by which we d e f i n e a given experience and p e r c e p t i o n . (1979, p. 75) Anderson's extensive q u a l i t a t i v e r e s e a r c h (1981a, 1985a,b; Anderson & Chung, 1982; Anderson & Lynam, 1987) on h e a l t h as a 32 s o c i o - c u l t u r a l c o n s t r u c t , and the p e r c e p t i o n s which v a r i o u s c u l t u r a l groups hold r e g a r d i n g h e a l t h and i l l n e s s , has been noted. Studying the c u l t u r a l i n f l u e n c e s on parents' p e r c e p t i o n s of t h e i r c h i l d ' s long term i l l n e s s , Anderson found that h e a l t h goals were d e f i n e d d i f f e r e n t l y w i t h i n d i f f e r e n t c u l t u r a l c ontexts. Chinese and white f a m i l i e s were found to d i f f e r in terms of what they e n v i s i o n e d as a d e s i r a b l e h e a l t h s t a t e f o r t h e i r c h r o n i c a l l y i l l c h i l d r e n . Chinese parents regarded contentment and happiness as the most d e s i r a b l e h e a l t h goals, while white parents c o n s i d e r e d n o r m a l i z a t i o n to be the most important (Anderson & Chung, 1982). A core f a c e t of Anderson's work i s the proposal that h e a l t h and i l l n e s s i n c o r p o r a t e the i n d i v i d u a l ' s s u b j e c t i v e experience. R e f e r r i n g to the work of Kleinman, Anderson (1985b) presents a framework f o r examining the s o c i o - c u l t u r a l context of h e a l t h and i l l n e s s which provides guidance f o r nursing p r a c t i c e and research. Sobralske's account of the p e r c e p t i o n s of h e a l t h held by Navajo Indians i l l u s t r a t e s how s o c i o - c u l t u r a l f a c t o r s shape p e r s p e c t i v e s on h e a l t h . Since s i m i l a r r e s e a r c h on the p e r c e p t i o n of h e a l t h held by i n d i v i d u a l s from India i s u n a v a i l a b l e , the f o l l o w i n g overview of Sobralske's r e s e a r c h f i n d i n g s i s p e r t i n e n t to t h i s d i s c u s s i o n . Sobralske's (1985) study of Navajo Indians i s an example of c r o s s - c u l t u r a l enquiry s p e c i f i c a l l y f o c u s i n g on i n d i v i d u a l p e r c e p t i o n of h e a l t h . She notes that the language employed by a c u l t u r a l group r e f l e c t s that c u l t u r e ' s unique view of world phenomena; a view which i n c l u d e s d e f i n i t i o n of h e a l t h . Sobralske 33 mentions, f o r example, that Navajo h e a l t h p e r c e p t i o n s may be b e t t e r understood when t h e i r "concept of the universe being in motion" i s recognized. Navajo i n d i v i d u a l s found i t very d i f f i c u l t " i f not i m p o s s i b l e " to d e f i n e h e a l t h , because "they have never r e a l l y thought about the d e f i n i t i o n of h e a l t h before" and regard h e a l t h as i n s e p a r a b l e from t h e i r surroundings. The i n s e p a r a b i l i t y of r e l i g i o n and h e a l t h was a l s o found to be an e s s e n t i a l component of Navajo c u l t u r e . Navajo p e r c e p t i o n of h e a l t h i s compared to "a s t a t e of not being v u l n e r a b l e to t h r e a t e n i n g s i t u a t i o n s " , and i n c l u d e s "a p e r f e c t body and mind" in harmony with the surrounding environment (p. 35-37). Sobralesky's (1985) r e s e a r c h underscores the f a c t that c o n c e p t u a l i z a t i o n s of h e a l t h , as well as the terms used to denote h e a l t h , vary among c u l t u r e s . Consequently, e f f e c t i v e ways of asking an i n d i v i d u a l about h i s / h e r p e r c e p t i o n of h e a l t h , and encouraging a d e s c r i p t i o n of the phenomenon, may d i f f e r from c u l t u r e to c u l t u r e . Health and I l l n e s s : T r a d i t i o n a l B e l i e f s h e l d i n India Although Western ( a l l o p a t h i c ) medicine i s common in India, p r a c t i t i o n e r s of indigenous medicine are c o n s u l t e d by p r o f e s s i o n a l s and laymen a l i k e from a l l s o c i a l c l a s s e s , r e l i g i o u s backgrounds, e t h n i c and o c c u p a t i o n a l groups. The t r a d i t i o n a l indigenous Indian medical systems are Ayurveda (based upon S a n s k r i t t e x t s ) , Yunani or Greek medicine (based on A r a b i c and 34 P e r s i a n t e x t s ) , and Siddha (a South Indian system of humoral medicine). Homeopathy i s a l s o p r a c t i c e d widely ( L e s l i e , 1978). The Ayurvedic and Yunani concepts of h e a l t h and i l l n e s s are "coded i n t o domestic c u l t u r e , c u i s i n e , r e l i g i o u s r i t u a l and the popular c u l t u r e of p h y s i c i a n s t r a i n e d in cosmopolitan medicine". In a d d i t i o n to c o n s u l t i n g cosmopolitan (Western) and indigenous p h y s i c i a n s , laymen o f t e n c o n f e r with Holy men, p r i e s t s and a s t r o l o g e r s concerning h e a l t h problems ( L e s l i e , 1978, p. 244). Pn overview of the e s s e n t i a l t e n e t s of Ayurveda provides u s e f u l i n f o r m a t i o n on the concepts of h e a l t h and i l l n e s s t r a d i t i o n a l to India. •beyesekere (1978) notes two fundamental f e a t u r e s of the Ayurvedic system of medicine: (1) "an indigenous conception of the body (and mind) and i t s funct i o n s " ; (2) "indigenous conceptions of body physiology and f u n c t i o n s are in t u r n d e r i v e d from the metaphysical and p h i l o s o p h i c a l conceptions of a great t r a d i t i o n , or, as in a l l t r a d i t i o n s , of an even l a r g e r c o s m o l o g i c a l or sacred world view" (p. 256). In accordance with the Ayurvedic t r a d i t i o n , Indian c u l t u r e sees the i n d i v i d u a l having a fundamental r e l a t i o n s h i p with nature. The universe i s seen to be made up of the f i v e elements: earth, water, f i r e , a i r and space. These f i v e elements are the b a s i c u n i t s of a l l l i f e , and comprise the 3 humors (wind, b i l e " f i r e " and phlegm "water") and the 7 p h y s i c a l components of the body (food j u i c e , blood, f l e s h , f a t , bone, marrow, and semen). Health 35 i s seen as a s t a t e where the three humors are in optimal balance, with harmonious f u n c t i o n i n g of p h y s i o l o g i c a l systems. I l l n e s s i s b e l i e v e d to a r i s e when there i s imbalance of the 3 humors, and consequent d i s e q u i l i b r i u m in the i n d i v i d u a l . Foods a l s o c o n t a i n the 5 elements and are c l a s s i f i e d as hot or c o l d , with c e r t a i n foods taken at d i f f e r e n t times of the year and f o r d i f f e r e n t p h y s i c a l c o n d i t i o n s so that h e a l t h i s maintained (Helman, 1984; Kakar, 1982; Dbeyesekere, 1978; Vora, 1986). Indian t h e r a p e u t i c approaches are l a r g e l y based upon r e s t o r a t i o n of p h y s i c a l and mental balance or e q u i l i b r i u m . Kakar (1982) e x p l a i n s t h i s Ayurvedic p e r s p e c t i v e : The r e s t o r a t i o n of the balance of b o d i l y elements and thus of h e a l t h r e s t s on the consumption of environmental matter in the r i g h t form, p r o p o r t i o n , combination and at the r i g h t time ... seasons, p l a n t s , n a t u r a l substances and c o n s t i t u e n t s of the body are a l l i n t e g r a t e d i n a complex yet a e s t h e t i c a l l y elegant theory of p h y s i c a l h e a l t h as an e q u i l i b r i u m of somatic and environmental elements, (p. 231) L i t e r a t u r e on I n d i v i d u a l s from India American l i t e r a t u r e i s e s s e n t i a l l y devoid of d i s c u s s i o n of the c u l t u r e of i n d i v i d u a l s from India. As a r e f l e c t i o n of the e t h n i c p o p u l a t i o n s found in the United S t a t e s , American c r o s s - c u l t u r a l h e a l t h care l i t e r a t u r e focuses p r i m a r i l y on the Black, L a t i n o / H i s p a n i c , Japanese, Chinese, Vietnamese and American Indian communities. The m a j o r i t y of textbooks on c r o s s - c u l t u r a l 36 h e a l t h care, such as those by Spector (1979), Harwood (1981), Orque, Bloch and Monrroy (1983) and Branch and Paxton (1976), do not i n c l u d e i n f o r m a t i o n about i n d i v i d u a l s from India. Canadian and B r i t i s h p u b l i c a t i o n s c o n s t i t u t e the main sources of i n f o r m a t i o n on the p e r s p e c t i v e s of i n d i v i d u a l s from India. Dobson's (1983, 1985) work with v a r i o u s e t h n i c groups in B r i t a i n looks at the problems immigrants from India encounter w i t h i n the Western h e a l t h care system. Dobson, however, d i s c u s s e s the Sikh community almost e x c l u s i v e l y . P r e v i o u s l y noted Canadian l i t e r a t u r e r e f l e c t s a s i m i l a r focus on i n d i v i d u a l s of the Sikh f a i t h (Buchignani, 1977, 198©; Detels et a l . , 1966; Gibson et a l . , 1987; S t r u s e r , 1985). Ps d e s c r i b e d in the subsequent s e c t i o n , accounts and r e s e a r c h on Indo-Canadians' h e a l t h concerns and p e r s p e c t i v e s on h e a l t h are l i m i t e d in number. Indo-Canad ians In the d i s c u s s i o n of the background to the problem, a p o r t i o n of the a v a i l a b l e l i t e r a t u r e on Indo-Canadians was c i t e d . Most l i t e r a t u r e was seen to concentrate on h i s t o r i c a l and s o c i o - c u l t u r a l c h a r a c t e r i s t i c s of the Indo-Canadian community r a t h e r than h e a l t h i s s u e s . L i t e r a t u r e d i s c u s s i n g Indo-Canadians i n the province of B r i t i s h Columbia has focused f o r the most part on the l i f e and h i s t o r y of the Sikh community (Pmes & I n g l i s , 1973; Bains, 1974). The study by D r a k u l i c and Tanaka (1981) focuses on the Sikh p o p u l a t i o n but a l s o r e f e r s to I s m a i l i i s m and Hinduism. Most p u b l i s h e d r e s e a r c h on Indo-Canadians i s d i s e a s e 37 o r i e n t e d . That of Ough (1976), Smith (1971), D e t e l s et a l . (1966), Gibson et a l . (1987) and Bindra & Gibson (1986) has a l r e a d y been noted as r e p r e s e n t a t i v e of t h i s r e s e a r c h . I n v e s t i g a t i o n s examining Indo-Canadian h e a l t h concerns are scarce, and s t u d i e s a d d r e s s i n g s u b j e c t i v e experience of h e a l t h r e l a t e d i s s u e s , such as c h i l d b i r t h ( Struser, 1985), are r a r e . Anderson's (1985a) research'on the h e a l t h concerns and h e l p - s e e k i n g experiences of Indo-Canadian and Greek women immigrants i s an example of i n v e s t i g a t i o n f o c u s i n g on Indo-Canadians from a f e m i n i s t p e r s p e c t i v e . To date no Indo-Canadian r e s e a r c h d e a l i n g s p e c i f i c a l 1 y with men has been found. The recent q u a n t i t a t i v e study by Majumdar and Carpio (1988) i n v e s t i g a t i n g the concept of h e a l t h among s e l e c t e d Canadian e t h n i c p o p u l a t i o n s , i s noteworthy as apparently the only r e s e a r c h which s p e c i f i c a l l y aims f o r s u b j e c t i v e d e s c r i p t i o n of the Indo-Canadian view on h e a l t h . T h i s survey r e c o g n i z e s the importance of c u l t u r e i n d e f i n i t i o n of h e a l t h , and o f f e r s d e s c r i p t i o n of the concept of h e a l t h a c c o r d i n g to four components: p h y s i c a l , s o c i a l , mental and l i f e s t y l e . The study, however, does not focus e x c l u s i v e l y on the p e r s p e c t i v e s of Indo-Canadians and presents an somewhat narrow account of the h e a l t h phenomenon. The study a l s o f a i l s to s p e c i f y the c h a r a c t e r i s t i c s of the Indo-Canadian sample p o p u l a t i o n i n terms of Hindu, Sikh or other e t h n i c i t y . L i t e r a t u r e on the h e a l t h concerns of Indo-Canadians i s l a r g e l y not grounded i n r e s e a r c h . Thompson's (1987) a r t i c l e on h e a l t h promotion s t r a t e g i e s f o r Indo-Canadian women in Ottawa i s good example of recent j o u r n a l l i t e r a t u r e f o c u s i n g on the h e a l t h needs of t h i s group, but l a c k i n g the support of data from a c t u a l n u r s i n g r e s e a r c h . Summary To provide a background f o r viewing the cur r e n t study, v a r i o u s p e r s p e c t i v e s on the concept of h e a l t h have been presented through an overview of s e l e c t e d l i t e r a t u r e . fin account of the d e r i v a t i o n of the word " h e a l t h " o f f e r e d support f o r h o l i s t i c p e r s p e c t i v e s on h e a l t h , and introduced d i s c u s s i o n of some c o n t r a s t i n g views on h e a l t h presented i n the s o c i o l o g i c a l , p h i l o s o p h i c a l and t h e o l o g i c a l l i t e r a t u r e . T r a d i t i o n a l biomedical p e r s p e c t i v e s on h e a l t h and i l l n e s s , as well as some of the s o c i o - c u l t u r a l p e r s p e c t i v e s found w i t h i n the h e a l t h care d i s c i p l i n e s , were summarized i n terms of t h e i r c o n t r i b u t i o n to c o n c e p t u a l i z a t i o n of h e a l t h . T h i s d i s c u s s i o n shows that h e a l t h remains an a b s t r a c t concept with parameters that vary c r o s s - c u l t u r a l l y and ac c o r d i n g to s o c i a l context. P. major p o r t i o n of t h i s review was concerned with c r o s s - c u l t u r a l n u r s i n g l i t e r a t u r e because of i t s s i g n i f i c a n c e to the c u r r e n t i n v e s t i g a t i o n . The nursing theory of L e i n i n g e r was emphasized as fundamental to c r o s s - c u l t u r a l n u r s i n g enquiry. The work of Anderson (1985b) was noted as cur r e n t q u a l i t a t i v e n u r s i n g r e s e a r c h f o c u s i n g on h e a l t h and i l l n e s s w i t h i n the s o c i o - c u l t u r a l context, which s p e c i f i c a l l y supports the focus of the cur r e n t 39 st udy. The key concepts from Sobralske's (1985) study on the Navajo p e r c e p t i o n of h e a l t h were d i s c u s s e d as p a r t i c u l a r l y u s e f u l background to the present r e s e a r c h , given the lack of s i m i l a r s t u d i e s s p e c i f i c to the Indo-Canadian c u l t u r e . Majumdar and C a r p i o s ' recent (1988) r e s e a r c h on the h e a l t h p e r s p e c t i v e s of v a r i o u s Canadian e t h n i c groups was noted as apparently the only i n v e s t i g a t i o n framed to s p e c i f i c a l l y address Indo-Canadian views on h e a l t h . Majumdar and C a r p i o s ' study, however, provides a q u a n t i t a t i v e d e s c r i p t i o n of h e a l t h r e s t r i c t e d to the four components: l i f e s t y l e , s o c i a l , mental and p h y s i c a l , and f a i l s to s p e c i f y d e t a i l s of the c h a r a c t e r i s t i c s of the Indo-Canadian sample po p u l a t i o n . Examination of the primary concepts of India's b e l i e f system surrounding h e a l t h and i l l n e s s provided f u r t h e r v a l u a b l e background i n f o r m a t i o n f o r t h i s study. Current h e a l t h l i t e r a t u r e on the Indo-Canadian community was found to c o n t a i n v i r t u a l l y no i n f o r m a t i o n on t h i s c u l t u r a l group's unique p e r s p e c t i v e s on h e a l t h . The need f o r r e s e a r c h i n t h i s area i s c l e a r l y evident. The d i s c u s s i o n i n t h i s chapter r e v e a l e d h e a l t h as a m u l t i d i m e n s i o n a l concept i n f l u e n c e d by s o c i o - c u l t u r a l f a c t o r s . The s u p p o r t i n g framework d i r e c t e d the r e s e a r c h e r to adopt the phenomenological approach in order to gain i n s i g h t i n t o the i n d i v i d u a l s u b j e c t i v e experience of h e a l t h . Chapter one provided an i n t r o d u c t i o n to the t h e o r e t i c a l and methodological p e r s p e c t i v e s which grounded t h i s r e s e a r c h . The f o l l o w i n g chapter w i l l present d e t a i l s of the methodology used in the study. 4-1 CHAPTER 3: METHODOLOGY Thi s chapter d e s c r i b e s the methodology used i n t h i s q u a l i t a t i v e r e s e a r c h . The s e l e c t i o n of study p a r t i c i p a n t s and procedures f o r data c o l l e c t i o n and a n a l y s i s , as d i r e c t e d by the phenomenological method, are presented. The conduct and outcome of the p i l o t study c a r r i e d out p r i o r to commencement of a c t u a l r e s e a r c h are d e t a i l e d i n the p r e l i m i n a r y d i s c u s s i o n on p a r t i c i p a n t s e l e c t i o n . Issues of r e l i a b i l i t y and v a l i d i t y i n phenomenological r e s e a r c h are con s i d e r e d in c o n c l u s i o n . S e l e c t i o n of P a r t i c i p a n t s T h e o r e t i c a l sampling T h i s phenomenological r e s e a r c h employed t h e o r e t i c a l , nonprobabi1 i t y sampling methods, i n c o n t r a s t to the p r o b a b i l i t y sampling methods used i n deductive, q u a n t i t a t i v e r e s e a r c h . In t h e o r e t i c a l sampling the r e s e a r c h e r u l t i m a t e l y s e l e c t s the study p a r t i c i p a n t s a c c o r d i n g to the needs and d i r e c t i o n of the research. T h e o r e t i c a l , or s e l e c t i v e , sampling i s based upon the premise that " a l l a c t o r s in a s e t t i n g are not eq u a l l y informed about the knowledge sought by the r e s e a r c h e r " . Some i n d i v i d u a l s i n a group or c u l t u r e are viewed as more knowledgeable and r e c e p t i v e to being i n t e r v i e w e d than others (Morse, 1986, p. 183). Morse (1986) provides the f o l l o w i n g r e l e v a n t d e s c r i p t i o n of the assumptions u n d e r l y i n g n o n - p r o b a b i l i t y sampling: Because the r e s e a r c h e r i s i n t e r e s t e d i n meaning, 42 understanding a concept, and making sense of the s e t t i n g , and the object i s to obt a i n data that are comprehensive, r e l e v a n t , and d e t a i l e d , the voluminous verbatim notes, i n bulk alone, l i m i t s the sample s i z e . Thus, because of the small sample s i z e and the time and e f f o r t r e q u i r e d to c o l l e c t data, i t i s e s s e n t i a l that the r e s e a r c h e r maximize o p p o r t u n i t i e s to ob t a i n the most i n s i g h t f u l data p o s s i b l e , (p. 183) T h e o r e t i c a l sampling i s used to enter i n t o the context of the phenomenon under study, obtain r i c h data samples and advance theory (Duffy, 1985; Stern, 1980). This r e s e a r c h method does not aim to t e s t theory. The method i n v o l v e s a c o n t i n u a l decision-making process which continues u n t i l data c a t e g o r i e s are sa t u r a t e d and no new themes emerge. Adequacy of the sample i s accomplished when "the r e s e a r c h e r experiences redundancy i n d e s c r i p t i o n s " , i n that " r e p e t i t i o n of statements r e g a r d i n g the phenomenon under study" occurs (Parse et a l . , 1985, p. 17). Morse d e s c r i b e s t h i s completeness of sampling as the point at which theory "does not have any gaps, makes sense, and has been confirmed" (1986, p. 184). The r e s e a r c h e r using n o n - p r o b a b i l i t y sampling techniques does not aim to g e n e r a l i z e study f i n d i n g s to the p o p u l a t i o n at large in the t r a d i t i o n a l q u a n t i t a t i v e sense. In q u a l i t a t i v e r esearch, phenomena are examined in " t h e i r n a t u r a l s e t t i n g s " , and r e s e a r c h e r s argue that " g e n e r a l i z a b i 1 i t y i s i t s e l f something of an i l l u s i o n " as no s i t u a t i o n can ever be e n t i r e l y context f r e e . 43 Q u a l i t a t i v e r e s e a r c h f i n d i n g s are a p p l i c a b l e in that the "general can be found i n the p a r t i c u l a r " (Sandelowski, 1986, p. 31). Sandelowski s t a t e s that a p p l i c a b i l i t y of q u a l i t a t i v e r e s e a r c h should be viewed in terms of the c r i t e r i o n of f i t t i n g n e s s . R e f e r r i n g to the work of Guba and L i n c o l n (1981), Sandelowski d e s c r i b e s t h i s " f i t " as f o l l o w s : ft study meets the c r i t e r i o n f o r f i t t i n g n e s s when i t s f i n d i n g s can ' f i t ' i n t o contexts o u t s i d e the study s i t u a t i o n and when i t s audience views i t s f i n d i n g s as meaningful and a p p l i c a b l e i n terms of t h e i r own experiences. In a d d i t i o n , the f i n d i n g s of the study ... ' f i t ' the data from which they are d e r i v e d . The f i n d i n g s are well-grounded i n the l i f e experiences s t u d i e d and r e f l e c t t h e i r t y p i c a l and a t y p i c a l elements, (p. 32) C r i t e r i a f o r S e l e c t i o n P a r t i c i p a n t s were s e l e c t e d on the b a s i s of t h e i r experience with the phenomenon under study and t h e i r a b i l i t y to communicate t h i s experience (Anderson, 1985a; Knaack, 1984). The c r i t e r i a f o r s e l e c t i o n of study p a r t i c i p a n t s were as f o l l o w s : Indo-Canadians between the age of 25-60 years who were born in India and had r e s i d e d i n Canada f o r at l e a s t 5 years at the time of the study; a l l p a r t i c i p a n t s were to be able to read and converse i n E n g l i s h so that the r e s e a r c h e r could conduct a l l i n t e r v i e w s independently without the a i d of a t r a n s l a t o r . R a t i o n a l e f o r C r i t e r i a v. Hindu r a t h e r than Sikh i n d i v i d u a l s were s e l e c t e d f o r t h i s 4 4 study because: (1) they represent a group towards which l e s s r e s e a r c h has been focused; (2) i t was assumed that t h i s group's command of the E n g l i s h language would be s u p e r i o r to that of Sikh i n d i v i d u a l s coming from the r u r a l Punjab, s i n c e Hindu immigrants g e n e r a l l y come from urban s e t t i n g s ; (3) the r e s e a r c h e r i s f a m i l i a r with the t r a d i t i o n s and l i f e w a y s of the Hindu community. Adul t s were s e l e c t e d as study p a r t i c i p a n t s because longer years of l i f e experience imply g r e a t e r f a m i l i a r i t y with the phenomenon of h e a l t h , and increased a b i l i t y to provide d e t a i l e d v e r b a l d e s c r i p t i o n of that phenomenon to the r e s e a r c h e r . A wide age range (between 25-60 years) was set f o r p a r t i c i p a n t s in order to assure access to an adequate sample. F i r s t generation Indo-Canadians who had r e s i d e d in Canada f o r a minimum of f i v e years at the time of the study were s p e c i f i e d to insure p a r t i c i p a n t s ' grounding in India's c u l t u r e , as well as o p p o r t u n i t y f o r experience of l i f e in Canadian s o c i e t y . A maximum time of r e s i d e n c e i n Canada was not s p e c i f i e d f o r the sample. Both men and women were inc l u d e d in the study in order that the r e s e a r c h e r d i s c o v e r i f any s e x - d i f f e r e n c e i s i n v o l v e d in the p e r c e p t i o n of h e a l t h , and avoid the e r r o r of assuming that both sexes respond s i m i l a r l y . The f a c t that the p a r t i c i p a n t s were E n g l i s h speaking Hindus q u i t e l i k e l y determined a c e r t a i n s o c i a l s t a t u s , and no formal socio-economic c r i t e r i a were s p e c i f i e d f o r the sample. S e l e c t i o n Procedure In t h i s study p a r t i c i p a n t s were r e c r u i t e d through an informal 45 network of c o l l e a g u e s and acquaintances advised of the i n v e s t i g a t i o n focus by the r e s e a r c h e r . I n i t i a l contact with p o t e n t i a l p a r t i c i p a n t s was made through a person from t h i s i n f o r m a l network. The network person presented s u i t a b l e p o t e n t i a l study p a r t i c i p a n t s with a formal l e t t e r of i n f o r m a t i o n d e s c r i b i n g the purpose and conduct of the study, and a consent to contact form (see Appendix A). P o t e n t i a l informants i n t e r e s t e d in study p a r t i c i p a t i o n signed the consent to contact form. They then communicated t h e i r consent f o r contact by e i t h e r d i r e c t l y phoning the r e s e a r c h e r , or r e t u r n i n g the consent to contact form to the r e s e a r c h e r through the network person. In the case of those p a r t i c i p a n t s who contacted the r e s e a r c h e r by phone to convey t h e i r consent f o r contact, the r e s e a r c h e r obtained the signed consent to contact form at the i n i t i a l meeting with the p a r t i c i p a n t . Only one d e v i a t i o n from the d e s c r i b e d procedure f o r i n d i c a t i o n of consent f o r contact occurred. Dne p o t e n t i a l informant mailed the signed consent to contact form to the r e s e a r c h e r ; t h i s i n d i v i d u a l , however, was not i n c l u d e d i n the study as an adequate sample s i z e had a l r e a d y been obtained. A f t e r r e c e i v i n g consent f o r contact, the r e s e a r c h e r communicated with the p o t e n t i a l informants by phone, and d e s c r i b e d the study i n d e t a i l and answered any questions at that time. An i n i t i a l i n t e r v i e w was arranged with i n d i v i d u a l s who agreed to p a r t i c i p a t e i n the study. Upon a c t u a l meeting, the r e s e a r c h e r r e a s s e s s e d the p o t e n t i a l p a r t i c i p a n t ' s s u i t a b i l i t y f o r i n c l u s i o n 46 in the study, and the formal consent form f o r p a r t i c i p a t i o n in the study (see Appendix B) was signed. A t o t a l of 16 i n d i v i d u a l s were contacted by the informal network f o r study p a r t i c i p a t i o n . Of these 16, 3 people contacted were not i n t e r e s t e d i n t a k i n g part i n the study, and 2 people f a i l e d to i n d i c a t e t h e i r consent f o r contact to the r e s e a r c h e r although they had i n i t i a l l y expressed i n t e r e s t in study p a r t i c i p a t i o n to the network person. The r e s e a r c h e r thus obtained a l i s t of 11 knowledgeable and r e c e p t i v e p a r t i c i p a n t s . From t h i s l i s t of 11, 3 persons were not inc l u d e d in the study as a sample s i z e of eight was determined s u f f i c i e n t . The f i n a l sample c o n s i s t e d of s i x women and two men. Fo l l o w i n g d e s c r i p t i o n of the p i l o t study, the c h a r a c t e r i s t i c s of the sample p o p u l a t i o n w i l l be presented in d e t a i l . The P i l o t Study P r i o r to a c t u a l conduct of the research, informal meetings were arranged with two Indo-Canadian women contacted through the informal network ac c o r d i n g to the c r i t e r i a and contact procedure d e s c r i b e d f o r the study sample. At t h i s time the r e s e a r c h e r t e s t e d the i n i t i a l t r i g g e r q u e s t i o n s (see Appendix C). The two i n d i v i d u a l s p a r t i c i p a t i n g i n the p i l o t study were asked the i n i t i a l t r i g g e r q u e s t i o n s and requested to provide feedback on the app r o p r i a t e n e s s of these q u e s t i o n s f o r e l i c i t i n g a d e s c r i p t i o n of the phenomenon of h e a l t h from Indo-Canadians. The in f o r m a t i o n obtained from the p i l o t t e s t a s s i s t e d i n the f o r m u l a t i o n of a p p r o p r i a t e t r i g g e r q u e s t i o n s to be 47 used in the re s e a r c h i n t e r v i e w s (see Appendix D). Both of the p i l o t i n t e r v i e w s were tape-recorded, and one was t r a n s c r i b e d by the r e s e a r c h e r . The c o n s i d e r a t i o n s f o r p r o t e c t i o n of human r i g h t s o u t l i n e d f o r the a c t u a l r e s e a r c h were observed d u r i n g the p i l o t study. P i l o t i n t e r v i e w s were commenced subsequent to r e c e i p t of formal approval f o r conduct of the res e a r c h study. The p i l o t t e s t i n g procedure was completed during the f i r s t two weeks of the re s e a r c h p e r i o d . P i l o t Study: R e s u l t s The i n i t i a l t r i g g e r q u e s t i o n s were r e v i s e d a c c o r d i n g to the feedback obtained during the p i l o t t e s t . The two p i l o t p a r t i c i p a n t s d e s c r i b e d the i n i t i a l t r i g g e r questions as "good", and o f f e r e d two suggestions r e g a r d i n g a l t e r a t i o n of the t e s t q u e s t i o n s : (1) that study p a r t i c i p a n t s be asked about the r e l a t i o n s h i p between food and h e a l t h ; (2) that the r e s e a r c h e r should ask about the phenomenon of h e a l t h using the q u e s t i o n "What do you thi n k about h e a l t h " ? The p i l o t p a r t i c i p a n t s suggested that t h i s s i n g l e q u e s t i o n would e l i c i t a d e s c r i p t i o n of h e a l t h i n terms of h e a l t h maintenance, f e e l i n g s about h e a l t h and a c t i v i t i e s c a r r i e d out when healthy. C h a r a c t e r i s t i c s of the Sample The f i n a l study sample c o n s i s t e d of eight Indo-Canadians, of whom s i x were female and two were male. P a r t i c i p a n t s ' ages ranged from 28 to 5& years, with the major i t y of study p a r t i c i p a n t s being in t h e i r middle 40s. 48 The sample was q u i t e homogeneous in terms of socio-economic s t a t u s and l i f e s t y l e . fill p a r t i c i p a n t s were of comfortable means. Of the 8 study p a r t i c i p a n t s , 6 l i v e d i n f r e e - s t a n d i n g homes, and 2 in attached d w e l l i n g s . Three women i n the study were homemakers, of whom one o c c a s i o n a l l y worked outside the home. The remaining study p a r t i c i p a n t s were c u r r e n t l y employed i n p r o f e s s i o n a l occupations; two i n d i v i d u a l s in t h i s group were self-employed. Seven of the eight p a r t i c i p a n t s l i v e d in the Greater Vancouver area, and one l i v e d in a nearby m u n i c i p a l i t y . Seven of the p a r t i c i p a n t s were married and one was a s i n g l e parent, fill p a r t i c i p a n t s had c h i l d r e n , with 6 p a r t i c i p a n t s having c h i l d r e n l i v i n g at home. fit the time of the study, the p a r t i c i p a n t s ' time of re s i d e n c e in Canada ranged from 6 1/2 to 21 years; most p a r t i c i p a n t s had l i v e d in Canada f o r about 12 years. One female p a r t i c i p a n t had l i v e d in the United Kingdom f o r three years p r i o r to coming to Canada; the remaining p a r t i c i p a n t s had come to Canada d i r e c t l y from India. P a r t i c i p a n t s were born in var i o u s areas of northern India, i n c l u d i n g the Punjab. Se v e r a l p a r t i c i p a n t s commented to the r e s e a r c h e r that they had not given much thought to the meaning of h e a l t h p r i o r to the re s e a r c h e r ' s i n t e r v i e w s . The two male p a r t i c i p a n t s i n d i c a t e d f a m i l i a r i t y with t r a d i t i o n a l Indian medicines, and spontaneously d e s c r i b e d t h i s subject matter dur i n g the course of the in t e r v i e w s . One p a r t i c i p a n t , d e s c r i b i n g the sense of pri d e she had in her c u l t u r a l background, mentioned the f a c t that she "couldn't be Canadian without her Indian h e r i t a g e " . For t h i s p a r t i c i p a n t , 49 being Canadian meant being Indo-Canadian. Data C o l l e c t i o n The phenomenological method aims to c o n s t r u c t human experience as i t i s l i v e d . E l i c i t a t i o n of a d e s c r i p t i o n of the phenomenon under study i s a process of e x p l o r a t i o n shared by the r e s e a r c h e r and p a r t i c i p a n t . Data are not considered to be biased by the r e s e a r c h e r ' s f u l l involvement i n the c o l l e c t i o n of data nor the " s u b j e c t i v i t y " of the p a r t i c i p a n t s . "Meaning" i s r a t h e r c o n s t r u c t e d as an " i n t e i — s u b j e c t i v e " phenomenon during the encounter between the r e s e a r c h e r and p a r t i c i p a n t . In order to a p p r e c i a t e human experience from the p e r s p e c t i v e of the i n d i v i d u a l , the phenomenological approach r e q u i r e s the r e s e a r c h e r to use " b r a c k e t i n g " during data c o l l e c t i o n . During t h i s process, the r e s e a r c h e r lays a s i d e "the n a t u r a l a t t i t u d e to the world" r e s u l t i n g from personal biography, so that the " l a y e r s of meaning" which give r i s e to i n t e r p r e t e d experience are removed ( O i l e r , 198&, p. 72-73). In other words, the r e s e a r c h e r r e c o g n i z e s that the mind i s not a " t a b l a r a s a " , and that the world appears a c c o r d i n g to the way the i n d i v i d u a l c o n s t r u c t s and i n t e r p r e t s i t . B r a c k e t i n g i s the process of d e l i b e r a t e l y suspending, or s e t t i n g a side, these preconceived n o t i o n s about the meaning of the phenomenon under study so that "bias in r e f l e c t i o n on experience" i s c o n t r o l l e d and the experience i s brought i n t o " c l e a r e r focus" (Knaack, 1984; O i l e r , 1982, p. 179). 50 Data C o l l e c t i o n ; The Procedure Data were c o l l e c t e d through 15 in-depth, s e m i - s t r u c t u r e d i n t e r v i e w s . Interviews v a r i e d from 45 to 90 minutes i n d u r a t i o n , with most i n t e r v i e w s c o n t i n u i n g f o r a one hour period. In s e v e r a l i n s t a n c e s , the r e s e a r c h e r ' s a c t u a l contact time with the study p a r t i c i p a n t s extended past that of the formal i n t e r v i e w s . fill i n t e r v i e w s were conducted i n the p a r t i c i p a n t s ' own homes. In the major i t y of cases, i n t e r v i e w s were completed without any d i s t u r b a n c e from e x t e r n a l sources. In those few instances where a f a m i l y member or household pet entered the room during the course of the int e r v i e w , the d i s c u s s i o n between the r e s e a r c h e r and the p a r t i c i p a n t was not apparently a f f e c t e d . Interviews were tape-recorded on an a u d i o - r e c o r d e r and t r a n s c r i b e d verbatim. Ten i n t e r v i e w s were t r a n s c r i b e d by the r e s e a r c h e r h e r s e l f . L i s t e n i n g to and t r a n s c r i b i n g the i n t e r v i e w s proved very h e l p f u l aspects of the data c o l l e c t i o n and a n a l y s i s process. T h i s experience a f f o r d e d the r e s e a r c h e r a d d i t i o n a l i n s i g h t i n t o the p a r t i c i p a n t s ' sentiments and emphasis placed on c e r t a i n p o r t i o n s of the i n t e r v i e w s , and so encouraged the r e s e a r c h e r ' s entrance i n t o the p a r t i c i p a n t s ' d e s c r i p t i o n s of the phenomenon. In the case of the 5 i n t e r v i e w s t r a n s c r i b e d by a t y p i s t , the r e s e a r c h e r l i s t e n e d to the i n t e r v i e w s i n d e t a i l during the process of c o r r e c t i n g and p r o o f i n g the s c r i p t . A l l p a r t i c i p a n t s s t a t e d that they f e l t comfortable with i n t e r v i e w s being tape-recorded. During the second set of i n t e r v i e w s p a r t i c i p a n t s were notably more r e l a x e d than during the 51 i n i t i a l i n terview, and appeared to t o t a l l y ignore the presence of the a u d i o - r e c o r d e r . The r e s e a r c h e r e s t a b l i s h e d good rapport with a l l p a r t i c i p a n t s d u r i n g the i n i t i a l meeting. The vast m a j o r i t y of p a r t i c i p a n t s i n d i c a t e d that they had enjoyed d e s c r i b i n g t h e i r p e r c e p t i o n s on h e a l t h to the re s e a r c h e r . D e t a i l s of the Interviews and C o n s t r u c t i o n of Accounts Two i n t e r v i e w s were conducted with 7 of the 8 study p a r t i c i p a n t s ; one p a r t i c i p a n t d e c l i n e d a second i n t e r v i e w . The f i r s t set of i n t e r v i e w s i n v o l v e d the r e s e a r c h e r asking one or a l l of the formulated t r i g g e r q u e s t i o n s (see Appendix D) to i n i t i a t e d e s c r i p t i o n of the phenomenon. Once the r e s e a r c h e r had asked an i n i t i a l t r i g g e r q u e s t i o n the d i r e c t i o n of the i n t e r v i e w was determined by the p a r t i c i p a n t , with the r e s e a r c h e r ' s subsequent ques t i o n s concerning the h e a l t h experience being framed a c c o r d i n g to the p a r t i c i p a n t ' s responses and f r e e d e s c r i p t i o n of the phenomenon. Each i n t e r v i e w b u i l t upon e a r l i e r i n t e r v i e w s so that a complete account of the phenomenon under study was obtained. In accordance with phenomenological methodology, the second set of i n t e r v i e w s permitted the r e s e a r c h e r to v a l i d a t e and c l a r i f y data c o l l e c t e d d u r i n g the i n i t i a l i n t e r v i e w s . During the second in t e r v i e w , the p a r t i c i p a n t was a l s o able to expand f u r t h e r on the d e s c r i p t i o n of h e a l t h and d e s c r i b e deeper l e v e l s of p e r c e p t i o n i n t o the phenomenon. Upon c o n c l u s i o n of the second i n t e r v i e w a l l p a r t i c i p a n t s s t a t e d that they had exhausted the theme of d i s c u s s i o n . T h i s was a l s o the o p i n i o n of the r e s e a r c h e r . The two 52 s e t s of i n t e r v i e w s r e s u l t e d i n r i c h data p r o v i d i n g a concrete d e s c r i p t i o n of the phenomenon of h e a l t h . F i e l d Notes The r e s e a r c h e r maintained f i e l d notes throughout the study to complement the data obtained in the i n t e r v i e w s . The method of keeping f i e l d notes i s unique to each r e s e a r c h e r (Spradley, 1979). In t h i s study the r e s e a r c h e r kept a j o u r n a l c o n t a i n i n g notes d e s c r i b i n g the ambience and conduct of each interview, as well as the r e s e a r c h e r ' s personal experiences of i n t e r a c t i o n with the study p a r t i c i p a n t s . P r o t e c t i o n of Human Rights Informed Consent Each study p a r t i c i p a n t r e c e i v e d a d e t a i l e d e x p l a n a t i o n of the r e s e a r c h purpose and procedure i n the form of o r a l and p r i n t e d i n f o r m a t i o n . The network person or r e s e a r c h e r provided the p a r t i c i p a n t with a l e t t e r d e t a i l i n g i n f o r m a t i o n about the study, and an accompanying consent to contact form (see Appendix A). A f t e r d i s c u s s i o n with the r e s e a r c h e r at the i n i t i a l meeting, each p a r t i c i p a n t was asked to s i g n a w r i t t e n consent form f o r p a r t i c i p a t i o n in the study (see Appendix B). The p a r t i c i p a n t ' s s i g n a t u r e on each form acknowledged r e c e i p t of a copy of the form. Each p a r t i c i p a n t was given the o p p o r t u n i t y to ask questions concerning the r e s e a r c h p r i o r to s i g n i n g the consent form. P a r t i c i p a n t s were informed that p a r t i c i p a t i o n i n the study was e n t i r e l y v o l u ntary, and that they might r e f u s e p a r t i c i p a t i o n and remove themselves from the study, or r e f u s e to answer any 53 q u e s t i o n s without negative consequences of any kind. P a r t i c i p a n t s were a l s o informed that they might request erasure of any tape, or p o r t i o n of a tape, at any time during the study without negative consequences of any kind. Written permission was obtained from each p a r t i c i p a n t f o r i n t e r v i e w s to be tape-recorded; t h i s was inc l u d e d in the formal consent form d e s c r i b e d above. C o n f i d e n t i a l i t y C o n f i d e n t i a l i t y of a l l c o l l e c t e d data was assured. The audio tapes were t r a n s c r i b e d and coded so that the names of the p a r t i c i p a n t s d i d not appear on the t r a n s c r i p t s , and were known only to the r e s e a r c h e r . Any names used by p a r t i c i p a n t s during the course of the i n t e r v i e w were removed from the t r a n s c r i p t by the re s e a r c h e r . The r e s e a r c h e r , her t h e s i s committee, and a t y p i s t were the only i n d i v i d u a l s with access to recorded data. Study p a r t i c i p a n t s were assured that t h e i r i d e n t i t y would not be r e v e a l e d e i t h e r during the course of the study or in any unpublished or publ i s h e d m a t e r i a l s . . The U n i v e r s i t y of B r i t i s h Columbia Behavioural Science Screening Committee f o r Research I n v o l v i n g Human Subjects provided an e t h i c a l review of the study, and granted approval before a c t u a l r e s e a r c h was commenced (see Appendix E). The process phenomenological Data A n a l y s i s of constant comparative a n a l y s i s used study d i r e c t s the r e s e a r c h e r to begin in dat a 54 a n a l y s i s as soon as data are c o l l e c t e d (Morse, 1986). Data c o l l e c t i o n and data a n a l y s i s are n e c e s s a r i l y d e s c r i b e d as separate events f o r p r a c t i c a l purposes. In r e a l i t y , , however, the r e s e a r c h e r ' s " a n a l y t i c a l and o b s e r v a t i o n a l a c t i v i t i e s run c o n c u r r e n t l y (and) there i s temporal o v e r l a p p i n g of o b s e r v a t i o n a l and a n a l y t i c a l work. The f i n a l stage of a n a l y s i s ( o c c u r r i n g a f t e r o b s e r v a t i o n has ceased) becomes, then, a p e r i o d f o r b r i n g i n g f i n a l order i n t o p r e v i o u s l y developed ideas" (Lofland, 1971, p. 118). Parse and co-workers (1985) d e s c r i b e t h i s process in s l i g h t l y d i f f e r e n t terms. Accord ing to these i n v e s t i g a t o r s , data a n a l y s i s i n v o l v e s the t h r e e - f o l d process of i n t u i t i n g (or contemplative d w e l l i n g with the data), a n a l y z i n g and d e s c r i b i n g . In the f i n a l process of d e s c r i p t i o n of the f i n d i n g s , the r e s e a r c h e r moves from the s u b j e c t ' s d e s c r i p t i o n to a s t r u c t u r a l d e f i n i t i o n of the phenomenon. In t h i s study data a n a l y s i s was c a r r i e d out a c c o r d i n g to the methodology advanced by Knaack (1984) as o u t l i n e d by C o l a i z z i (1978) and G i o r g i (1975). F o l l o w i n g each int e r v i e w , audio-tapes were t r a n s c r i b e d verbatim. As the i n i t i a l step i n formal data a n a l y s i s , the t r a n s c r i p t s were read through s e v e r a l times to give the r e s e a r c h e r an o v e r a l l sense of the s u b j e c t ' s d e s c r i p t i o n of the phenomenon of h e a l t h . In the next step of a n a l y s i s , s i g n i f i c a n t statements p e r t a i n i n g d i r e c t l y to the t o p i c under i n v e s t i g a t i o n were e x t r a c t e d from the data. Meaning u n i t s (which remained f a i t h f u l 55 to the o r i g i n a l data) were formulated as they emerged from s i g n i f i c a n t statements. Using c r e a t i v e i n s i g h t , the r e s e a r c h e r contemplated upon and r e f i n e d each unit in order to capture the most complete meaning, r e t a i n i n g the informant's own words as much as p o s s i b l e d u r i n g t h i s process. The above steps were repeated f o r each t r a n s c r i p t . In accordance with the t e n e t s of t h e o r e t i c a l sampling (Morse, 1986), meaning u n i t s e x t r a c t e d from the f i r s t t r a n s c r i p t were compared with those e x t r a c t e d from the second t r a n s c r i p t , and so f o r t h , u n t i l a point of s a t u r a t i o n was reached where redundancy in d e s c r i p t i o n s of the phenomenon occurred. Formulated meaning u n i t s e x t r a c t e d from the d e s c r i p t i o n s were then organized i n t o c l u s t e r s of themes r e g a r d i n g the experience of h e a l t h . The r e s e a r c h e r at t h i s point r e f e r r e d back to the o r i g i n a l t r a n s c r i p t s to v a l i d a t e the c l u s t e r s of themes. Any c o n t r a d i c t o r y themes were recognized as r e a l and v a l i d , and the data r e t a i n e d . The non-redundant c l u s t e r s of themes were i n t e g r a t e d i n t o a comprehensive d e s c r i p t i o n of the experience of h e a l t h . T h i s a n a l y s i s was v a l i d a t e d with the study p a r t i c i p a n t s d u r i n g the second i n t e r v i e w s by asking i f the a n a l y s i s c o r r e c t l y d e s c r i b e d t h e i r experience of the phenomenon. fis a r e s u l t of t h i s a n a l y t i c a l process, the r e s e a r c h e r c o n s t r u c t e d a phenomenological d e s c r i p t i o n of the e s s e n t i a l s t r u c t u r e of h e a l t h as experienced by the study p a r t i c i p a n t s . 56 R e l i a b i l i t y and V a l i d i t y of Data The i s s u e s of r e l i a b i l i t y and v a l i d i t y in q u a l i t a t i v e r e s e a r c h c e n t e r around t r u t h f u l n e s s , c r e d i b i l i t y , a u d i t a b i l i t y and confirmabi1 i t y . In order to f u l f i l l these requirements, data must f a i t h f u l l y r e f l e c t the human experience, and the i n v e s t i g a t o r ' s " d e c i s i o n t r a i l " must be c l e a r so that other r e s e a r c h e r s can e a s i l y f o l l o w the l i n e of reasoning (Sandelowski, 1986). In phenomenological s t u d i e s , the r e s e a r c h e r c o l l e c t s data p e r s o n a l l y . The v a l i d i t y of data depends upon the a b i l i t y of the r e s e a r c h e r to "tap the s u b j e c t ' s experiences" and use the method of " r e d u c t i o n or b r a c k e t i n g " of personal p r e s u p p o s i t i o n s . Obtained data i s accepted to have both face and content v a l i d i t y under the assumption that the p a r t i c i p a n t s "have experience with the r e s e a r c h t o p i c and can communicate t h e i r experiences". Feedback and c l a r i f i c a t i o n of c o l l e c t e d data are employed to assure the v a l i d i t y and r e l i a b i l i t y of the r e s e a r c h ; as the r e s e a r c h e r can "never assume that s/he understands the meaning of the phenomenon" (Knaack, 1984, p. 112-113). Sandelowski (1986) has d i s c u s s e d s t r a t e g i e s f o r a c h i e v i n g r i g o r i n q u a l i t a t i v e r e s e a r c h . A u d i t a b i l i t y i s achieved by the d e s c r i p t i o n , e x p l a n a t i o n or j u s t i f i c a t i o n of a number of steps i n the r e s e a r c h process such as how the i n v e s t i g a t o r f i r s t became i n t e r e s t e d in the t o p i c and how the t o p i c i s viewed. The r e s e a r c h r e p o r t i t s e l f i s of great importance in the achievement of a u d i t a b i l i t y . C r e d i t a b i 1 i t y i s managed by the r e s e a r c h e r adopting such s t r a t e g i e s as checking f o r the r e p r e s e n t a t i v e n e s s of data, 57 t r i a n g u l a t i o n , and o b t a i n i n g v a l i d a t i o n of data from s u b j e c t s . The establishment of a u d i t a b i l i t y , t r u t h value and a p p l i c a b i l i t y a chieves confirmabi1 i t y . The t r u t h value of the rese a r c h i s determined by phenomena and experiences being d i s c o v e r e d as they are p e r c e i v e d by the s u b j e c t s (Sandelowski, 1986). Summary The phenomenological p e r s p e c t i v e determined the methodology employed i n t h i s study. T h i s chapter has d e s c r i b e d the methods of p a r t i c i p a n t s e l e c t i o n , data c o l l e c t i o n and data a n a l y s i s u t i l i z e d i n t h i s r e s e a r c h consequent to i n t e r p r e t a t i o n and implementation of the phenomenological approach. Issues of r e l i a b i l i t y and v a l i d i t y in q u a l i t a t i v e r e s e a r c h were d i s c u s s e d i n b r i e f . T h e o r e t i c a l sampling methods d i r e c t e d s e l e c t i o n of p a r t i c i p a n t s meeting the s t a t e d c r i t e r i a f o r i n c l u s i o n in t h i s r e s e a r c h . The i n i t i a l p i l o t study provided d i r e c t i o n f o r f o r m u l a t i o n of s p e c i f i c t r i g g e r questions to i n i t i a t e p a r t i c i p a n t s ' d e s c r i p t i o n of the phenomenon duri n g s e m i - s t r u c t u r e d i n t erv i ews. Shared, in-depth e x p l o r a t i o n and dialo g u e between the r e s e a r c h e r and p a r t i c i p a n t s a c c o r d i n g to the phenomenological method, r e s u l t e d i n c o n s t r u c t i o n of a d e s c r i p t i o n of h e a l t h based upon informant accounts. The f o l l o w i n g chapter presents the r e s u l t s of t h i s study. CHAPTER 4: PERCEPTION OF HEALTH: THE MEANING OF HEALTH TO INDO-CANADIANS 58 T h i s chapter presents the r e s u l t s of the study, using p a r t i c i p a n t accounts to d e s c r i b e how p a r t i c i p a n t s experienced h e a l t h . Although the s u b j e c t i v e experience of h e a l t h i s unique, by v i r t u e of the d i s t i n c t s o c i a l , c u l t u r a l and h i s t o r i c a l f a c t o r s inherent in the i n d i v i d u a l l i f e context, study p a r t i c i p a n t s d e s c r i b e d the h e a l t h phenomenon in a s t r i k i n g l y s i m i l a r manner. During data c o l l e c t i o n and a n a l y s i s , c e n t r a l themes emerged which were common to the d e s c r i p t i o n s of h e a l t h provided by a l l p a r t i c i p a n t s . A f i n a l o r d e r i n g of the common c e n t r a l themes, and r e f i n i n g of p r e v i o u s l y developed ideas, led to the f o r m u l a t i o n of a d e f i n i t i v e a n a l y t i c framework f o r the re s e a r c h f i n d i n g s . T h i s coherent "general design", or framework, supporting a n a l y t i c a l d e s c r i p t i o n of data, r e p r e s e n t s a "set of l o g i c a l l y i n t e r r e l a t e d i d e a s " d i s c e r n e d by the r e s e a r c h e r a f t e r contemplating upon the data f o r an i n t e n s i v e p e r i o d (Lofland, 1971, p. 124). This f i n a l a n a l y t i c framework i s used to organize the data presented i n t h i s chapter, and r e p r e s e n t s the fundamental meaning of h e a l t h f o r the Indo-Canadians who p a r t i c i p a t e d i n t h i s study. It p rovides a v i s i o n of h e a l t h true to the accounts of i n d i v i d u a l study p a r t i c i p a n t s , and i n c l u d e s the e s s e n t i a l aspects of each p a r t i c i p a n t ' s d e s c r i p t i o n of the phenomenon. When study p a r t i c i p a n t s d e s c r i b e d t h e i r experience of h e a l t h , they l o c a t e d i t w i t h i n the o v e r a l l context of doing normal 59 a c t i v i t i e s . P a r t i c i p a n t s ' d e s c r i p t i o n s of doing normal a c t i v i t i e s t h e r e f o r e make up the f i r s t s e c t i o n of t h i s chapter, along with an i n t r o d u c t o r y d i s c u s s i o n of the importance which p a r t i c i p a n t s a s c r i b e d to h e a l t h . T h i s o v e r a l l context of doing normal a c t i v i t i e s frames two c e n t r a l themes, or l e v e l s of d e s c r i p t i o n of h e a l t h , a r i s i n g from p a r t i c i p a n t accounts. The f i r s t l e v e l of d e s c r i p t i o n focuses p r i m a r i l y on the c o n d i t i o n of the p h y s i c a l body and e x p l a i n s h e a l t h i n terms of complete h e a l t h , p a r t i a l h e a l t h , and s i c k n e s s ; a three phase continuum r e f e r r e d to here as "the three phases of the h e a l t h experience". The second l e v e l of d e s c r i p t i o n e x p l a i n s h e a l t h i n r e l a t i o n to the mind and other f a c t o r s i n f l u e n c i n g h e a l t h . These two l e v e l s of d e s c r i p t i o n t ogether represent a h o l i s t i c view of h e a l t h , and c o n s t i t u t e the second and t h i r d s e c t i o n s of t h i s chapter r e s p e c t i v e l y . A schematic and n a r r a t i v e d e s c r i p t i o n of the f i n a l a n a l y t i c framework w i l l now be presented. 60 H e a l t h : The Most Important Thing i n L i f e DOING NORMAL ACTIVITIES: A) The Three Phases of the Health Experience Complete Health - P a r t i a l Health - S i c k n e s s : 1) Complete He a l t h : - Body and mind t o g e t h e r : T o t a l unit healthy - Doing h a p p i l y , doing well - E n e r g e t i c r e s i s t a n c e - Independence and c o n t r o l 2) P a r t i a l H e a l t h : - Can do with e f f o r t , and not well - Decreased energy and r e s i s t a n c e - Decreased independence and c o n t r o l — Temporary and bothersome 3) S i c k n e s s : - Cannot do, cannot f u l f i l l r e s p o n s i b i l i t i e s - Low energy and r e s i s t a n c e - Dependence, lack of c o n t r o l - Serious, permanent, worrisome - Return to h e a l t h , or c h r o n i c i l l n e s s and death B) F a c t o r s i n f l u e n c i n g the Health S t a t e : 1) The Mind: - Worry (mental s t r e s s ) - P o s i t i v e mental a t t i t u d e 2) E x t e r n a l F a c t o r s - Diet and e x e r c i s e - Sleep and c l e a n l i n e s s - Use of medicines - M a i n t a i n i n g r o u t i n e - Working ou t s i d e of the home - Home atmosphere Fi g u r e 2: Components of the Framework. 61 DOING NORMAL ACTIVITIES Do ing We 1 EXTERNAL FACTORS MIND Med i c i n e s Sleep Diet Maintain ing Rout ine E x e r c i se Work ing o u t s i d e of the home C l e a n l i n e s s Home At mosphere Worry P o s i t i v e Mental Att itude F a c t o r s I n f l u e n c i n g Health 1 ^^^V Doi ing Happily Complete Health it P a r t i a l Health CAN DO BUT NOT WELL CANNOT DO NORMAL ROUTINE 1 Chronic I l l n e s s De*ath 4 F i g u r e 3: Schematic D e s c r i p t i o n of the Framework from the P a r t i c i p a n t s ' P e r s p e c t i v e H e a l t h : The Most Important Thing i n L i f e P a r t i c i p a n t s d e s c r i b e d h e a l t h as something of great importance to them in t h e i r l i v e s , a resource which allowed them to c a r r y out l i f e a c t i v i t i e s as well as a source of happiness. Health was seen as something of fundamental worth to a l l people. One p a r t i c i p a n t d e s c r i b e d h e a l t h as "the f i r s t and foremost happiness i n l i f e " ; others spoke of h e a l t h as something f a r more v a l u a b l e than e i t h e r w o rldly wealth or possessions. The importance of h e a l t h was explained i n terms of how i t allows a person to do t h i n g s . The f o l l o w i n g accounts i l l u s t r a t e the v a r i o u s p e r s p e c t i v e s p a r t i c i p a n t s o f f e r e d on h e a l t h as an e s s e n t i a l resource f o r being able to do e v e r y t h i n g i n l i f e . P = P a r t i c i p a n t R = Researcher P: Well, h e a l t h i s very important, you know. I th i n k one should r e a l l y take care of h e a l t h f i r s t before anything e l s e . R: flh huh. P: Yeah. Because i f you're not healthy you j u s t can't do anything. So a l l your dreams, or whatever you want to do, a l l your wishes so h e a l t h i s I t h i n k the f i r s t t h i n g to look a f t e r . R: The most important t h i n g ? P: The most important t h i n g , yeah. P: That (health) means a l o t to you. That means the world t you, you know, you're being healthy and being f i t . Because i f you are not, doesn't matter what you have got, you have got a l l the wealth in the world, but i f you are not healthy what can you do with i t ? P: That's (health i s ) the most important t h i n g i n l i f e . I f you are not healthy, you are nowhere. R: Health i s the best t h i n g ? P: Health i s the best t h i n g in l i f e . R: The most important t h i n g in l i f e , you're saying. P: That's r i g h t . R: Because i t allows you to do everything? P: Whatever I want to do. P: — Health i s important i n every case, you Know. Whatever you want to do, the h e a l t h comes f i r s t . The importance of h e a l t h was d e s c r i b e d i n terms of happiness. One p a r t i c i p a n t s t a t e d that h i s a t t i t u d e s about h e a l t h stemmed from h i s ch i l d h o o d experiences and upbringing in India. He explained that elementary school t e x t books i n India commonly c o n t a i n a le s s o n or parable about the importance of h e a l t h i n 1 i f e . P: When we were c h i l d , the f i r s t lesson that we were taught i n school, i f I were to quote that lesson, t h a t ' s a G u j a r a t i t i t l e , a p r o v i n c i a l language i n India, "Pahelu sukh te j a t e narya": the f i r s t and foremost happiness i s the h e a l t h . We always thought that h e a l t h i s the most important t h i n g in l i f e . These accounts d e s c r i b i n g the importance of h e a l t h , and provide a f i t t i n g i n t r o d u c t i o n to the f o l l o w i n g d i s c u s s i o n of the o v e r a l l context w i t h i n which p a r t i c i p a n t s experienced h e a l t h : doing normal act i v i t i es. Part i c i pants' Doing Normal A c t i v i t i e s d e s c r i p t i o n s of the h e a l t h experience were 64 l o c a t e d w i t h i n the o v e r a l l context of doing normal a c t i v i t i e s . When the r e s e a r c h e r asked p a r t i c i p a n t s how they f e l t about h e a l t h , or what t h e i r experience of h e a l t h was, d e s c r i p t i o n s were p r i m a r i l y in terms of being able to do normal a c t i v i t i e s . When d i r e c t l y questioned r e g a r d i n g the " f e e l i n g s a s s o c i a t e d with h e a l t h " , p a r t i c i p a n t s s t a t e d that they f e l t good, or f e l t happy when they were healthy. These f e e l i n g s of happiness, contentment, or " f e e l i n g good", however, stemmed from being able to c a r r y out the a c t i v i t i e s when healthy. The f o l l o w i n g s e c t i o n examines how p a r t i c i p a n t s d e s c r i b e d normal a c t i v i t i e s . What Normal A c t i v i t i e s Are As the r e s e a r c h e r explored p a r t i c i p a n t d e s c r i p t i o n s , i t became c l e a r that doing d a i l y a c t i v i t i e s was viewed as a normal l i f e process i n t i m a t e l y l i n k e d to h e a l t h . P a r t i c i p a n t s explained normal a c t i v i t i e s as the d a i l y d u t i e s a s s o c i a t e d with i n d i v i d u a l l i f e r o l e s and r e s p o n s i b i l i t i e s , as we l l as those a c t i v i t i e s they p e r s o n a l l y wanted to engage i n . Upon f u r t h e r r e f l e c t i o n , however, p a r t i c i p a n t s g e n e r a l l y s t a t e d that the t h i n g s they "wanted to do" were, i n f a c t , t h e i r d u t i e s and r o u t i n e a c t i v i t i e s . D e s c r i p t i o n s of normal a c t i v i t i e s v a r i e d in terms of s p e c i f i c d e t a i l s , as each person's l i f e i n c l u d e d d i s t i n c t personal, f a m i l y and s o c i a l f a c t o r s . The f o l l o w i n g accounts i l l u s t r a t e how p a r t i c i p a n t s e x p l a i n e d normal a c t i v i t i e s i n terms of d u t i e s and d a i l y r o u t i n e s . R: So "normal" means normal a c t i v i t i e s means what? P: The d a i l y l i f e a c t i v i t i e s . 65 R: So, how do "normal" and " d a i l y a c t i v i t i e s " r e l a t e ? P: They're the same. You go to school. Do your, you know, r e g u l a r work. R: When you were t a l k i n g about normal a c t i v i t i e s , you s a i d "normal" d u t i e s . Do you see d u t i e s and a c t i v i t i e s as the same t h i n g , or i s there any d i f f e r e n c e ? P: No, they are the same t h i n g s . R: The same t h i n g s . Just a d i f f e r e n t word to d e s c r i b e the same th i n g ? what you do? P: Um hum. Another p a r t i c i p a n t e l a b o r a t e d on t h i s point, e x p l a i n i n g that "being normal" meant doing a c t i o n : R: Being normal then i s being able to do your d a i l y dut i es? P: Right. Yeah. R: So i t s more a being able to do than a f e e l i n g ? P: I t h i n k so. The f e e l i n g comes, you see, i f you are doing i t . R: Okay, so being "normal" means doing normally do i n h e a l t h — i n a s t a t e of g e t t i n g up, and you t o l d me showering, and working. P: Right. T h i s was expanded upon: R: So "being normal" i s i n terms of a c t i o n ? P: Yeah. That's r i g h t , a c t i o n , and then — yeah, same t h i n g you see. R: A c t i o n and what? P: And d u t i e s Other p a r t i c i p a n t s presented s i m i l a r views, i l l u s t r a t i n g the p e r c e p t i o n that d a i l y r o u t i n e and d u t i e s were viewed as synonyms. the t h i n g s you'd h e a l t h . Such as and going out, 66 The f o l l o w i n g accounts d e s c r i b e the nature of these d u t i e s : R: Your " d u t i e s " . Okay, could you t e l l me a l i t t l e b i t more about what you mean by your " d u t i e s " ? P: Well, these are my d u t i e s . You know, I'm supposed to look a f t e r my kids, look a f t e r my husband, and my mothe>—in-law. Do what I can do f o r them. R: find you can only do those t h i n g s when you are heal t h y ? P: Yeah. P: Well, ah, r o u t i n e , you know, when you are doing t h i n g s and loo k i n g a f t e r your f a m i l y and you know, s t a y i n g content. And you know, you t h i n k you have done a l l your d u t i e s and a l l that s t u f f . R: Ah, huh. You mentioned d u t i e s before when we t a l k e d a b i t about t h a t . P: Yeah, um hum. R: So t h a t ' s what you mean by a " r o u t i n e " r e a l l y ? P: Yeah, yeah. That's r i g h t , yeah. The kind of a c t i v i t i e s c o n s i d e r e d to be normal d a i l y r o u t i n e t h i n g s were f u r t h e r explained by one p a r t i c i p a n t as f o l l o w s : R: So "normal" to you, normal t h i n g s means again what e x a c t l y ? Could you e l a b o r a t e a minute on that ? P: Well, a l l my t h i n g s whatever I do, the housework, look a f t e r the kids and go out shopping. Normal a c t i v i t i e s were d e s c r i b e d by one p a r t i c i p a n t as those a c t i v i t i e s a person u s u a l l y does that do not harm, or ad v e r s e l y a f f e c t the body. R: How do you know what i s normal f o r you and what i s n ' t normal ? P: Okay, there i s not a v a l i d chart that t h i s i s normal, t h i s i s abnormal, but the t h i n g s which you have been doing and which has not ad v e r s e l y a f f e c t e d your otherwise d a i l y a c t i v i t i e s the next day or something l i k e t h a t . It s only f o r the person to judge from h i s own d a i l y look 67 in l i f e , that what i s normal f o r him, what i s abnormal f o r him. That person only has to f i n d out. R: Um hum. P: Something might be normal f o r me which would not be normal f o r you. R: A l r i g h t , could you t e l l me a l i t t l e b i t more about what "normal" means? What that term means? How you are using i t ? P: Normal i n the sense I meant, something which you K e e p doing and which does not hurt you. That's what I mean, normal. The same p a r t i c i p a n t e xplained that the work which a person u s u a l l y does, i s normal f o r him. He d e s c r i b e d doing h i s usual p r o f e s s i o n a l work versus suddenly t a k i n g on a job which he would be unaccustomed to, s t a t i n g that a person can adapt to a c t i v i t i e s which at f i r s t are not normal f o r him. P: But say, normal i n the sense that I'm used to doing t h i s type of work (his own p r o f e s s i o n a l work). And tomorrow i f I were to s t a r t working in a sawmill, i t s not normal f o r me. But i t s q u i t e r i g h t that i n course of time I would get used to t h a t . R: Yes. P: But i n the i n i t i a l stages i t would d e f i n i t e l y hurt me, i n the sense that every day eight hours work when I come home I f e e l so t i r e d , which doing t h i s job 10 hours a day I would not. That's what I mean by normal. R: So I t h i n k you're t e l l i n g me that normal means doing t h i n g s that don't a f f e c t your h e a l t h a d v e r s e l y ? P: Yeah. As I s a i d , but then those which are normal f o r me, may not be normal f o r another person, as I s a i d , because mine i s a d i f f e r e n t type of work. But i f I go and work i n a sawmill and p u l l logs R: Yes. P: t h a t ' s abnormal f o r me in the i n i t i a l stages. Quite f i n e that a f t e r a month there, I would become so used to that and I would not f e e l , and I would say that t h a t ' s the normal work f o r me. But i t s a qu e s t i o n of g e t t i n g 68 used to what i s normal and abnormal. P a r t i c i p a n t s a l s o d e s c r i b e d normal a c t i v i t i e s as the t h i n g s they wanted to do: R: So when you are healthy, what kinds of t h i n g s are you able to do i n your l i f e ? P: Whatever I want — any you know, l i k e i f I have the aim f o r music, or f o r concert, or f o r dancing, or f o r t e a c h i n g somebody, or you know, h e l p i n g out, v o l u n t e e r b a s i s or anything. Whatever. R: You're able to do whatever you f e e l l i k e doing, whatever you want to do? P: Yeah. Whatever I f e e l l i k e doing, yeah. P a r t i c i p a n t s spoke of h e a l t h i n terms of a complete h e a l t h , p a r t i a l h e a l t h and s i c k n e s s continuum, r e f e r r e d to here as the three phases of the h e a l t h experience. They explained how being completely healthy, p a r t i a l l y h e a lthy or s i c k a f f e c t e d , or  a l t e r e d , t h e i r a b i l i t y to do normal a c t i v i t i e s . P a r t i c i p a n t accounts d e s c r i b e d these three phases of the h e a l t h experience i n terms of how the c h a r a c t e r i s t i c s , or c o n d i t i o n s , of each phase impinged upon, or f a c i l i t a t e d c a r r y i n g out a c t i o n . The three phase continuum making up the h e a l t h experience i s now examined in i t s t o t a l i t y , to provide the context f o r subsequent d e s c r i p t i o n of the unique parameters of each phase. T h e T h r e e P h a s e s o f t h e H e a l t h E x p e r i e n c e : C o m p l e t e H e a l t h - P a r t i a l H e a l t h - S i c k n e s s P a r t i c i p a n t s ' e x p l a n a t i o n s of h e a l t h were i n e x t r i c a b l y r e l a t e d to the three phase "complete h e a l t h - p a r t i a l h e a l t h -s i c k n e s s " continuum (see f i g u r e 3 ) . fill p a r t i c i p a n t s without 69 e x c e p t i o n viewed h e a l t h in terms of complete h e a l t h and p a r t i a l h e a l t h and s i c k n e s s , although they used s l i g h t l y d i f f e r e n t terms to s i g n i f y the three phases and d e s c r i b e d the three phases with v a r y i n g degrees of s p e c i f i c i t y . Complete h e a l t h and s i c k n e s s were d e s c r i b e d the most c l e a r l y . S ickness was explained as a s t a t e d i a m e t r i c a l l y opposed to complete h e a l t h . P a r t i a l h e a l t h , i n c o n t r a s t , was d e s c r i b e d r a t h e r vaguely in most accounts as a nebulous s t a t e somewhere " i n between" complete h e a l t h and s i c k n e s s . The f o l l o w i n g account d e s c r i b e s the h e a l t h experience in terms of i t s three d i s t i n c t phases: complete h e a l t h , p a r t i a l h e a l t h and s i c k n e s s . The p a r t i c i p a n t here r e f e r s to the "in-between" phase of p a r t i a l h e a l t h as "i 1 1-hea 1th". P: Maybe i f I took being healthy i s the f i r s t stage, i l l -h e a l t h being the second stage — R: Um hum. P: — and t h i r d stage being s i c k n e s s or i l l . Okay? R: Yes. P: In whatever order you want to take i t . So, i f I had only three stages, the t h i r d stage i s being s i c k , second stage i s being i l l - h e a l t h , and f i r s t stage i s being p e r f e c t l y healthy. R: Yeah. P: Okay? find you could add any degrees to i t . Whatever degrees are there i n between. I mean, from one to ten. R: Okay. That's what I'm wondering r i g h t now. P: Yeah. Whichever way you want to s c a l e i t or measure i t . In terms of the body. Other informants d e s c r i b e d parts of t h i s continuum. The subsequent account focused on the t r a n s i t i o n from complete h e a l t h 7 0 to p a r t i a l h e a l t h . The p a r t i c i p a n t r e f e r s to complete h e a l t h as " h e a l t h " and p a r t i a l h e a l t h as " l e s s healthy", or " g e t t i n g i n t o a pro b1e m " . P: I'm, I f e e l okay, you know, I'm healthy, and I want to give a best of care to the p a t i e n t s . But supposing I hurt my back, and then I can't bend, can't do anything and then I would say: Yes, I don't f e e l good. Whether you can c a l l i t l e s s healthy, or g e t t i n g i n t o a problem. The movement from p a r t i a l h e a l t h to s i c k n e s s was explained in other accounts. In the f o l l o w i n g d e s c r i p t i o n , the p a r t i c i p a n t c l e a r l y d i s t i n g u i s h e d h e a l t h from s i c k n e s s , but was vague about the " i n between" p a r t i a l h e a l t h stage (which i s r e f e r r e d to here as "unhealth"). The p a r t i a l h e a l t h stage was explained as p o t e n t i a l l y p r o g r e s s i n g to s i c k n e s s . R: I'm j u s t wondering i f you see, you know, that you're healthy, and then i f you're not healthy, you're c a l l i n g that "being s i c k " ? Which I b e l i e v e you are. P: Yes. Well, healthy i s healthy. Ond when you are s i c k you are s i c k . so. R: Okay, so the word unhealthy means being s i c k , or i s that something e l s e ? P: No, s i c k i s s i c k . You've got some ailment or whatever I guess i t does mean the same t h i n g . R: Unhealthy means being s i c k ? P: Yes, unhealthy means would e v e n t u a l l y mean you are not i n f u l l h e a l t h . R: You mean so you'd be unhealthy, then i f you l e t that go on you could become s i c k ? P: You could become s i c k , yeah. Another p a r t i c i p a n t viewed t h i s p r o g r e s s i o n from p a r t i a l h e a l t h t s i c k n e s s s l i g h t l y d i f f e r e n t l y : P: I mean, i t could be, okay, a higher stage or a lower stag 71 — whatever you want to c a l l i t , of unhealthiness ( p a r t i a l h e alth) makes you s i c k . To summarize, h e a l t h was explained by p a r t i c i p a n t s with r e f e r e n c e to the three ph ase h e a l t h continuum. Although p a r t i c i p a n t s d e s c r i b e d these three phases with varying degrees of s p e c i f i c i t y , complete h e a l t h and s i c k n e s s were i d e n t i f i e d most c l e a r l y and perc e i v e d as opposite s t a t e s of experience. P a r t i c i p a n t s were l e s s p r e c i s e in t h e i r d e s c r i p t i o n s of p a r t i a l h e a l t h . The three phases (complete h e a l t h , p a r t i a l h e a l t h , s i c k n e s s ) were d i s t i n g u i s h e d p r i m a r i l y by the c o n d i t i o n of the p h y s i c a l body, although p a r t i c i p a n t s r e c o g n i z e d the body and mind as two in s e p a r a b l e aspects of the human person. (The r o l e of the mind in the three phases of the h e a l t h experience w i l l be d i s c u s s e d s e p a r a t e l y i n the l a s t s e c t i o n of t h i s c h a p t e r ) . P a r t i c i p a n t s d e s c r i b e d these three phases of the h e a l t h experience i n terms of c a p a c i t y f o r a c t i v i t y . They explained that i n d i v i d u a l a b i l i t y to c a r r y out normal a c t i v i t i e s was a f f e c t e d by the amounts of energy, r e s i s t a n c e (to disease and change), independence and c o n t r o l present i n each phase of the h e a l t h experience. E x i s t i n g measures of these four c h a r a c t e r i s t i c s of h e a l t h i n d i c a t e d whether a person was completely healthy, s i c k , or in the " i n between" stage of p a r t i a l h e a l t h , and supported the c a p a c i t y f o r normal a c t i o n inherent i n each phase (see f i g u r e s 2 & 3) . Each phase of the h e a l t h experience w i l l now be d i s c u s s e d . The parameters of complete h e a l t h are presented f i r s t . 72 Complete Health Being able to do normal a c t i v i t i e s well ( e f f e c t i v e l y ) , with a s s o c i a t e d f e e l i n g s of happiness and s a t i s f a c t i o n , was the main c h a r a c t e r i s t i c that d i s t i n g u i s h e d complete h e a l t h from p a r t i a l h e a l t h and s i c k n e s s . As w i l l be d i s c u s s e d l a t e r in t h i s s e c t i o n , the four c h a r a c t e r i s t i c s of the h e a l t h experience (energy, r e s i s t a n c e , independence and c o n t r o l ) were d e s c r i b e d as present in the greatest measure in complete h e a l t h . They were l i n k e d to the other d i s t i n c t i v e f e a t u r e s of complete h e a l t h d e s c r i b e d by p a r t i c i p a n t s : such as f e e l i n g f u l l of energy, being able to do a c t i o n without g e t t i n g t i r e d , being able to do t h i n g s without the help of other people, being i n c o n t r o l of one's l i f e , and so on. P a r t i c i p a n t s d e s c r i b e d complete h e a l t h v a r i o u s l y as: "general h e a l t h " , "100 percent healthy", " t o t a l h e a l t h " , "being okay", " p e r f e c t l y healthy", "being f i n e " and "being very healthy". One p a r t i c i p a n t explained complete h e a l t h as the main component of o v e r a l l w e l l - b e i n g . (Well-being, i t s e l f , viewed as a broader concept embracing l i f e a c t i v i t i e s , and f a m i l y and personal r e l a t i o n s h i p s i n a d d i t i o n to complete h e a l t h ) . As s t a t e d p r e v i o u s l y , p a r t i c i p a n t s viewed the mind and body as one u n i t . Complete h e a l t h meant that both mind and body were healthy. Body and Mind Together: The T o t a l Unit i n Balance and Harmony P a r t i c i p a n t s d e s c r i b e d complete h e a l t h as a t o t a l i t y , a s t a t e where they were both p h y s i c a l l y and mentally healthy. When p a r t i c i p a n t s spoke of " h e a l t h " i n general, they r e f e r r e d to the 73 s t a t e of complete h e a l t h , or general h e a l t h . The f o l l o w i n g accounts i l l u s t r a t e complete h e a l t h as a h o l i s t i c phenomenon. P: I never r e f e r to h e a l t h as p a r t l y mentally or p a r t l y p h y s i c a l l y because whenever the q u e s t i o n of h e a l t h , i f someone r e f e r s to i t , I always thought i t r e f e r s to the general h e a l t h , and i t covers the mental as well as phys i c a l . R: Okay. P: find t h a t ' s a l l I always say, " f i n e " . R: Okay. So you mean h e a l t h i s general h e a l t h ? P: General h e a l t h , yeah. I t s p h y s i c a l as well as mental, t h a t ' s how I take i t i n the e n t i r e t y . R: Health i n general means what then? P: L i k e , um, I'm not s u f f e r i n g from anything and I'm n i c e l y r e s t e d , and I'm going around doing e v e r y t h i n g that I have to and mentally I'm prepared f o r everything, and my mental h e a l t h i s a l r i g h t . L i k e I'm t h i n k i n g s t r a i g h t , and I'm not — l i k e I won't have to "I'm not too t i r e d and I can't do anything" — that sort of t h i n g . R: So i t seems you're t a l k i n g about your mental s t a t e and your p h y s i c a l , when you say general h e a l t h ? Is that r i ght ? P: Yeah, t h a t ' s r i g h t . R: I t s the two together t h a t ' s general h e a l t h ? P: Is general h e a l t h . R: How your mind i s and how you're p h y s i c a l l y f e e l i n g ? P: Yeah, um hum. P: I am. okay, l i k e I am mentally okay and I'm p h y s i c a l l y okay. R: What does "okay" mean? P: Means l i k e I have — my b r a i n i s p e r f e c t and my body's p e r f e c t . 74 The body and mind were d e s c r i b e d as i n s e p a r a b l e e n t i t i e s w h i c h make up t h e whole p e r s o n , and e x e r t an mutual i n f l u e n c e on each o t h e r . The f o l l o w i n g a c c o u n t s d e s c r i b e t h e u n i t y o f body and mind i n c o m p l e t e h e a l t h . R: Y o u ' r e c o n s i d e r i n g t h a t t h e mind i s i n v o l v e d i n h e a l t h as w e l l , you s a i d t h a t t h e two c a n ' t be s e p a r a t e d . P: Yes, t h a t ' s r i g h t , yeah. R: So you see mental h e a l t h and p h y s i c a l h e a l t h as s e p a r a t e t h i n g s , o r as t o g e t h e r i n y o u r h e a l t h ? P: T o g e t h e r as one u n i t , b e c a u s e body i s one u n i t , and mind i s p a r t o f body. Yeah. P: They a r e i n t e r r e l a t e d , t h e mind and body, you c a n n o t s e p a r a t e t h e two. P: To say p e r f e c t l y h e a l t h y you have t o be h e a l t h y b o t h ways, p h y s i c a l and m e n t a l . Then you a r e p e r f e c t h e a l t h y . I f one t h i n g i s wrong, l i k e i f you a r e p h y s i c a l l y s i c k , you a r e not p e r f e c t h e a l t h y . I f you a r e m e n t a l l y s i c k t h e n you a r e not p e r f e c t l y h e a l t h y . So j u s t t h e way i t i s , you know. So you j u s t c a n ' t d e f i n e y o u r s e l f t h a t you a r e a h e a l t h y p e r s o n e i t h e r way ( i f o n l y body o r o n l y mind i s h e a l t h y ) . C o m p l e t e h e a l t h was f u r t h e r d e s c r i b e d i n terms o f harmony between t h e mind and body, w i t h t h e " t o t a l u n i t " b e i n g i n a s t a t e o f h e a l t h : R: You s a i d t h a t i n a s t a t e o f h e a l t h , w hich I b e l i e v e you s a i d t h a t t h e mind and body a r e one — P: In harmony. R: i n harmony, and c a n ' t be s e p a r a t e d . P: Yes, t h a t ' s r i g h t . R: So when you say t h a t y o u ' r e h e a l t h y , you mean t h e mind and body t o g e t h e r a r e h e a l t h y ? 75 P: Yes, the whole unit i s healthy. The way the body and mind i n f l u e n c e each other was d e s c r i b e d in other accounts: P: I f you are mentally happy and healthy, then only you would be n a t u r a l l y p h y s i c a l l y healthy as w e l l . I f you are mentally unwell, then i t d e f i n i t e l y a f f e c t s your p h y s i c a l as w e l l . P: Health, you know, mental and p h y s i c a l , are again two components of he a l t h , because they are so c l o s e to each other. R: Yes. P: That's what I mean. R: "So c l o s e to each other" again you mean? P: In terms of how they a f f e c t each other. P h y s i c a l h e a l t h a f f e c t s mental h e a l t h , mental h e a l t h a f f e c t s emotional w e l l -being, and my job performance, and how I deal with the family, and how I f e e l about myself, completely, you know. It s so c l o s e you know, that i t s hard to say what i s r e a l l y what i n my mind. But c e r t a i n l y p h y s i c a l and mental h e a l t h are very c l o s e , because they a f f e c t each other. You know, i f you had s t r e s s at work i t w i l l a f f e c t your stomach; i f you eat too much i t w i l l a f f e c t your mind, you know! As noted, p a r t i c i p a n t s explained that complete h e a l t h meant, not only being able to do normal a c t i v i t i e s , but being able to do these a c t i v i t i e s well and h a p p i l y . T h i s primary f e a t u r e of complete h e a l t h i s d i s c u s s e d below. Doing Happily. Doing. Well P a r t i c i p a n t s s t a t e d that they could not perform a c t i o n w e l l , or at t h e i r best l e v e l of e f f i c i e n c y and e f f e c t i v e n e s s , unless they were i n a s t a t e of complete h e a l t h . Being able to c a r r y out d a i l y a c t i v i t i e s i n complete h e a l t h , and thus f u l f i l l l i f e 76 r e s p o n s i b i l i t i e s , was d e s c r i b e d as g i v i n g r i s e t o f e e l i n g s o f h a p p i n e s s , c o n t e n t m e n t and s a t i s f a c t i o n . Doing h a p p i l y . The f o l l o w i n g a c c o u n t s i l l u s t r a t e t h e h a p p i n e s s a s s o c i a t e d w i t h d o i n g a c t i o n s w e l l . In t h e s e d e s c r i p t i o n s t h e word " h e a l t h " r e f e r s t o c o m p l e t e h e a l t h . P: I t h i n k , you know, h e a l t h i s i m p o r t a n t t o do, you know a l l y o u r a c t i v i t i e s . T h a t makes you f e e l good. P: L i k e when I'm h e a l t h y I f e e l t h a t I can do t o o (so) much, you know. I'm a c t i v e a l l t h e t i m e . L i k e I f e e l good t o o , I'm happy, I'm e n e r g e t i c . P: Oh, you f e e l good, you see, you a r e c a p a b l e o f p e r f o r m i n g t h e d u t i e s and not b e i n g s i c k . R: Um hum. You mean t h a t s a t i s f a c t i o n — P: S a t i s f a c t i o n . R: — comes from d o i n g t h e t h i n g s ? P: Yes, t h a t ' s r i g h t . Yeah. R: And t h e n you f e e l good. T h a t ' s what y o u ' r e t e l l i n g me? P: Yeah. And t h a t comes w i t h t h e h e a l t h you see. P: Most o f t h e t i m e I'm on a r e a l h i g h . B e c a u se I f e e l r e a l l y good when I wake up i n t h e morning, and I'm r e a d y t o f a c e t h e day, and o f f I go. And you know, s i n g my h e a r t out i n t h e morning. You know, I e n j o y . J u s t e v e r y t h i n g comes from, i t stems from good h e a l t h . And i t s , o f c o u r s e , you know, r e l a t e d t o b e i n g b o t h m e n t a l l y and p h y s i c a l l y h e a l t h y . Doing w e l l . The e n s u i n g a c c o u n t s d e s c r i b e " d o i n g w e l l " as t h e s e c o n d a s p e c t o f d o i n g normal a c t i v i t i e s i n t h e c o m p l e t e h e a l t h s t a t e . B e i n g a b l e t o do a c t i o n w e l l was l i n k e d t o h a v i n g 77 both a healthy body and a healthy mind. One p a r t i c i p a n t d e s c r i b e d t h i s in terms of p h y s i c a l and mental energy (or e f f o r t ) , and e x p l a i n e d why both the body and mind need to be healthy to perform a c t i o n at a high l e v e l of e f f e c t i v e n e s s . P: Because to do something good, you have to concentrate on i t mentally and p h y s i c a l l y both. P h y s i c a l l y you are doing something, mentally you are p u t t i n g your c o n c e n t r a t i o n i n t o i t . So suppose i f I'm studying, i f I put my both energy together i n t o the study, then I can achieve the top, you know best out of i t . R: Um hum. P: Otherwise I can't. So t h a t ' s the way. She explained "doing something good" more e x p l i c i t l y : R: In your mind f o r you to be completely healthy, the two have to be there the p h y s i c a l and mental h e a l t h together? P: Yeah, Yeah. Um hum. I f you want to do something good. That's the only way you can perform something that whatever you want. P a r t i c i p a n t s s t a t e d that a c t i o n could not be p e r f e c t l y executed i f only the mind, or only the body was healthy. The f o l l o w i n g account i l l u s t r a t e s t h i s p o i n t : P: I f you are not, i f you are mentally healthy and p h y s i c a l l y not healthy, i s s t i l l you cannot perform w e l l . find i f you are l i k e mentally good and p h y s i c a l l y not good, then s t i l l you cannot perform the way you want to perform t h i n g s . fts mentioned e a r l i e r , p a r t i c i p a n t s d e s c r i b e d energy, r e s i s t a n c e , independence and c o n t r o l as four h e a l t h c h a r a c t e r i s t i c s d i r e c t l y u n d e r l y i n g a person's a b i l i t y to c a r r y out normal a c t i v i t i e s i n each phase of the h e a l t h experience. In complete h e a l t h , amounts of these f o u r h e a l t h c h a r a c t e r i s t i c s are g r e a t e s t , a l l o w i n g the i n d i v i d u a l to do more a c t i v i t i e s , and to do these a c t i v i t i e s e f f e c t i v e l y and e a s i l y . fts 78 one enters the p a r t i a l h e a l t h stage, the amount of each c h a r a c t e r i s t i c decreases. In s i c k n e s s , measures are very low or t o t a l l y absent a l t o g e t h e r . As one recovers from s i c k n e s s , amounts of these four c h a r a c t e r i s t i c s increase again. COMPLETE HEALTH PARTIAL HEALTH SICKNESS Energy " ' ; •)> l e s s ^ very low Resistance ^ l e s s ;> very low Independence ^ l e s s •)> very low % C o n t r o l . % l e s s ^ very low  . % F i g u r e 4: The Four Health C h a r a c t e r i s t i c s in each Phase of the Health Experience These four h e a l t h c h a r a c t e r i s t i c s are d e s c r i b e d w i t h i n two themes: energy and r e s i s t a n c e , and independence and c o n t r o l . The f o l l o w i n g d i s c u s s i o n presents accounts of these two themes in complete h e a l t h ; l a t e r s e c t i o n s in t h i s chapter w i l l d i s c u s s the four h e a l t h c h a r a c t e r i s t i c s i n p a r t i a l h e a l t h and s i c k n e s s . Energy and r e s i s t a n c e . In complete h e a l t h , p a r t i c i p a n t s d e s c r i b e d being able to do a c t i v i t i e s without g e t t i n g t i r e d and without e f f o r t . They a l s o spoke of having s t r e n g t h and enthusiasm, and not e x p e r i e n c i n g "any burden" when doing act i v i t i es. The ensuing d e s c r i p t i o n s i l l u s t r a t e how p a r t i c i p a n t s d e s c r i b e d the energy present i n complete h e a l t h , and how t h i s energy promoted doing normal a c t i v i t i e s . P: So b a s i c a l l y h e a l t h means, you know, energy and, you know, with me, the d e s i r e to do t h i n g s and the a b i l i t y to do them — to be a c t i v e i n many th i n g s , and l i k e to do a l o t of running around, and end up t a k i n g on t h i n g s that I r e a l l y don't have to, because there i s that energy. And i f I didn't have good h e a l t h then c e r t a i n l y , I wouldn't be able to do 79 t h a t . T h i s energy was f u r t h e r explained i n terms of "not f e e l i n g t i r e d " when doing a c t i v i t i e s : R: Could you d e s c r i b e — how a healthy s t a t e f e e l s f o r you p e r s o n a l l y , or what i t means to you? P: I'm q u i t e j o y f u l a l l throughout the day. I f I keep doing t h i n g s , there a l s o , so long as I don't f e e l t i r e d , I f e e l that r e a l l y I'm healthy. F e e l i n g s of enjoyment and enthusiasm f o r work and l i f e were a l s o a s s o c i a t e d with the energy in complete h e a l t h : P: I mean i f good h e a l t h i s not there then, you know, you r e a l l y don't enjoy anything. There i s always that lack of you know, enjoyment, lack of enthusiasm f o r l i v i n g , lack of enthusiasm f o r t a k i n g on new p r o j e c t s and l i f e becomes a r e a l drag. You don't have because h e a l t h gives you energy, and you take on t h i n g s , because otherwise you'd j u s t say: "wel l , f o r g e t i t , you know, i f I took on any more I wouldn't be able to handle i t , so j u s t l e t ' s not bother with i t " . That would prevent me from making f r i e n d s , or l i k e meeting f r i e n d s as of t e n and i t would have a bearing on ev e r y t h i n g I do. I f I wasn't healthy. Abundant energy was d e s c r i b e d as a core f e a t u r e of complete h e a l t h , and a p r e r e q u i s i t e f o r doing normal a c t i v i t y . As the f o l l o w i n g accounts i l l u s t r a t e , the abundance of energy in complete h e a l t h allows a person to do d a i l y a c t i v i t i e s without being t i r e d or f e e l i n g any "burden": P: As long as you're not s u f f e r i n g from any dise a s e , or you are say, i f you can c a r r y out a l l your normal d u t i e s , the s a i d a c t i v i t i e s of l i f e without f e e l i n g any f a t i g u e or t h i n g s l i k e t h a t . Then I thin k you are a healthy person. P: Health to me means no headaches, no t i r e d n e s s at the end of the day, energy to do t h i n g s . You know, not j u s t go to work and come home and c o l l a p s e on the bed. Health means that I should have the energy when I come home to be able to do other t h i n g s , go f o r walks and b a s i c a l l y f e e l i n g good about myself. 80 P: L i s t e n , i f you are healthy you don't f e e l t i r e d . You don't f e e l i l l at a l l , and when you enjoy the work you don't f e e l i t . I t ' s more that you don't f e e l t i r e d , because you are enjoying the work at the same time. R: So you mean you have a l o t of energy? Is that what you are t e l l i n g me? P: You have energy. I f you are s i c k , there i s no energy to f i g h t with those t h i n g s — with your r o u t i n e work even. But i f you are healthy you don't f e e l i t i s t i r i n g or burden, or anything you have done e x t r a o r d i n a r y . R: You don't f e e l "a burden" when? P: I'm moving around, e v e r y t h i n g i s great f o r me. T h i s energy a l s o allowed the i n d i v i d u a l to take on e x t r a u n a n t i c i p a t e d work. Speaking of what he could do i n h e a l t h , one p a r t i c i p a n t s a i d : P: Not only that (doing the a c t i v i t i e s you want to do), you c o u l d do what you haven't scheduled a l s o when i t comes on. Go ahead and do them anyways and not f e e l (anything). R: You mean take on e x t r a t h i n g s ? P: That's r i g h t . Take on e x t r a t h i n g s . R: find not f e e l anything. P: find not f e e l p h y s i c a l l y t i r e d about i t . Another p a r t i c i p a n t explained energy in terms of v i t a l i t y . He saw v i t a l i t y as the outer expression of inner energy l e v e l s . V i t a l i t y t r a n s l a t e d i n t o a c t i o n , or being able to do a c t i v i t i e s . Thus, the " h e a l t h i e r " the person, the more v i t a l i t y he would have, and t h e r e f o r e , the more a c t i v i t y he would be capable of doing. T h i s energy, or v i t a l i t y , was equated with r e s i s t a n c e to both environmental changes and changes w i t h i n the body. P: Yeah. V i t a l i t y , I mean, the v i t a l i t y should be l i k e t h i s , that a l i t t l e change in weather, a l i t t l e change in e a t i n g h a b i t s I mean, out of r o u t i n e does not make 81 you s i c k . I f you're going out of r o u t i n e i t does not make you s i c k . R: I see. P: Sometimes I have seen people being s i c k j u s t because they di d n ' t get enough sleep. Or j u s t because they had to go out and pick up something and fo r g o t to put t h e i r j a c k e t on or something l i k e that, and got a c o l d and got s i c k . Healthy persons do not, I mean t h e i r own h e a l t h i s such a way that they c o u l d weather that out and not have the e f f e c t of the weather a l l the way around. R: I see. P: Body r e s i s t a n c e i s more, as a matter of f a c t . Good h e a l t h keeps body r e s i s t a n c e b e t t e r . He expanded on the r e l a t i o n s h i p between energy and r e s i s t a n c e in complete h e a l t h : P: Yeah, and you don't f e e l the e f f e c t of that non-routine t h i n g ( i n complete h e a l t h ) . R: find you're saying t h i s i s because you have that e x t r a energy, or a s p e c i a l kind of energy? P: You can c a l l i t energy, or the body develops r e s i s t a n c e against these t h i n g s . E x p l a i n i n g that the body's r e s i s t a n c e was a s i g n of good h e a l t h , he s t a t e d that the energy, or r e s i s t a n c e present i n complete h e a l t h was the reason why healthy people do not get c o l d s or f l u , even though they might be exposed to the v i r u s . P: and t h a t ' s your own body r e s i s t a n c e which you have developed, and t h a t , to me i s a sign of good h e a l t h . And that comes from r i g h t , h ealthy l i v i n g h a b i t s . E x p l a i n i n g t h i s same point from a medical p e r s p e c t i v e , he s a i d : P: — Now w e ' l l go to i n medical terms. You say your own blood c e l l s f i g h t i t out against those v i r u s e s , or whatever, and they win out and so you do not get s i c k . T h i s r e s i s t a n c e to d i s e a s e and the environment was d e s c r i b e d by another p a r t i c i p a n t as "not always a i l i n g from something". 82 P: I would see h e a l t h as not — always a i l i n g with something, and not always t a k i n g medication f o r something or the other. I n d e p e n d e n c e a n d c o n t r o l . P a r t i c i p a n t s d e s c r i b e d independence and c o n t r o l as two a d d i t i o n a l c h a r a c t e r i s t i c s i n t i m a t e l y a s s o c i a t e d with doing normal a c t i v i t i e s . Independence in complete h e a l t h had var i o u s meanings: not being dependent on other people to c a r r y out personal work and r e s p o n s i b i l i t i e s , being independent of vitamins and medications, and being g e n e r a l l y f r e e of other r e s t r i c t i o n s on a c t i v i t y or l i f e s t y l e . The f o l l o w i n g accounts i l l u s t r a t e aspects of the independence c h a r a c t e r i s t i c of complete h e a l t h . One p a r t i c i p a n t spoke of t h i s independence in terms of not using vitamins or t a k i n g medicines. She s a i d : P: Completely healthy i s e v e r y t h i n g i s working in your system as i t should be, without the a i d of a r t i f i c i a l means. R: I see. P: That's completely healthy. Whereas you know, you can have, you know, 60 d i f f e r e n t medicines a day and f e e l r e a l l y great, but I don't c a l l that h e a l t h . R: What would you c a l l that s t a t e ? P: I would c a l l that, you know, the s t a t e of a r t i f i c i a l h e a l t h . How can you f e e l good about y o u r s e l f i f you're having so many vitamins and so many medicines to r e l i e v e t h i s or r e l i e v e that from the system? That's what I mean. Completely healthy i s h e a l t h on your own without the a i d of s u p e r f i c i a l t h i n g s , which are vitamins which can be acq u i r e d by good d i e t s . And without the a i d of p a i n - k i l l e r s and what-have-you. The same informant l a t e r spoke of being independent of r e s t r i c t i o n s concerning d i e t , a c t i v i t y and l i f e s t y l e . In t h i s account she d e s c r i b e d complete h e a l t h as being 100 percent 83 h e a l t h y . R: You c o n s i d e r y o u r s e l f 100 percent healthy now. P: Um hum. R: So do you f e e l you have any r e s t r i c t i o n s on any part of your l i f e at the moment? P: Not f o r now. I can do whatever I want to do. I can run as much as I want. I can eat whatever I want, and I can do j u s t about l i k e nobody has t o l d me "you have to take medication f o r so and so", so I have no r e s t r i c t i o n s about anything l i k e t h a t . She explained how a very obese person would not be completely healthy, because of the numerous r e s t r i c t i o n s placed on him. P: Well, ( i f I were obese) my system would be working a l l r i g h t , but I wouldn't c o n s i d e r myself very healthy because you know, I cannot do every I cannot run, I cannot play a l o t of games, I cannot do a l o t of t h i n g s . I may even put a r e s t r i c t i o n on myself f o r ea t i n g t h i n g s , because I want to get back to my normal. I might catch a c e r t a i n something c o u l d happen to me. I don't know. My heart being heavy i s one of the reasons they say shouldn't do that because i t does cause a l o t of heart problems. Being healthy i s I think, r e a l l y being able to do eve r y t h i n g without any r e s t r i c t i o n s . Notions of independence were very c l o s e l y a s s o c i a t e d with the idea of being i n c o n t r o l of one's l i f e . C o n t r o l was d e s c r i b e d as "being able to plan ahead" or "plan f o r the f u t u r e " , and a l s o as being able to do something to r e s o l v e h e a l t h concerns so that d a i l y a c t i v i t i e s c o u l d go on i n a normal way. In a d d i t i o n , c o n t r o l i n h e a l t h was explained as "being in charge" and "being able to cope". Some p a r t i c i p a n t s spoke of c o n t r o l i n terms of what aspects of h e a l t h they could p e r s o n a l l y c o n t r o l , and what aspects were viewed to be i n the c o n t r o l of nature, or God. fls with other aspects of the accounts, the male and female study p a r t i c i p a n t s provided very s i m i l a r d e s c r i p t i o n s of independence 84 and c o n t r o l in h e a l t h . The subsequent n a r r a t i v e i l l u s t r a t e s how c o n t r o l , or coping, i s r e l a t e d to independence. R: It seems you're t e l l i n g me that when you're healthy you're in c o n t r o l . P: Well, you know, you need to the kind of l i f e you l i v e here, ah, you're on your own, you have to do eve r y t h i n g . You don't depend on anybody, or t r y not to depend on the c h i l d r e n , or whatever. You have to be able to work, you have to be able to move around, and you have to be able to cope with your day to day l i f e . find how could you do a l l those t h i n g s of you d i d not enjoy good h e a l t h ? R: So being able to cope i s part of being healthy? P: Oh, d e f i n i t e l y ! D e f i n i t e l y ! I t s to cope with your r e s p o n s i b i l i t i e s , with your o b l i g a t i o n s , with your commitments, you know. Your whole l i f e depends on your h e a l t h b a s i c a l l y . E v e r y t h i n g you do depends on whether you can deal with, f u l f i l l those a l l those d e c i s i o n s depend on whether you can f u l f i l l them. Your job, your work, your c h i l d r e n I mean r e a l l y , without good h e a l t h , you j u s t , you don't have a hope! (LftUGHS) You know? With a l l the, you know, a l l your I don't know there might be some t h i n g s one can do even though i t s not p e r f e c t l y healthy, there may be t h i n g s you can do, but i t does l i m i t you. Being i n c o n t r o l in the sense of being able to plan one's l i f e a c t i v i t i e s , and not having to put o f f scheduled programs because of h e a l t h problems, was d e s c r i b e d as f o l l o w s : P: Any scheduled r o u t i n e , I mean g e n e r a l l y people have set t h e i r r o u t i n e , from g e t t i n g up in the morning t i l l going to sleep, to bed. There i s a set r o u t i n e , and then in that time frame they set t h e i r own schedules f o r what they want to do. find i f they are healthy, they do not have to worry about changing that schedule or missing t h i n g s because of i 1 1 - h e a l t h . P: That's r i g h t . That (health) gives you your own time to your prayers and t h i n g s , and keeps e v e r y t h i n g on a c e r t a i n time and c e r t a i n place. That i s j u s t great. R: When you're healthy you're able to keep a c e r t a i n schedule? 85 P: That's r i g h t . R: Whereas when you're f e e l i n g s i c k P: F e e l i n g s i c k , you might not get up i n time to do the t h i n g . You might not be able to handle the few t h i n g s which you want to do, but you can't because you are s i c k . Another p a r t i c i p a n t spoke of t h i s c o n t r o l more e l o q u e n t l y : P: If your h e a l t h i s good, then your whole p e r c e p t i o n i s d i f f e r e n t about l i f e . About work, about family, about what you do, how you view t h i n g s , planning h o l i d a y , planning what ever. R: And f o r you p e r s o n a l l y , what i s that p e r s p e c t i v e l i k e ? P: I don't know, j u s t a sense of, you know, a sense of optimism, a sense of being in c o n t r o l . And you know, there i s the f e e l i n g t hat, you know, I can do t h i n g s , I can do what I want to do, b a s i c a l l y . R: A sense of "being i n c o n t r o l " ? P: Yeah. Yeah, being i n c o n t r o l of your h e a l t h , being in c o n t r o l of your l i f e , you're s o r t of being i n charge of t h i n g s r a t h e r than dragging your f e e t . She f u r t h e r d e s c r i b e d t h i s p e r s p e c t i v e : P: Well, being healthy, you know, i s being i n c o n t r o l of your l i f e , t h a t ' s what I f e e l . In the sense that i f you're not healthy you can't make plans, you don't know what your c o n d i t i o n w i l l be. You can't take on any jobs. You can't take on anything which r e q u i r e s , you know, depending on the kind of p h y s i c a l and mental c o n d i t i o n you're i n , you can't commit y o u r s e l f to anything. I f you do, you don't have the energy to do i t . So you g r a d u a l l y , you know, have to cut down on t h i n g s , so you r e a l l y don't have you're going to be so you can't take on anything. But i f you are healthy and, you know, you don't t h i n k about: "w e l l , of course, you know, I can do t h i s " . You j u s t get up and do i t . Or you say: " f i n e , I ' l l do i t " . And I j u s t f i n d that t h a t ' s what c o n t r o l means i n terms of h e a l t h , i s the a b i l i t y to do t h i n g s and to decide to do t h i n g s , and make plans and go ahead with them - without which, you know, (without) which h e a l t h you couldn't do i t . What would you do i f you were s i c k a l l the time? R: So i t seems that t h e r e ' s a c e r t a i n t y , i s that what you're saying? 86 P: Yeah. R: Because i f you're s i c k , you say you can't plan because you're not sure P: You don't know what you R: — what's going to happen. P: Yeah, yeah. I thin k so. That's what i t means. You're c e r t a i n about your a b i l i t y to do th i n g s , that gives you that c o n t r o l over your plans and f u t u r e and commitments and eve r y t h i n g . Two p a r t i c i p a n t s spoke of the independence inherent i n complete h e a l t h as p a r t i c u l a r l y important f o r l i f e i n Canada. They explained that Canadian s o c i e t y r e q u i r e d a person to be independent. In c o n t r a s t , when they were l i v i n g i n India independence was a l e s s important f a c e t of h e a l t h , because i f they were s i c k , members of the extended f a m i l y or servants could do the dai 1y chores. R: Do you f e e l that being healthy in Canada e n t a i l s anything d i f f e r e n t than being healthy when you were in India? P: You know, i f you are healthy here means ev e r y t h i n g has to be done by you. There's nobody e l s e . fls you th i n k everybody mind t h e i r own business. I f you are s i c k , means somebody comes f o r r e s t , you might need a g l a s s of water, you might need something. But at home there are a l l j o i n t f a m i l i e s , and they help with s i c k n e s s and with h e a l t h i n e s s . You know, that makes a d i f f e r e n c e . Because you are in a j o i n t f a m i l y , and they look a f t e r you, and you don't worry that much. You might thi n k that your c h i l d i s s i c k , and you have to get up here, but not there ( i n I n d i a ) . — R: So are you t e l l i n g me that being healthy here, means being independent and being able to do t h i n g s f o r y o u r s e l f ? P: For y o u r s e l f and f o r the f a m i l y and with happiness, means you are content, and you don't mind and e v e r y t h i n g i s going j u s t great. Here you have to be healthy to cope with the world. ft few p a r t i c i p a n t s a l s o spoke of c o n t r o l i n terms of what they 87 p e r s o n a l l y could do to keep healthy. Health was seen as not t o t a l l y in the c o n t r o l of the i n d i v i d u a l , but r a t h e r i n the domain of nature, or in God's hands to some extent. P r e v e n t i v e a c t i o n s l i k e d i e t , e x e r c i s e , keeping a c t i v e , maintaining a calm, c l e a r mental a t t i t u d e , and s t a y i n g contented or happy with l i f e , were regarded as h e a l t h f u l a c t i v i t i e s under i n d i v i d u a l c o n t r o l . P: Health i s something that can't be p r e d i c t e d r i g h t ? I would say i t s not in your hands. I mean i t ' s not even in the hands of doctors, or scie n c e or anybody. Because i f i t was, nobody would ever get s i c k , r i g h t ? We'd be a l l healthy f o r a l l of t h e i r l i f e , r i g h t ? I t ' s , I mean, i t ' s — you don't c o n t r o l these t h i n g s , somebody e l s e does, find, but you s t i l l , you know, a l l we can do i s j u s t , you know, do whatever we can to stay healthy. R: So i f you're saying that "someone e l s e " does i t . Could you d e s c r i b e to me P: Yeah, t h a t ' s , you know, someone e l s e — I mean God! The p a r t i c i p a n t l a t e r c l a r i f i e d what she could p e r s o n a l l y do to stay h e a l t h y : P: Well, I guess I've alre a d y t o l d you. You s a i d , yeah, c o n t r o l your d i e t a l i t t l e , and then do your, you know, t r y to do a b i t of e x e r c i s e and be content, and t r y to be happy a l i t t l e . Do a l l those t h i n g s , and then leave the r e s t i n HIS hands, I guess. Another p a r t i c i p a n t presented a s i m i l a r p e r s p e c t i v e : P: Nature i s not in your c o n t r o l . You can only c o n t r o l your f e e l i n g s , or your, you know, body - l i k e d i sease. But nature you can't c o n t r o l , you know. Because maybe i t s in your d e s t i n y that you have to go i n acc i d e n t and lose your leg or lose your hand or something. That, Hindu philosophy says i s the karmas (past a c t i o n s ) , you know. You have to s u f f e r whatever you have done, maybe in your past l i f e or t h i s l i f e . R: Okay. So you s a i d t h i n g s l i k e d i e t and e x e r c i s e , a l l those t h i n g s that you have c o n t r o l over. P: Yeah! You can do i t , yeah. You can meditate, you can f a s t , you can change your b r a i n ( d i s c i p l i n e your t h i n k i n g ) , aa you can r e d i r e c t your t h i n k i n g , you can okay, you are not good in study, you can always go to music. If you are not good in music, you can always pick up s p o r t s , you know. So these t h i n g I'm t a l k i n g about which you can do. To conclude, complete h e a l t h was presented as the f i r s t phase of the h e a l t h experience. In complete h e a l t h , both the body and mind are healthy and i n a s t a t e of balance and harmony. P a r t i c i p a n t s explained that in complete h e a l t h they were able to do normal a c t i v i t i e s w e l l and h a p p i l y . Abundant energy, r e s i s t a n c e , independence and c o n t r o l supported t h i s c a p a c i t y f o r a c t i o n . The f o l l o w i n g s e c t i o n d e s c r i b e s p a r t i a l h e a l t h as the second phase of the h e a l t h experience. P a r t i a l Health Although the p a r t i a l h e a l t h phase was d e s c r i b e d the l e a s t c l e a r l y , p a r t i c i p a n t s agreed that a d e f i n i t e "in-between" stage e x i s t e d between complete h e a l t h and s i c k n e s s (see f i g u r e 3). P a r t i a l h e a l t h was d e s c r i b e d v a r i o u s l y i n p a r t i c i p a n t accounts as: "a l i t t l e b i t s i c k " , "not f e e l i n g w e l l " , "being s t i l l h ealthy, but with a b i t of a problem", as l e s s than 100% healthy (80-95% healthy, f o r example), "more or l e s s h e a l t h y " and i l l - h e a l t h . P a r t i c i p a n t s d e s c r i b e d the experience of a c o l d or the f l u , a temporary headache or other type of short term ache or pain, as being i n t h i s "in-between" s t a t e of p a r t i a l h e a l t h . An important f e a t u r e of p a r t i a l h e a l t h i s that the symptoms, or h e a l t h problems, are short term. In t h i s s t a t e , p a r t i c i p a n t s ' a b i l i t y to do normal d a i l y a c t i v i t i e s was i n t e r r u p t e d f o r a temporary p e r i o d of time, u s u a l l y days or weeks. Most p a r t i c i p a n t s spoke of the pain, discomfort 89 and other complaints a s s o c i a t e d with ailments l i k e c o l d s , f l u and headache, f o r example, i n terms of a few days d u r a t i o n . T h i s experience was d e s c r i b e d as "bothersome". Bothersome was explained to mean annoying, a nuisance or a hindrance, i n the sense that i n d i v i d u a l a b i l i t y to do normal a c t i v i t i e s was i n t e r r u p t e d f o r a short p e r i o d of time. P a r t i c i p a n t s s t a t e d that they were not worried about being in p a r t i a l h e a l t h , but that i t j u s t "bothered or annoyed" them. (Being worried was something a s s o c i a t e d with s i c k n e s s , as w i l l be d i s c u s s e d i n the f i n a l s e c t i o n of t h i s c h a p t e r ) . Although most p a r t i c i p a n t s saw themselves as completely healthy, p a r t i a l h e a l t h was not an uncommon experience. P a r t i c i p a n t s r e p o r t e d having a c o l d , f l u or headache reasonably f r e q u e n t l y d u r i n g the year. P a r t i a l h e a l t h was g e n e r a l l y d e s c r i b e d as le a d i n g back to t o t a l h e a l t h . P a r t i c i p a n t s explained that p a r t i a l h e a l t h could d e t e r i o r a t e i n t o s i c k n e s s i f the small h e a l t h problems didn' t go away spontaneously, or were l e f t untreated. P a r t i a l h e a l t h i s d i s c u s s e d below i n terms of (1) c a p a c i t y f o r doing normal a c t i v i t i e s , d e s c r i b e d here as "can do with e f f o r t , but not w e l l " , and (2) as temporary and bothersome. In p a r t i a l h e a l t h , the fou r h e a l t h c h a r a c t e r i s t i c s were d e s c r i b e d as present i n l e s s e r amounts than i n complete h e a l t h . These c h a r a c t e r i s t i c s are d i s c u s s e d w i t h i n the next p o r t i o n of the text d e s c r i b i n g normal a c t i v i t y i n p a r t i a l h e a l t h . 90 Can do with E f f o r t . But not Well The f o l l o w i n g accounts d e s c r i b e p a r t i c i p a n t s ' p e r c e p t i o n s of p a r t i a l h e a l t h as a s t a t e where they could s t i l l do normal a c t i v i t i e s , but with e f f o r t and with l e s s e f f e c t i v e n e s s than i n a s t a t e of complete h e a l t h . In t h i s phase, p a r t i c i p a n t s d e s c r i b e d "not f e e l i n g l i k e doing anything". In p a r t i a l h e a l t h , something i s s l i g h t l y " o f f " , e i t h e r p h y s i c a l l y or mentally. Consequently, the t o t a l " u n i t " or person i s not regarded as completely healthy. This c o n d i t i o n of being " a l i t t l e b i t s i c k " r e s u l t s i n l e s s e f f e c t i v e a c t i v i t y and t i r e d n e s s when doing a c t i v i t y . Some p a r t i c i p a n t s d e s c r i b e d t h i s experience as "dragging themselves" through the day's work. fit t h i s time, p a r t i c i p a n t s p erceived themselves as s t i l l h ealthy because they could s t i l l do t h i n g s , although not as well or as h a p p i l y as in complete h e a l t h . They saw themselves as s t i l l h ealthy because the c o n d i t i o n (cold, f l u , headache) was temporary and considered "no big d e a l " , as i t would go away more or l e s s on i t s own, with l i t t l e or no in t ervent i on. The f o l l o w i n g accounts i l l u s t r a t e how p a r t i c i p a n t s d e s c r i b e d p a r t i a l h e a l t h , and t h e i r a b i l i t y to do normal a c t i v i t i e s in t h i s phase. P: Sometimes you're a l i t t l e s i c k , you can s t i l l drag around when i t s a c e r t a i n time of age. Means the person has some r e s p o n s i b i l i t i e s . You've got to do a few t h i n g s whether you are well or no. P: I f say, you've got up with a headache, you'd s t i l l be 91 healthy, you know. It doesn't take away from i t . I t ' s j u s t a b i t o f f . One p a r t i c i p a n t d e s c r i b e d the f a c t that when she was sad, she di d n ' t c o n s i d e r h e r s e l f p e r f e c t l y healthy. fit that time she could not do d a i l y a c t i v i t i e s as well as when i n a s t a t e of complete h e a l t h : P: L i k e I can't say that time ( i n p a r t i a l health) that I'm, you know, p e r f e c t l y healthy. Because I cannot perform t h i n g s good, and my speed i s slow that time, l i k e the way I do th i n g s . D e s c r i b i n g the miserable experience he had with the watering eyes and running nose a s s o c i a t e d with developing a l l e r g i e s , one p a r t i c i p a n t explained how p a r t i a l h e a l t h r e f e r s to the c o n d i t i o n of the body. Here p a r t i a l h e a l t h i s denoted by the term i 11-health. R: So are you t e l l i n g me that i l l - h e a l t h f o r you, i s in terms of the body? P: Yes. Because with the mind I could s t i l l r a t i o n a l i z e and t r y to r a t i o n a l i z e t h i n g s . Okay. find have no problem because I s t i l l maintained a l l my, a l l the r o u t i n e s of work, and so a reasonable thought process. But body remains miserable because of whatever chemical changes happen in the body. The four h e a l t h c h a r a c t e r i s t i c s u n d e r l y i n g a c t i v i t y i n p a r t i a l h e a l t h are d e s c r i b e d below. Decreased energy and r e s i s t a n c e . P a r t i a l h e a l t h was c h a r a c t e r i z e d by decreased amounts of energy and r e s i s t a n c e . The low energy in p a r t i a l h e a l t h was d e s c r i b e d in terms of being t i r e d , or f a t i g u e d . The f o l l o w i n g account i l l u s t r a t e s t h i s : P: (finy change) in normal healthy h a b i t , whether i t s in chemical food intake, or p h y s i c a l change, I mean i t w i l l even make me i l l , i l l - h e a l t h , or t i r e d t i r e d n e s s i s a sign of i l l - h e a l t h . 92 P a r t i a l h e a l t h was f u r t h e r d e s c r i b e d in terms of lowered r e s i s t a n c e to di s e a s e s and e x t e r n a l environmental changes. One p a r t i c i p a n t viewed t h i s lowered r e s i s t a n c e as the r e s u l t of chemical changes o c c u r r i n g in the body, due to the s t r e s s a r i s i n g from mental worry. He d e s c r i b e d t h i s s t a t e of lowered r e s i s t a n c e as a time when the body i s in a "low v i t a l i t y mode". Mental s t r e s s , or worry, was seen as the primary cause of lowered p h y s i c a l r e s i s t a n c e . It was h i s experience that i n p a r t i a l h e a l t h a person becomes a l l e r g i c to t h i n g s such as dust and foods, because h i s r e s i s t a n c e i s low. In t h i s account, he a l s o explained how p a r t i a l h e a l t h can d e t e r i o r a t e i n t o s i c k n e s s , or move back to complete h e a l t h . In t h i s account the term " i l l - h e a l t h " denotes p a r t i a l h e a l t h . R: So i n t h i s s t a t e of i l l - h e a l t h , the body's l o s t i t s r e s i s t a n c e ? P: Yes. Body has l o s t i t s r e s i s t a n c e to f i g h t any kind of change happening, and chemical change i t gets exposed to. R: So t h i s s t a t e of i l l - h e a l t h can become si c k n e s s ? P: It c o u l d ! R: I f i t gets worse? P: It could. R: find would t h i s r e s i s t a n c e then change as well i n si c k n e s s ? P: Yes, i t would go lower. It w i l l decay. R: It w i l l decay? P: Yes. R: And so when a person, in t h i s s t a t e of i l l - h e a l t h then, i f a person's r e s i s t a n c e improves, then h e ' l l become h e a l t h i e r ? 9 3 P: That's r i g h t . Yes. Decreased independence and c o n t r o l . Decreased independence was d e s c r i b e d in terms of imposed r e s t r i c t i o n s , or l i m i t a t i o n s on a c t i v i t y and l i f e s t y l e . One p a r t i c i p a n t d e s c r i b e d p a r t i a l h e a l t h in terms of being r e s t r i c t e d i n doing normal a c t i v i t i e s , and having to take medicine f o r the pain r e l a t e d to a t o r n knee c a r t i l a g e . The pain she experienced was i t s e l f a l i m i t a t i o n , as i t i n t e r f e r e d with her a b i l i t y to do a c t i o n . She s t i l l saw h e r s e l f as healthy, although not completely healthy. Her independence was reduced by these r e s t r i c t i o n s on her d a i l y l i f e , and she d e s c r i b e d f e e l i n g "a b i t handicapped". In the f o l l o w i n g account, she r e f e r r e d to p a r t i a l h e a l t h as "not being a 100 percent healthy". R: You gave me the f e e l i n g that you didn't see y o u r s e l f as completely healthy at the moment. P: I'm not completely a hundred percent healthy, because I r e a l l y cannot use my knees a hundred percent. find i f I s t r e s s i t too much, i f I go running down the s t a i r s or, l i k e I used to do a l l kinds of t h i n g s . I can't. I cannot s i t on the f l o o r , I cannot squat, I cannot bend my knees. find I f e e l a b i t handicapped, you know, i n the sense that I can't use, I cannot do t h i n g s that I could, as e a s i l y . So other than that I'm not, I'm not unhealthy, I don't f e e l that my h e a l t h i s a problem r i g h t now. But t h a t ' s a small — you know, i t i s a nagging pain, because I'm not used to not being able to go up and down the s t a i r s as I f e e l . R: So to do with your knee again, i s i t the l i m i t a t i o n i n a c t i o n that you are loo k i n g at? Or i s i t your you s a i d you f e e l "handicapped" or i s i t both of these t h i n g s ? P: I t ' s both of these t h i n g s . Because there i s that f e e l i n g of not being a hundred percent. And a l s o the a c t u a l pain, i f I'm s i t t i n g on the f l o o r , or you know, I l i k e to, the music I play or sing, I have to use, s i t on the f l o o r and bend my knee to be able to play the harmonium, whatever, the tamboora. 94 R: Yes. P: Ond i t s a problem. Because you know i t pains. I have to s i t on a cushion. find a year ago I would have not thought twice about these t h i n g s and the small d i s c o m f o r t s . But now I have to thin k about i t . I have to f i n d a cushion, and I have to f i n d something to r e s t t h i s knee on. Then I can s i t in the proper p o s i t i o n . But a l s o there i s the f e a r , or — that I may never have f u l l use of my knee as I had before. And i t ' s , you know, when I go i n and out of the cars, i n the car i t s a b i t of a s t r a i n to get i n and out. I can't do t h i n g s as f r e e l y . Movements have become a b i t r e s t r i c t e d . The same informant explained t h i s from a d i f f e r e n t p e r s p e c t i v e a f t e r her knee was much improved. In the ensuing account, she r e f l e c t e d on why she f e l t she was in p a r t i a l h e a l t h when her knee had r e s t r i c t e d movement and she was on pain medication. P: I j u s t don't have anything (no pain medication) now. And sometimes i t j u s t hurts a l i t t l e b i t . So I am much h e a l t h i e r I f e e l than I was when I saw you l a s t . Because now I am not having Entrophen (medication). And my knee i s much b e t t e r , i t ' s not h u r t i n g , so t h a t ' s what I'm t r y i n g to say. I was only p a r t i a l l y healthy, although there was r e a l l y nothing d r a s t i c a l 1 y wrong with me. But I didn't f e e l healthy because I was having four of these t a b l e t s a day. R: Yes. Yes. P: And now I thin k i t s over a month I haven't had any, and I j u s t won't have i t unless I'm dying or something! (LAUGHS) You know, unless i t s r e a l l y necessary. So I mean, i n my mind h e a l t h i s r e l a t e d to I mean, i f you're having medication to curb some so r t of pain i n your system, then how can you c a l l y o u r s e l f completely h e a l t h y ? Another p a r t i c i p a n t d e s c r i b e d t h i s r e s t r i c t i o n on l i f e s t y l e and a c t i v i t y i n terms of the c o n d i t i o n of her husband who had open heart surgery. R: You s a i d your husband i s r e s t r i c t e d in h i s a c t i v i t i e s , and t h e r e f o r e you're c o n s i d e r i n g him 80 percent h e a l t h y ? P: Um hum. Even 90 percent, because he r e a l l y takes care of h i m s e l f very w e l l , but he has c e r t a i n r e s t r i c t i o n s . He cannot eat too much f r i e d food. He cannot eat too much sweet food. L i k e and he cannot l i f t too much weight. He's not 95 allowed to do that. Normally he's very healthy. I wouldn't say anything about him not being healthy, but inward I know, I'm always scared, l e t me say that, that I don't know what could happen to him. That's i t . She s t a t e d at another time: P: Well, he i s very healthy, l i k e i f he changes h i s way of ea t i n g and does not care about himself, and eats j u s t about ev e r y t h i n g , and he eats a l o t of s a l t , he eats a l o t of sweets, and he i s not going to be healthy, he is_ always going to be a i l i n g with something or the other. He might be bedridden f o r a l l I know, but r i g h t now he i s healthy. But i f you ask f o r a doct o r ' s opinion, he i s healthy, but he's not he cannot say that he i s a 100 percent healthy. R: So you c o n s i d e r him healthy now, but not a 100 percent healthy. Could you t e l l me the d i f f e r e n c e between those two t h i n g s i n your mind? P: Well, i f he didn't have t h i s h e a l t h problem about h i s heart, he would be doing j u s t e v e r y t h i n g that I do. I do a l o t of running. I eat j u s t about e v e r y t h i n g I f e e l l i k e . I don't r e s t r i c t myself about not e a t i n g anything or not doing i t . I eat a l o t of sweets, I eat a l o t of f r i e d food. He does not eat t h a t . So t h a t ' s why he eats l e s s s a l t . He's on medication. R: Yes. Yes. P: So these kind of t h i n g s they do r e f l e c t on you as not being a t o t a l l y healthy person. Another account d e s c r i b e d the experience of having an el e v a t e d temperature and how t h i s c o n d i t i o n r e s t r i c t e d a c t i v i t y . Pt t h i s time the p a r t i c i p a n t f e l t that he could not do the work w e l l , because he d i d not f e e l l i k e doing anything but l y i n g down. P: I f I'm running a temperature and s t i l l I have to work i n the house, I might do i t because I have got to do i t . But I might not be able to do i t with s i n c e r i t y , or I won't be able to do i t that good. That put r e s t r i c t i o n on my a c t i v i t y out put. R: Why won't you be able to do i t wel l ? P: Okay. Because my mind i s not attuned to t h a t . R: Okay, your "mind i s not attuned"? 96 P: Mind i s not attuned to that, or secondly when I am not wel l I n a t u r a l l y f e e l lazy, I f e e l l i k e l y i n g down, r a t h e r than do some l a b o r i o u s work. In a l a t e r i n t e r v i e w he explained that "mind not being attuned" meant not f e e l i n g l i k e doing a c t i v i t y . He s t a t e d : P: You don't f e e l l i k e doing anything a l t o g e t h e r , and j u s t l i e down or something l i k e t h a t . R: So "mind not attuned" means P: Mind not attuned means you don't f e e l l i k e doing i t . Yeah. R: Because your body want's to l i e down and r e s t ? P: That's r i g h t . One p a r t i c i p a n t d e s c r i b e d the l i m i t e d c o n t r o l a person has over h i s c o n d i t i o n i n p a r t i a l h e a l t h . P: Well, l i k e i f you are a l i t t l e b i t s i c k , l i k e I s a i d you are a l i t t l e b i t s i c k with the f l u and c o l d s and a l l t h a t . Of course you can have medication f o r that, r i g h t ? find stay i n bed and r e s t . find t h a t ' s a l l , t h a t ' s what you can do to c o n t r o l i t . Temporary and Bothersome fis d e s c r i b e d i n the i n t r o d u c t i o n to t h i s s e c t i o n , p a r t i c i p a n t s viewed p a r t i a l h e a l t h as both temporary and bothersome. The f o l l o w i n g accounts d e s c r i b e d p a r t i a l h e a l t h as bothersome because of the lessened a b i l i t y a person has to do normal a c t i v i t i e s i n t h i s phase of the h e a l t h experience. R: You s a i d t hat, I b e l i e v e , a c o l d "bothers" you, but i t doesn't worry you? P: Bothers you, t h a t ' s r i g h t . Urn hum. R: find I'm s t i l l not completely c l e a r on the d i f f e r e n c e between " b o t h e r i n g " and "worrying". P: Bothering means i t s annoying. You know, i t s annoying you, you say, I mean "what i s i t " you know. I can't do what I'm supposed to do, I can't do what I, you know, l i k e to do. But 97 worrying i s something when you s i t there and you say "what i s going to happen now"? Right? That kind of s t u f f . R: So you mean worry i s , worrying about being s i c k ? Worrying about whether i t s going to be more s e r i o u s ? P: Oh, yeah. That's r i g h t . R: So I t h i n k that you were saying that someone who has cancer, say, they would be worried? P: Yeah. The temporary nature of "not being able to do t h i n g s " in p a r t i a l h e a l t h i s i l l u s t r a t e d i n the f o l l o w i n g accounts d e s c r i b i n g the experience of the f l u , headache, fever, backache and s i m i l a r a i l m e n t s . These ailments were d e s c r i b e d as minor s i c k n e s s e s that would go away. R: find when l i t t l e t h i n g s come, l i k e a l i t t l e b i t of pain with a headache, f o r instance, then you're healthy but you have that temporary P: Temporary phase of being unable to do t h i n g s maybe, but you can s t i l l be f i n e . A f t e r a while i t goes away and you're a l r i g h t . P: You are a b i t s i c k , t e m p o r a r i l y , yeah. R: Temporarily s i c k . P: Yeah, but you're not r e a l l y , you can't r e a l l y c a l l y o u r s e l f ( s i c k ) i t j u s t bothers you i n s i d e . For you know, — you know, i t s only temporary. But s t i l l i t bothers you f o r a l i t t l e b i t . You know, you can't do get up and do t h i n g s f o r others and f o r y o u r s e l f . Or you know, you become somebody e l s e has to you know, cook f o r you or do t h i n g s f o r you. P: I f i t s a constant on-going problem then I would c a l l myself unhealthy ( s i c k ) . I f i t i s j u s t f l u or a l i t t l e b i t of pain, or a l i t t l e b i t of d i a r r h e a , t h a t ' s not I'm s t i l l h ealthy. 98 R: You're s t i l l h ealthy. P: That's j u s t a temporary pain, you know. And I don't worry about i t . I thin k I'm going to get over i t . P: That's a temporary i l l n e s s , l i k e i t s not an i l l n e s s — i t ' s not you're not healthy. I t ' s j u s t — I don't know what causes a headache, but t h a t ' s a very temporary t h i n g that you're t a k i n g (medication), and i f you take that and your headache i s a l r i g h t , you're f i n e . That's a very temporary t h i n g a c c o r d i n g to me. P: Again, i t ' s temporary, r i g h t ? You know i t i s going to go away. You have fever, you have f l u , but again you're worried that you're going to pass i t on to the kids and other members of the fa m i l y . But s t i l l you know that i t ' s not a big deal, i t w i l l go away. I t ' s j u s t something you get i n every season. P a r t i a l h e a l t h meant a temporary d e v i a t i o n from usual performance of normal a c t i v i t i e s . One p a r t i c i p a n t e xplained that when her daughter was very t i r e d f o r a few days, she could not carry out her normal a c t i v i t i e s i n a usual f a s h i o n . T h i s was i n d i c a t i v e of a short term i l l n e s s . P: E i t h e r she's got a fever, of she had something to eat something that i s not that i s bothering her, that i s a short-term i l l n e s s , but not a long-time, a long-term, something. But i t i s , again i t ' s d e v i a t i n g from her normal day a c t i v i t i e s normal l i f e , so i t i s d i f f e r e n t , I should say. And once she's taken her medication f o r i t s h e ' l l be a l l r i g h t . So that i s h e a l t h to me, to be able to resume your everyday a c t i v i t i e s i n a normal s o r t of way. To summarize, p a r t i a l h e a l t h was d e s c r i b e d as a somewhat uncl e a r phase "in-between" complete h e a l t h and s i c k n e s s . P a r t i c i p a n t s denoted t h i s s t a t e by d i f f e r e n t terms. A l l p a r t i c i p a n t s , however, c o n s i d e r e d p a r t i a l h e a l t h a temporary and bothersome experience r e l a t e d to lessened a b i l i t y to do normal a c t i v i t i e s . In p a r t i a l h e a l t h , p a r t i c i p a n t s could s t i l l c a r r y out normal a c t i v i t y , but 99 l e s s w e l l and with more e f f o r t than in complete h e a l t h . Decreased energy, r e s i s t a n c e , independence and c o n t r o l were the h e a l t h c h a r a c t e r i s t i c s u n d e r l y i n g a c t i o n in t h i s phase of the h e a l t h experience. The f o l l o w i n g p o r t i o n of t h i s s e c t i o n presents p a r t i c i p a n t d e s c r i p t i o n s of s i c k n e s s - the t h i r d phase of the h e a l t h experience. Sickness Sickness was c l e a r l y d e s c r i b e d as a s t a t e where a person i s t o t a l l y unable to c a r r y out normal a c t i v i t i e s , and incapable of independent a c t i o n . T h i s i n a b i l i t y to do a c t i o n was a s s o c i a t e d with having l i t t l e or no p h y s i c a l energy. P a r t i c i p a n t s s t a t e d t h a t . t h e y d i d not want to do anything and, i n f a c t , could not do anything in s i c k n e s s , because the body needed to r e s t and recuperat e. P a r t i c i p a n t s had r e l a t i v e l y l i t t l e experience with s i c k n e s s . Some d e s c r i b e d an episode of s i c k n e s s i n t h e i r l i f e , u s u a l l y i n c h i l d h o o d . Others were aware of the s i c k n e s s experiences of f a m i l y members or f r i e n d s . One informant s a i d that h i s d i s c u s s i o n of s i c k n e s s was r e a l l y t h e o r e t i c a l s i n c e he had never " f e l t " that he was s i c k . He d e s c r i b e d having typh o i d as a c h i l d , but i n r e t r o s p e c t he d i d not c o n s i d e r that a s i c k n e s s , because as a c h i l d he had not taken the i l l n e s s s e r i o u s l y . Sickness was viewed as a s e r i o u s s i t u a t i o n where "something" was wrong i n s i d e the body. T h i s "something wrong" was a t t r i b u t e d to d i s e a s e , chemical changes w i t h i n the body, or a c t i o n from e x t e r n a l agents ( l i k e v i r u s e s ) . In s i c k n e s s the body was 100 d e s c r i b e d as in a s t a t e of very low energy, with very low r e s i s t a n c e to change and dis e a s e . In s i c k n e s s , p a r t i c i p a n t s d e s c r i b e d that they d i d not f e e l l i k e s o c i a l i z i n g because of aches and pains. They had to f o r c e themselves to do t h i n g s . Being dependent on others, because a c t i o n i s very r e s t r i c t e d , a s i c k person i s l i t e r a l l y unable to c a r r y out normal a c t i v i t i e s . P a r t i c i p a n t s explained that a s i c k person i s dependent on others to meet personal needs, as well as f u l f i l l f a m i l y r e s p o n s i b i l i t i e s . Accounts a l s o d e s c r i b e d the s i c k person having l i t t l e c o n t r o l over a c t i o n and the dis e a s e process. In c o n t r a s t to p a r t i a l h e a l t h , s i c k n e s s was viewed as something long term, or permanent. Any c o n d i t i o n that went "on and on and on" was viewed as a s i c k n e s s . Cancer was unanimously and e m p h a t i c a l l y i d e n t i f i e d as a si c k n e s s , because i t was per c e i v e d as very s e r i o u s , and e i t h e r permanent or i n c u r a b l e . P a r t i c i p a n t s explained that a s i c k person would worry about the u n c e r t a i n t y of h i s c o n d i t i o n , and about why symptoms were p e r s i s t i n g so long and he was not g e t t i n g b e t t e r . Being s i c k was f r e q u e n t l y a s s o c i a t e d with being bed-ridden, although being i n bed i t s e l f d i d not mean one was s i c k . P a r t i c i p a n t s d e s c r i b e d being in bed as "being s i c k " , because when a person was i n bed he could not do h i s d a i l y a c t i v i t i e s . In other words, being bed-ridden denoted not being able to do  anyth ing, and t h i s i n a b i 1 i t y to do a c t i o n was what s i g n i f i e d s i c k n e s s . P a r t i c i p a n t s explained that a s i c k person was g e n e r a l l y , although not n e c e s s a r i l y , i n bed because he had no 101 energy or i n c l i n a t i o n to do anything. As with complete and p a r t i a l h e a l t h , d e s c r i p t i o n s of s i c k n e s s focused almost e x c l u s i v e l y on the p h y s i c a l body. In t h i s d i s c u s s i o n , the s i c k n e s s experience w i l l be d e s c r i b e d in terms of (1) not being able to do a c t i v i t i e s , and t h e r e f o r e not being able to f u l f i l l r e s p o n s i b i l i t i e s , and (2) as something s e r i o u s , permanent and worrisome. The s e c t i o n concludes with a b r i e f p r e s e n t a t i o n of p a r t i c i p a n t accounts d e s c r i b i n g the p o s s i b l e outcomes of s i c k n e s s : r e t u r n to h e a l t h , or d e c l i n e to c h r o n i c i l l n e s s and death. Cannot Do, Cannot f u l f i l l R e s p o n s i b i l i t i e s P a r t i c i p a n t s viewed a s i c k person as someone unable to do normal d a i l y a c t i v i t i e s and independently f u l f i l l l i f e r e s p o n s i b i l i t i e s . R: So i t seems you're t e l l i n g me that when you're s i c k , you're not able to do t h i n g s . P: Not only (not) able to do t h i n g s , you see. There i s something the pain i s there, constant pain. Let alone the work, you see. Your body's not able to do anything. Loss of one's a b i l i t y to do normal a c t i v i t i e s had d i f f e r e n t meaning depending upon one's d u t i e s and r e s p o n s i b i l i t i e s . The more a person was prevented from meeting h i s / h e r r e s p o n s i b i l i t i e s , the s i c k e r he/she was p e r c e i v e d to be. For example, one p a r t i c i p a n t d e s c r i b e d that the same c o n d i t i o n (breaking a leg) meant "being a l i t t l e b i t s i c k " when she was a c h i l d , but meant "being s e r i o u s l y s i c k " f o r her as a wife and mother. She e x p l a i n e d that breaking a leg now meant s i c k n e s s , because she had so many cu r r e n t r e s p o n s i b i l i t i e s to f a m i l y and o t h e r s ; whereas 10E when she was a c h i l d she had no r e s p o n s i b i l i t i e s other than going to sch o o l . R: What I'm wondering about here i s , you know, say when you were seven and you had t h i s broken leg, and you f e l t i t wasn't r e a l l y s i c k n e s s , because i t wasn't d i s r u p t i n g your school work, e t c e t e r a . But now f o r you, say you broke your leg now, and you had to be i n bed? P: That's r i g h t , I would c a l l myself r e a l l y s i c k then. R: Why that d i f f e r e n c e between when you were seven and now? P: Because I had no r e s p o n s i b i l i t i e s then. find I have l o t s now. find i f I were to be in bed with a broken leg, say f o r a few months, even f o r a month, that would be a l o t . P a r t i c i p a n t accounts a l s o e x p l a i n e d that being s i c k i n Canada was more s e r i o u s than being s i c k in India. T h i s p e r c e p t i o n was again l i n k e d to personal r o l e s and a s s o c i a t e d d u t i e s and r e s p o n s i b i l i t i e s . P a r t i c i p a n t s explained that in India, being s i c k was l e s s " s e r i o u s " , and d i d not lead to f e e l i n g s of worry or depression, because f a m i l y members or servants were there to complete the d a i l y chores. In c o n t r a s t , in Canada, being s i c k (and t h e r e f o r e dependent) was regarded as more s e r i o u s because extended f a m i l y are f r e q u e n t l y not a v a i l a b l e to a s s i s t with work. P: fit home, i f you are s i c k s t i l l you are not worried. You are s t i l l okay, because you know e v e r y t h i n g i s looked a f t e r . There you depend on e l d e r s and servants. That makes l i f e e a s i e r . Even i f you are s i c k , you don't f e e l that burden. Here, i f your husband i s not home, and you need the grocery i n the house and you are s i c k , you have to feed the k i d s you have to get out whether you l i k e i t or no. It i s apparent from p a r t i c i p a n t d e s c r i p t i o n s that the meaning of not being able to do d a i l y a c t i v i t i e s during s i c k n e s s was l i n k e d i n t i m a t e l y with the need to f u l f i l l personal l i f e 103 r e s p o n s i b i l i t i e s . The four c h a r a c t e r i s t i c s of the h e a l t h experience u n d e r l y i n g a c t i v i t y in s i c k n e s s are d i s c u s s e d below. Low energy and r e s i s t a n c e . P a r t i c i p a n t s viewed "not being able to do a c t i o n " as the primary f e a t u r e d i s t i n g u i s h i n g s i c k n e s s from the other two phases of the h e a l t h experience. Low energy and low r e s i s t a n c e were a s s o c i a t e d with t h i s i n c a p a c i t y f o r a c t i o n . P a r t i c i p a n t s a s s o c i a t e d s i c k n e s s with t i r e d n e s s , weakness and abnormal changes in the body, which led to d e v i a t i o n s from normal r o u t i n e ways of f e e l i n g and doing t h i n g s . Accounts d e s c r i b e d the low energy present in s i c k n e s s : R: So you mean in si c k n e s s then, the energy l e v e l i s l e s s ? P: Yes, i t i s . Lower than the normal person. This low energy manifested as t i r e d n e s s . One p a r t i c i p a n t explained that the t i r e d n e s s i n s i c k n e s s i n d i c a t e d that there was something that needed to be t r e a t e d . R: So i f you're s i c k , then, t h i s t i r e d n e s s comes? P: Yeah. Ti r e d n e s s comes. Or some other, I s a i d you might have stomach upset, you might go to the loose motion or c o n s t i p a t i o n , or t h i n g s l i k e t h a t . It gives me the idea t h a t : okay, there i s something that needs to be r e c t i f i e d . The f o l l o w i n g accounts e l a b o r a t e d on being t i r e d and not doing act i v i t i es. P: — (when s i c k ) j u s t I take l i t t l e b i t , you know. I slow down my l i f e and r e l a x and s i t down. Don't do too much, you know, a c t i v i t y . P: You f e e l l e t h a r g i c and then you think, you see, the r e ' s no s t r e n g t h i n you. R: You've t o l d me you f e e l l e t h a r g i c and weak (when s i c k ) . 104 P: Um hum. I don't f e e l l i k e doing anything. The r e l a t i o n s h i p between the low energy in si c k n e s s , and being bedridden was explained as f o l l o w s : R: You're bedridden because the body's — - you have to recuperat e ? P: Yeah, you use up that energy to make that body f e e l b e t t e r , to recuperate. R: So a l l your energy when you're s i c k i s going to recuperate the body? P: Yeah. R: Whereas when you're healthy, you can use that energy f o r t h i n g s other than ( r e c u p e r a t i o n of) the body? P: That's i s r i g h t . Yes. One p a r t i c i p a n t d e s c r i b e d the need f o r e x t r a energy during s i c k n e s s . He explained that the d i e t of a s i c k person needed to be a l t e r e d i n order to in c r e a s e the s t o r e of a v a i l a b l e energy. R: So you say that when you're s i c k , your body i s n ' t able to handle that e x t r a work? P: Pny work! R: Pny work. P: Yeah, because i t puts a l l i t s energy to recuperate i t s e l f , than p u t t i n g energy to do other work. Yeah. I think whatever energy i s there and t r y i n g to heal you from i n s i d e to make you f e e l b e t t e r . find t h at, I mean i s where n u t r i t i o n comes i n . I mean you r e q u i r e e x t r a n u t r i t i o n to feed yourse1f. R: When you are s i c k ? P: When you are s i c k . You do r e q u i r e e x t r a n u t r i t i o n to supplement the same energy as to make you f e e l w e l l . I mean to make you f e e l b e t t e r then, the opposite of being i l l , okay? find then to do some a c t i v i t i e s . S i c kness was perce i v e d as a s t a t e a r i s i n g i f symptoms such as pain were neglected. One p a r t i c i p a n t advanced that view that symptoms 105 of "something wrong" in the body warned of developing s i c k n e s s . R: So something wrong with your body means s i c k n e s s ? Is that r i g h t ? P: Wouldn't say s i c k n e s s . But t h a t ' s a sign of coming s i c k n e s s . Yeah. Because i f you neglect i t t h e r e a f t e r , then q u i t e p o s s i b l y you might be s i c k at a l a t e r date. Or you might be aggravating the s i c k n e s s , you can put i t that way. Older people were perc e i v e d as more prone to becoming s i c k , because t h e i r r e s i s t a n c e i s lower than that of a younger person. P: But my mothei—in-law, she catches i t (a cold) every time the k i d s get i t . So she's s i c k with them anytime they are s i c k . So I guess when you are o l d e r you cat c h them (colds) you've got l e s s r e s i s t a n c e in your body and take medicine more. R: So, when a person gets older, you t h i n k that they would get s i c k more? P: Un hun. I th i n k so. The p a r t i c i p a n t went on to e x p l a i n that a c o l d would have d i f f e r e n t meaning f o r h e r s e l f as a young wife and mother, and her o l d e r mother-in-law. ft c o l d would mean p a r t i a l h e a l t h to her because she would s t i l l be able to do some a c t i v i t i e s . However, a c o l d would mean si c k n e s s to her mother-in-law because she would have l e s s r e s i s t a n c e , and be capable of l e s s a c t i v i t y than a younger person. R: You'd s t i l l say y o u r s e l f that you were healthy with a c o l d ( p a r t i a l health) at a younger age, but the same c o l d when you were o l d e r P: You'd c a l l y o u r s e l f s i c k , yeah. R: You'd c a l l y o u r s e l f s i c k , because you wouldn't be able to do t h i n g s ? Is that r i g h t ? P: Um hum. That's r i g h t . P a r t i a l h e a l t h was d e s c r i b e d as a s t a t e c h a r a c t e r i z e d by decreased 106 independence and c o n t r o l . Sickness, in c o n t r a s t , was explained as a s t a t e c h a r a c t e r i z e d by dependency and lack of c o n t r o l . Dependency and lack of c o n t r o l . Dependency i n s i c k n e s s meant both l i m i t e d a c t i v i t y and a c t u a l dependency on others. P a r t i c i p a n t s f e l t that they were s i c k when t h e i r normal l i f e a c t i v i t i e s were s e v e r e l y impeded or r e s t r i c t e d . The f o l l o w i n g accounts d e s c r i b e the 1 i m i t e d . a c t i v i t y i n d i c a t i v e of si c k n e s s . P: I f you are s i c k , you won't be able to perform a l l your everyday chores or your whatever you have to do. You are s i c k then, yeah. One p a r t i c i p a n t d e s c r i b e d t h i s f u r t h e r , s t a t i n g that although he had no personal experience with s i c k n e s s , he had seen other people who were s i c k . P: I f cancer i s there i t w i l l l i m i t because of the pain. Or pain, or s t r e s s . I haven't experienced that, okay. So I don't know what happens with car\cer. I honestly don't know. I mean I have seen other people being i n pain and very s i c k . I mean in very much pain and not able to do t h i n g s which they want to, and be in bed. Another p a r t i c i p a n t e l a b o r a t e d on the meaning of being s i c k : P: I thought being s i c k means you are i n bed i n the h o s p i t a l . being s i c k means once you are bedridden and i n the h o s p i t a l and you are not able to attend to your day to day d u t i e s , or your day to day r o u t i n e , not d u t i e s . R: — Okay, you say s i c k n e s s i s say, being bedridden and not being able to do your normal r o u t i n e . P: That i s r i g h t , yes. R: So you're saying that when you're in i l l - h e a l t h ( p a r t i a l h ealth) you're s t i l l able to do your t h i n g s ? P: Yes, yeah. R: Whatever r o u t i n e i s there. Okay. So si c k n e s s i s determined by p h y s i c a l l y being l i m i t e d i n terms — P: P h y s i c a l l y — to p h y s i c a l l i m i t a t i o n s of the body, that 107 I'm so much i n pain, or my body temperature i s so much that I have to r e s t i t (the body) some more. Okay? R: Yeah, okay. P: That's' being s i c k . P s i c k person was d e s c r i b e d as incapable of independent a c t i v i t y , and t h e r e f o r e in need of a t t e n t i o n and care from others. P: Sickness, I mean a s i c k person needs a l o t of a t t e n t i o n . P: Well, by dependence, I mean you r e l y on others i f you're unable to do t h i n g s . You know, i f you are s i c k f o r a lengthy peri o d of time, somebody would have to take care of you. Or you won't be able to do something, so you're always r e l y i n g on others. The r e l a t i o n s h i p between dependency and c o n t r o l was d e s c r i b e d as f o i l o w s : P: It a l l , you know, r e l a t e s to what I f e e l about being i n c o n t r o l . When you are depending on somebody e l s e , or even a simple t h i n g , l i k e you know, i f something, I can bend my knee and go underneath t h i n g s to get them out. I couldn't do that f o u r months ago. I was always would have to get somebody in the f a m i l y to say, you know: "I've dropped t h i s t h i n g there, can you reach out and get i t f o r me". So dependency and l i m i t a t i o n , they are both, you know c o n t r a r y to being i n c o n t r o l . F e e l i n g s of h e l p l e s s n e s s , l o n e l i n e s s and f e a r were other aspects of the l o s s of c o n t r o l a s s o c i a t e d with s i c k n e s s . P: Sickness would mean, h e l p l e s s , a f e e l i n g of being h e l p l e s s . P f e e l i n g of being dependent on others, a f e e l i n g of f e a r , l o n e l i n e s s . Scary. I l l n e s s means something I don't want to t h i n k about i t . Pnd I'm t a l k i n g about s e r i o u s i l l n e s s . I'm not t a l k i n g about a headache or a c o l d . I'm t h i n k i n g i n terms of prolonged i l l n e s s , even l i k e breaking an arm, or something which makes me an i n v a l i d , or makes me handicapped, or i n some way, you know, that I'm dependent on others. R: so you're t a l k i n g about dependency. Being dependent and being h e l p l e s s , you say. P: Yeah. Pnd again, l o s i n g c o n t r o l . Because I've been a 108 s i n g l e parent f o r 11, 12 years, and make a l l the d e c i s i o n s , and down goes t h i n g s , and sort of, you know,always looked a f t e r myself most of the time. So i t ' s that, you know, f e e l i n g t h a t : w e l l , what i f t h i s happened, what would I do? Another p a r t i c i p a n t expressed a s i m i l a r p e r s p e c t i v e : R: What i s i t l i k e when you are s i c k ? P: Oh, you are depressed and you can't do anything, and you are h e l p l e s s . The l o s s of c o n t r o l a s s o c i a t e d with s i c k n e s s was a l s o explained in terms of not being able to do anything about the s i t u a t i o n , and not being able to carry out scheduled a c t i v i t i e s . The f o l l o w i n g accounts i l l u s t r a t e these two views: P: And l i k e cancer, or heart disease, you see and then, you're s u f f e r i n g with i t , and at that same time, you know, you can't do anything about i t . R: When you're healthy you know f o r sure you can do a l l those t h i n g s you're planning. Whereas when a person's s i c k they're not able to c a r r y out t h e i r r o u t i n e s . P: Yeah, t h a t ' s true, yes. I thin k i t s d i f f i c u l t f o r anybody, because now you have one more t h i n g to take care of — t h e i r own body and t h e i r own h e a l t h . And i f i t s not up to what you had scheduled — R: What's "not up"? You mean your body? P: Yeah. Your body. I f you're not f e e l i n g w e l l , or you're i l l , then you cannot do many t h i n g s which you wanted to do, hoping that the body w i l l cooperate with you, with your schedule. Permanent. S e r i o u s and Worrisome As noted e a r l i e r , p a r t i c i p a n t s e xplained s i c k n e s s as something continuous, long-term or permanent. Sickness meant something s e r i o u s . P a r t i c i p a n t s d e s c r i b e d f e e l i n g uncomfortable, g e n e r a l l y being i n bed, not being able to do anything, and being 109 worried. The ensuing accounts i l l u s t r a t e s i c k n e s s as a s e r i o u s , long term c o n d i t i o n . In s i c k n e s s "something i s wrong", and o f t e n i n c u r a b l e . P a r t i c i p a n t s d e s c r i b e d the d i f f e r e n c e between p a r t i a l h e a l t h and s i c k n e s s , emphasizing the s e r i o u s , long term nature of s i c k n e s s . P: I'm s i c k , something's r e a l l y wrong with me. P: P short term i l l n e s s i s l i k e i f somebody's got the f l u . I wouldn't c a l l that a s e r i o u s s i c k n e s s . You go there (to the doctor) and you take medication. You go to the doctor, the d o c t o r gives you the medication, and you take care of that l i t t l e f l u or whatever — i t might j u s t be a bug. Pnd i f you're a l r i g h t you're normal again i t ' s a l r i g h t . But i f you prolong being s i c k f o r a long time, you are s i c k . Pnd you've got a high temperature, that i s being s i c k , because that i s not your normal day to day a c t i v i t y . You have a high temperature, you are t a k i n g medication f o r i t , and you are l y i n g down in bed, and so you are a s i c k person at that time u n t i l you resume your normal everyday act i v i t y. P: You know, s i c k n e s s i s much more s e r i o u s than the kind of l i m i t a t i o n I have now (torn knee c a r t i l a g e ) . I t h i n k i n my mind s i c k n e s s i s , you know, 104 degree temperature, or a very s e r i o u s cough, or you know, prolonged s t a t e of a f f a i r s . P: L i k e I had a cesarean s e c t i o n and that was j u s t temporary, because the weakness was only temporary. I got over i t , and I f o r g o t about i t . But supposing, you see, now somebody l i k e , have a chest pain continuous, you know, and then say three or four times, you know, and p e r s p i r i n g and having chest pain, and there i s something wrong. Pnd then you don't c a l l y o u r s e l f healthy. There i s something wrong and you have to have the i n v e s t i g a t i o n s , and go to the doctor. P: I mean s i c k n e s s i s a more s e r i o u s term f o r me than p a r t i a l h e a l t h . Yeah. Sickness means that I am not able to do on a r e g u l a r b a s i s , or I am i n great pain. Sickness i s more s e r i o u s , has a more s e r i o u s c o n n o t a t i o n than p a r t i a l h e a l t h 1 10 does you know. R: So when would you go from being healthy to being s i c k ? P: Si c k ? Oh, supposing you see, something wrong, l i k e I've got a g a l l bladder t h i n g , or I can't d i g e s t my food, or I have some kind of u l c e r , or a pain in my chest. So you are not , you see. R: Then you are not what? P: Then you are not healthy, you see. R: Then you are not healthy P: No. R: Why not? P: Because you see, there i s a reason that why you are having these pains, t h e r e ' s something wrong i n your system. P: Being s i c k i s i f your i l l n e s s doesn't go away f o r a long time, or permanently. The f o l l o w i n g accounts of the s i c k n e s s experience d e s c r i b e d the worry a s s o c i a t e d with constant pain and not knowing what i s going to happen. P: Constant pain going on. So at that time the mental worry a l s o comes. That r e l a t e s with the p h y s i c a l s i c k n e s s . R: How does i t r e l a t e ? P: Because you see, you don't know what's going to happen. Your mind i s wandering, you know, whether you're going to have surgery, whether i t ' s going to be s u c c e s s f u l , whether you're going to get through. So many t h i n g s , you see, go through your mind. Rs At the time you are s i c k ? P: At the time you are s i c k . P: If i t s constant pain week a f t e r week, week a f t e r week, 111 you don't f e e l good. find you are worried. find you're f e e l i n g some aches : "what's going to happen, the pain i s s t i l l there, whether I am going to have surgery, what's goin to be done. Doctor takes X-rays and he can't f i n d anything, but the pain i s s t i l l t here. So t h a t ' s when I say that, you see, you c a l l y o u r s e l f that you're not healthy. R: You're not healthy. P: find t h e r e ' s something there. R: When would you r e a l l y be s i c k then? P: When someone's got cancer, as I a l r e a d y t o l d you. Or heart d i s e a s e or something l i k e t h a t . Yeah, you get worried about that and that r e a l l y worries you. Cancer was the c o n d i t i o n d e s c r i b e d most f r e q u e n t l y in p a r t i c i p a n t accounts as meaning a person was s i c k . In f a c t , some informants equated only cancer with s i c k n e s s . T u b e r c u l o s i s , small pox, and more commonly chest pain and heart d i s e a s e , however, were other c o n d i t i o n s p e r c e i v e d as meaning s i c k n e s s . On informant mentioned " r e g u l a r " b l e e d i n g from the stomach as i n d i c a t i v e of being s i c k , and something "to worry about", because of the on-going nature of the symptom. Sickness was d e s c r i b e d as a "major t h i n g " , while c o n d i t i o n s l a b e l l e d as p a r t i a l h e a l t h were d e s c r i b e d as "minor t h i n g s " . The f o l l o w i n g accounts provide d e s c r i p t i o n s of cancer as a major t h i n g because i t meant something i n c u r a b l e and permanent. R: I j u s t wanted to understand a b i t b e t t e r why you s a i d something l i k e cancer was a major t h i n g . P: Yeah. You know, somebody i s , yeah, that s i c k , you know they're not going to ever get b e t t e r , r i g h t ? So that i s not minor. I t s major. R: I t s major because you s a i d "they're not going to get 1 1 2 b e t t e r " ? P: Yeah, t h a t ' s r i g h t . R: I'd l i k e to understand a l i t t l e b i t b e t t e r how you are seeing the two t h i n g s : the d i f f e r e n c e between something minor and something major? P: Well, t h a t ' s major because you know that what i t i s le a d ( i n g ) you to. find i f i t s minor, you know i t s something that i s going to go away i n a few days, a few weeks, say. P: Sickness I always thought that i t ' s r e a l l y something very s e r i o u s . I f f o r example the t h i n g s which, of course I have never p e r s o n a l l y experienced, but something l i k e say cancer or TB, or some such t h i n g . R: You mentioned cancer and a l l those kinds of i l l n e s s e s . P: Yeah, well yeah, when somebody has that, I guess that you w i l l c a l l them s i c k , yeah. Nothing can be done f o r i t . P a r t i c i p a n t s d e s c r i b e d r e t u r n to h e a l t h , or c h r o n i c d i s e a s e and death, as the two outcomes of s i c k n e s s . The next p o r t i o n provides accounts i l l u s t r a t i n g p e r s p e c t i v e s on these two outcomes. Return to Health, or Chro n i c I l l n e s s and Death The vast m a j o r i t y of accounts d e s c r i b e d recovery to h e a l t h from s i c k n e s s . A few p a r t i c i p a n t s , however, d i d speak of the f a c t that a s i c k person c o u l d d i e i f (s)he was unable to get treatment, or i f the body's r e s i s t a n c e was very low and h e a l i n g could not take place. P a r t i c i p a n t s a l s o i n d i c a t e d , a l b e i t i m p l i c i t l y , the p o s s i b i l i t y of s i c k n e s s p r o g r e s s i n g to c h r o n i c i l l n e s s . The f o l l o w i n g accounts i l l u s t r a t e the two main aftermaths of s i c k n e s s : r e t u r n to h e a l t h and death. The f i r s t account ex p l a i n e d recovery to h e a l t h . P: In the s i t u a t i o n s l i k e , l i k e supposing — I won't say f o r e v e r , but when I'm s u f f e r i n g from something, l i k e I'm s i c k . I'm running a f e v e r or something, i f I have to go to 113 the doctor then I'm not a healthy person at that time. Once I'm recovered I am a healthy person. Another account d e s c r i b e d the d e c l i n e towards p o s s i b l e death, l i n k e d with the body's decreased a b i l i t y to r e s i s t i n t e r n a l l y or e x t e r n a l l y caused s i c k n e s s . P: It (the cause of the s i c k n e s s ) could be an e x t e r n a l source a l s o (as well as an i n t e r n a l source). A bug which I haven't seen, made me s i c k with the f l u , okay? Which got d e t e r i o r a t e d i n t o worse and worse and I died because of t h a t . That must be s i c k n e s s . Okay? My body not able to take i t . To conclude, s i c k n e s s was d e s c r i b e d c l e a r l y by p a r t i c i p a n t s as a s t a t e c h a r a c t e r i z e d by not being able to c a r r y out normal a c t i v i t i e s , and t h e r e f o r e not being able to f u l f i l l personal r e s p o n s i b i l i t i e s . Low energy and r e s i s t a n c e , along with dependence and lack of c o n t r o l , were explained as the c h a r a c t e r i s t i c s u n d e r l y i n g the very l i m i t e d a c t i v i t y i n s i c k n e s s . In c o n t r a s t to the temporary, bothersome nature of p a r t i a l h e a l t h , s i c k n e s s was p e r c e i v e d as s e r i o u s , permanent and worrisome. Understanding the c h a r a c t e r i s t i c s of p a r t i a l h e a l t h and s i c k n e s s c l a r i f i e s the parameters of complete h e a l t h , and provides a v i s i o n of the t o t a l h e a l t h experience as a three phase continuum. Complete h e a l t h , p a r t i a l h e a l t h and s i c k n e s s were d e f i n e d and understood by p a r t i c i p a n t s in terms of being able to do normal a c t i v i t i e s . Two p o s s i b l e consequences of s i c k n e s s were d e s c r i b e d : r e t u r n to h e a l t h , or c h r o n i c i l l n e s s and death. P a r t i c i p a n t s g e n e r a l l y had l i t t l e personal experience with s i c k n e s s , but were cognizant of the s i c k n e s s experiences of other persons. The f i n a l s e c t i o n of t h i s chapter presents p a r t i c i p a n t accounts d e s c r i b i n g the 114 i n f l u e n c e which the mind and other f a c t o r s exert on the t o t a l h e a l t h experience. In f l u e n c e s on the S t a t e of Health Within the o v e r a l l frame of "being able to do normal a c t i v i t i e s " , data a n a l y s i s r e v e a l e d two d i s t i n c t c a t e g o r i e s of d e s c r i p t i o n of h e a l t h : (1) the complete h e a l t h - p a r t i a l - h e a l t h -s i c k n e s s continuum, and (2) the f a c t o r s i n f l u e n c i n g the t o t a l h e a l t h experience (see f i g u r e s 2 & 3). The previous s e c t i o n presented p a r t i c i p a n t d e s c r i p t i o n s of the three phases of the h e a l t h experience. This s e c t i o n d i s c u s s e s the f a c t o r s which p a r t i c i p a n t s c o n s i d e r e d to i n f l u e n c e h e a l t h . The r o l e of the mind w i l l be presented in most d e t a i l , as i t was d e s c r i b e d by p a r t i c i p a n t s as the f a c t o r e x e r t i n g the g r e a t e s t i n f l u e n c e over h e a l t h . E x e r c i s e , d i e t , s l e e p and c l e a n l i n e s s , use of medicines and maintaining r o u t i n e , w i l l be b r i e f l y d e s c r i b e d as e x t e r n a l f a c t o r s e x e r t i n g a l e s s e r i n f l u e n c e on the t o t a l h e a l t h experi ence. The Mind: Body-Mind I n t e r a c t i o n Although p a r t i c i p a n t s explained h e a l t h as a i n t e g r a t e d experience based upon the i n s e p a r a b i l i t y of body and mind, they nonetheless s i n g l e d out the c o n d i t i o n of the mind (or mental a t t i t u d e ) as the f a c t o r most a f f e c t i n g a person's h e a l t h . It i s t h e r e f o r e important to d i s c u s s the ways that p a r t i c i p a n t s e x p l a i n e d the r o l e of the mind in h e a l t h , and r a t i o n a l to focus on the r o l e of the mind as a separate theme f o r d i s c u s s i o n . 115 P a r t i c i p a n t s provided a h o l i s t i c d e s c r i p t i o n of h e a l t h in terms of a balance between body and mind (see f i g u r e 3), with both body and mind i n v o l v e d in the three phases of the h e a l t h experience. Ps d i s c u s s e d e a r l i e r , p a r t i c i p a n t s d e s c r i b e d the three phases predominantly in terms of the p h y s i c a l body, f o c u s i n p r i m a r i l y on how the c o n d i t i o n of the body impacts upon a person' c a p a c i t y f o r doing normal a c t i v i t i e s . P a r t i c i p a n t accounts, however, a l s o d e s c r i b e d how the mind i n f l u e n c e s complete h e a l t h , p a r t i a l h e a l t h and s i c k n e s s . Accounts unanimously d e s c r i b e d a r e c i p r o c a l i n t e r a c t i o n between the mind and the body, with mental h e a l t h seen to a f f e c t p h y s i c a l h e a l t h and v i s a versa. P a r t i c i p a n t s acknowledged the r o l e of the mind in h e a l t h . The vast m a j o r i t y of p a r t i c i p a n t s f e l t that the mind exerted the g r e a t e s t i n f l u e n c e on the t o t a l h e a l t h experience, a f f e c t i n g the i n d i v i d u a l ' s a b i l i t y to do normal a c t i v i t i e s and f u l f i l l r e s p o n s i b i l i t i e s i n d a i l y l i f e . The mind was explained to have both a p o s i t i v e ( b e n e f i c i a l ) and a negative ( d e s t r u c t i v e ) i n f l u e n c e on h e a l t h . According to p a r t i c i p a n t accounts, the mind can e i t h e r a s s i s t in the maintenance and improvement of h e a l t h , or exert a d e t r i m e n t a l e f f e c t on h e a l t h . Worry, d e s c r i b e d in r e l a t i o n to s t r e s s i n some accounts, was c o n s i d e r e d capable of making a healthy person l e s s healthy, and u l t i m a t e l y s i c k . In c o n t r a s t , a p o s i t i v e mental a t t i t u d e , c h a r a c t e r i z e d p r i m a r i l y by freedom from worry, was viewed as b e n e f i c i a l to h e a l t h . P a r t i c i p a n t s s t a t e d that t h i s p o s i t i v e 116 mental a t t i t u d e could help a person remain completely healthy, a s s i s t a p a r t i a l l y - h e a l t h y person to r e g a i n complete h e a l t h , and even heal the s i c k body. P a r t i c i p a n t accounts of the e f f e c t s of worry are presented below. Horry Although worry was explained i n various ways in p a r t i c i p a n t accounts, i t was b a s i c a l l y equated with mental a g i t a t i o n ; a s t a t e opposite to the calm mental c o n d i t i o n found when the i n d i v i d u a l c u l t i v a t e d a " p o s i t i v e mental a t t i t u d e " (described in the f o l l o w i n g s e c t i o n ) . Being a f f e c t e d by, or r e a c t i n g to, e x t e r n a l circumstances and l i f e s i t u a t i o n s , lamenting over the past and being anxious over the f u t u r e were d e s c r i b e d as the fundamental causes f o r worry. Worried thoughts were viewed as capable of making the body l e s s healthy. Worry was viewed as a f a c t o r which d r a i n s away a person's p h y s i c a l and mental energy, and t h e r e f o r e decreases i n d i v i d u a l r e s i s t a n c e to i l l n e s s . Some p a r t i c i p a n t s equated worry with mental unhealth, or s i c k n e s s . Several p a r t i c i p a n t s r e f e r r e d to s t r e s s as the r e s u l t , or e f f e c t , of worry. One p a r t i c i p a n t d e s c r i b e d the way s t r e s s can r u i n h e a l t h : P: Yeah, because i f you're under pressure a l l the time, i t ' s ( s t r e s s i s ) a mental c o n d i t i o n , i t becomes l i k e a and i t j u s t has a chain r e a c t i o n over e v e r y t h i n g . And you know, you get f r u s t r a t e d , and you can't deal with i t ( s t r e s s ) so you get depressed, or you get angry. And then t h a t ' s how my u l c e r c o n d i t i o n s t a r t e d , i s because I didn' t know how to deal with i t . And I j u s t thought about i t and thought about i t and never r e a l l y acted. So I t h i n k i t d i d almost r u i n my, you know, h e a l t h . As noted, worry was equated with mental s i c k n e s s i n some accounts. 117 P: That's when you'd say that your mind i s s i c k , r i g h t ? Because you have l o t s of worries i n there. T h i s negative mental a t t i t u d e was a l s o d e s c r i b e d i n terms of " l o s s of mental balance". One p a r t i c i p a n t viewed l o s s of mental balance in terms of "being c o n t r o l l e d " by f e e l i n g s (emotions): P: When mental balance i s not there, t h a t ' s the way they (people) become s i c k . R: So f o r you, i f you had the p h y s i c a l h e a l t h , but you l o s t your mental balance, then you would say that you were mentally s i c k ? P: Yeah. Yeah. That's the time you become s i c k , you know. Something overcome, you know, your t h i n k i n g power, you know. Maybe i s the depression, maybe i s greed, maybe i s the je a l o u s y , maybe anger, or maybe revenge f e e l i n g , you know. Thi s negative mental s t a t e i n v o l v e d on-going worry, not j u s t temporary worry about l i f e s i t u a t i o n s . The f o l l o w i n g accounts exp l a i n e d how mental worry decreases the body's r e s i s t a n c e and g e n e r a l l y a f f e c t s h e a l t h . P: Mind i s the thought process which, i n t h i s i l l h e a l t h , ( p a r t i a l health) b r i n g s out chemical changes i n the body, which makes body n o n - r e s i s t i v e to a l l o u t s i d e e f f e c t s , l i k e a l l e r g i e s . P: Well, i f you don't keep y o u r s e l f happy, of course you can get worried. Pnd worries are not good f o r your h e a l t h . You know, they give you u l c e r s sometimes. Ps I t o l d you l a s t time, you can get u l c e r s i f you worry too much. R: Would you f e e l you were healthy i f you had any kind of worri e s ? P: No. I wouldn't r e a l l y because i t i s not a — normal s t a t e of mind at that time. So I have these worries and i t coul d a f f e c t my h e a l t h as w e l l , i n the sense that i f my mind i s worried I might not eat pro p e r l y , I might not do my chores p r o p e r l y . Pnd that could a f f e c t my body. The p a r t i c i p a n t c l a r i f i e d t h i s p o i n t : 118 P: i f you're mentally not healthy, i f you're worried about something a l l the time, i t does a f f e c t your ( p h y s i c a l ) h e a l t h as we 11. A c l e a r d e s c r i p t i o n of worry as a f a c t o r a d v e r s e l y a f f e c t i n g h e a l t h was provided by another p a r t i c i p a n t . Speaking of a t r a d i t i o n a l Indian saying about the e f f e c t s of worry, he r e l a t e d worry with s t r e s s , and mentioned the opposite mental a t t i t u d e : keeping happy. R: I am wondering what the e q u i v a l e n t word i n , say, Hindi would be f o r s t r e s s ? P: "Chinta" R: Oh, so t h i n k i n g ! P: Yeah, " c h i n t a " . R: Okay, so I was wondering i f I could get a b e t t e r understanding of what you were saying, by not using the eng1i sh word. P: Yeah. You know what " c h i n t a " means? Worry. You know, worry? R: Okay. P: find somebody might have t o l d you " c h i n t a " and " c h i t a " are two t h i n g s . " C h i t a " d e s t r o y s or f i n i s h e s the dead body. You know what i s " c h i t a " ? R: I'd r a t h e r have you t r a n s l a t e i t . P: " C h i t a " i s the cremation t h i n g . Where you put the body w i t h t h e l o g s . R: Yes. P: and put f i r e to i t . That's " c h i t a " . That destroys the dead body. "Chinta" d e s t r o y s the l i f e . Okay? R: So that r e a l l y shows the importance t h a t ' s placed on t h i s s t r e s s then i n terms of h e a l t h and i l l n e s s . P: Yeah. That i s r i g h t . Yes. R: And so t h a t ' s something that you learned as you were 119 growing up, or heard then? P: Um hum. The song i s , I mean, a p p r o p r i a t e "don't worry, be happy"! It i s very a p p r o p r i a t e . The same p a r t i c i p a n t explained how worry leads to mental s t r e s s . P: S t r e s s i s again the a t t i t u d e towards i t , towards that t h i n g , how you want to re a c t or counter act. I mean, okay F i r s t t h i n g i s your thought process, okay? I could be worried about my mother's leg. R: Yes. P: find i f I am so much worried that my r a t i o n a l t h i n k i n g goes o f f , and I s t a r t shouting at my c h i l d r e n and at my wife and th i n g s l i k e t h at, i s s t r e s s . — - Worrying about something (that) might happen, or has alre a d y happened beyond our c o n t r o l . I mean "what i f " s c e n a r i o . R: — I'm s t i l l not sure about how you're d e f i n i n g s t r e s s . Are you saying s t r e s s i s a l o t of worry? Or i r r a t i o n a l worry? P: No. No. That worry causes, i n your t h i n k i n g , s t r e s s . Worry i s c r e a t i n g s t r e s s . How would I meet my tomorrow's payment? Okay. R: — So the worry, t h a t ' s there in the thoughts, can cause t h i s s t r e s s or t e n s i o n , which P: Yeah. Which w i l l change your chemical, body's — body chemicals to re a c t d i f f e r e n t l y . Chemical changes i n your body i t b r i n g s . I mean t h a t ' s what causes a l l e r g i e s . The r o l e of mental a t t i t u d e i n h e a l t h was f u r t h e r explained i n another account. Reacting n e g a t i v e l y to e x t e r n a l events was viewed to cause s t r e s s . R: So t h i s a t t i t u d e you have plays a r o l e i n your h e a l t h ? P: That i s r i g h t . A t t i t u d e to the e x t e r n a l t h i n g s . I mean to me you are an e x t e r n a l person. And what you s a i d , I re a c t — how I r e a c t , or counter r e a c t my a t t i t u d e towards — I mean you might be d r i n k i n g tea, and I d o n ' t ' l i k e you d r i n k i n g t e a while I am s i t t i n g here. Or you might be s c r a t c h i n g your head, and to me i t s , i t might bother me. I r e a c t d i f f e r e n t l y . So r e a c t i o n to that a l s o causes e i t h e r s t r e s s or happiness r e a c t i o n , or counter a c t i o n to other people's a c t i o n or words or whatever. 120 The f o l l o w i n g accounts i l l u s t r a t e the b e n e f i c i a l , or p o s i t i v e , i n f l u e n c e the mind exerts on the t o t a l h e a l t h experience. P o s i t i v e Mental A t t i t u d e P a r t i c i p a n t s d e s c r i b e d p o s i t i v e mental a t t i t u d e as e s s e n t i a l l y opposite to the s t a t e of worry j u s t d e s c r i b e d . Although t h i s mental a t t i t u d e was d e s c r i b e d v a r i o u s l y in p a r t i c i p a n t accounts, the b a s i c c h a r a c t e r i s t i c emerging from the data was being f r e e from worry. P a r t i c i p a n t s f u r t h e r d e s c r i b e d t h i s a t t i t u d e as having "nothing bothering you", not t a k i n g t h i n g s s e r i o u s l y , being o p t i m i s t i c , seeing the p o s i t i v e side of l i f e , being content with what one has, and keeping happy. Being in c o n t r o l of one's f e e l i n g s , or emotions, and not r e a c t i n g to (or worrying about) l i f e events and small p h y s i c a l problems were d e s c r i b e d as other aspects of t h i s p o s i t i v e mental a t t i t u d e . •ne p a r t i c i p a n t d e s c r i b e d how p o s i t i v e mental a t t i t u d e i n v o l v e d f e e l i n g s of "being healthy at a l l times", d e s p i t e having small h e a l t h problems. He f e l t that t h i s a t t i t u d e kept him healthy, and a l s o helped him r e g a i n h e a l t h when he was in p a r t i a l h e a l t h or s i c k n e s s . P: Even i f there i s some (health) problem, okay, that i t w i l l take care of i t s e l f in course of time, so i t s f i n e . That's what I f e e l . And that i s why I say that mental a t t i t u d e gives you helps you being healthy. He explained f u r t h e r how t h i n k i n g can a f f e c t h e a l t h , s t a t i n g that t h i n k i n g you are healthy, makes you healthy, and t h i n k i n g you are s i c k , makes you s i c k . P: I d e f i n i t e l y f e e l that the mental a t t i t u d e which you 121 develop, i t d e f i n i t e l y helps your p h y s i c a l body as w e l l . Because over a pe r i o d of time I have always thought: yes, i f you t h i n k that you are healthy, you r e a l l y are. He e l a b o r a t e d on t h i s as f o l l o w s : R: I was wondering i f the mind can e i t h e r harm the body — P: Yes. R: — or i t can work in a p o s i t i v e way and help the body heal or keep healthy? P: P o s i t i v e way, yeah. That's r i g h t . That's what I f e e l . Because s e v e r a l times I see that, okay, i f I r e a l l y want to be sad i n my l i f e a l l I need to do i s s i t l i k e t h i s f o r a couple of hours, and you w i l l see that two hours l a t e r you w i l l f e e l that you r e a l l y are, there i s something wrong somewhere. R: You mean j u s t s t a y i n g s i t t i n g f o r two hours? P: Yes, s i t t i n g two hours t h i n k i n g that you are unhappy. It d e f i n i t e l y a f f e c t s your h e a l t h . R: Because you s t a r t to r e a l l y b e l i e v e that you are unhappy? P: Yeah, t h a t ' s r i g h t . R: So, keeping p o s i t i v e thoughts, you could say P: Yeah, keeping p o s i t i v e thoughts does help, power of p o s i t i v e t h i n k i n g . R: Power of p o s i t i v e t h i n k i n g . So do you f e e l that the mind a c t u a l l y can heal the body? If we use the word heal, or cure t h i n g s ? P: Ph, not e i t h e r heal or not cure but i t d e f i n i t e l y c o n t r i b u t e s to both processes I would say. Th i s a t t i t u d e was a t t r i b u t e d , at l e a s t i n part, to the p a r t i c i p a n t ' s upbringing i n India and a s s o c i a t e d f a m i l y i n f l u e n c e s . He e x p l a i n s how he a c q u i r e d t h i s mental a t t i t u d e . P: T h i s i s not a very conscious e f f o r t to t r a i n i t (the mind) as such. But I b e l i e v e i n i t , and that i s how i t has happened. R: Okay. Pnd you — y o u ' d say you b e l i e v e i n t h i s because of your past? You were saying l i k e with your grandfather 122 t a l k i n g about (ayurvedic medicine) P: Because of the yes, p a r t l y because of the i n f l u e n c e , p a r t l y because of whatever we s t u d i e d in the schools. R: So the whole e d u c a t i o n a l system? P: Or my f a t h e r ' s i n f l u e n c e might have worked to a great extent on me. My f a t h e r i s one of my type, who would never say even i f he i s s u f f e r i n g from anything. Nobody would know in the fa m i l y a l t o g e t h e r . One p a r t i c i p a n t l i n k e d t h i s a t t i t u d e to the tenets of Hindu philosophy. To her the most important aspect of t h i s mental a t t i t u d e was "being in c o n t r o l of the f e e l i n g s , and not l e t t i n g the f e e l i n g s c o n t r o l you". In c o n t r a s t to the view of the e a r l i e r p a r t i c i p a n t , she l i n k e d t h i s c o n t r o l of emotions with conscious t r a i n i n g of the mind, which she d e s c r i b e d as " t r a i n i n g the b r a i n " . P: A c t u a l l y t h i s t h i n g which I'm d i s c u s s i n g with you, i t s the Indian philosophy — that meditation s t a r t , yogas you must have heard, yoga and meditation? They are a l l f o r t r a i n i n g the b r a i n . She e l a b o r a t e d as f o l l o w s : P: t h a t ' s the way (through yoga and meditation) you t r a i n your b r a i n (mind), so l i k e nothing bothers you. R: Okay. P: Happiness or sorrow, you take everything, you know, as they come and go. L i k e t h a t . R: Okay, so you're t e l l i n g me that to " t r a i n your b r a i n " then t h i s meditation p r a c t i c e i s important? P: Right. — so your b r a i n doesn't wander l i k e f o r nothing here and there, you know. E x p l a i n i n g t h i s " t r a i n i n g " f u r t h e r she s t a t e d : P: — You have to p r a c t i c e i t . L i k e p r a c t i c e i t , not to — l i k e you should overcome, your b r a i n (mind) should overcome a l l those f e e l i n g s , not those f e e l i n g s should command your b r a i n , you know. 123 This mental balance, or a t t i t u d e , was r e l a t e d to not being o v e r l y a f f e c t e d by surrounding s i t u a t i o n s , and not l e t t i n g t h i n g s bother you. P o s i t i v e mental a t t i t u d e was f u r t h e r d e s c r i b e d as a mental s t a t e c h a r a c t e r i z e d by inner balance and c l e a r r a t i o n a l i t y . R: So mental h e a l t h means having c o n t r o l over your mind? P: Having c o n t r o l over your mind, yeah. R: And not, as you say, g e t t i n g P: Dist u r b e d over, say g e t t i n g e m o t i o n a l l y upset over something f o r any reasons, e i t h e r e m o t i o n a l l y or otherwise. P: Yeah, i f the balance i s not there, t h i s t h i n g (bad news) w i l l a f f e c t me more or longer time. P: Nothing bothers me too much. And even i f something, you know, sometimes somebody does bad to me, or says something bad to me, i t doesn't hurt. I don't take that t h i n g too deeply, you know. A few p a r t i c i p a n t s viewed working o u t s i d e of the home as a f a c t o r c o n t r i b u t i n g to t h i s p o s i t i v e mental a t t i t u d e . Economic gain was not mentioned in r e l a t i o n to t h i s work. Both s a l a r i e d employment and v o l u n t e e r work were d e s c r i b e d in t h i s context. One p a r t i c i p a n t e x p l a i n e d that doing work outside of the home was "mental therapy", as i t provided a change of atmosphere. R: I wondered i f you co u l d j u s t e l a b o r a t e on that f o r a few minutes, about what you mean by "mental therapy"? P: L i k e you see Yeah, I'11 t e l l you. Some of my f r i e n d s , you know, when I t a l k to them, "Oh, we are both s t a y i n g at home, you know". And then they complain, you know, j u s t "I have to go to the doct o r because I have t h i s ache, and I got, you know, backache or headache". I say, l i s t e n you have to change your atmosphere. You have to go out and meet other people. Or even working f o r a few hours, part time, I s a i d . That w i l l change your mental a t t i t u d e . So that, you see, you're not t h i n k i n g a l l the time about y o u r s e l f . 1E4 She went on to say that t h i s work helped her to stay mentally a c t i v e , and that t h i s mental a t t i t u d e was important to her h e a l t h : P: So t h i s i s what I s a i d , that i t s a mental therapy, you see. Work i s a mental therapy. R: And that f o r you i s important i n being healthy? P: Right. Even as worry was sometimes r e f e r r e d to as mental s i c k n e s s , or unhealth, t h i s p o s i t i v e mental a t t i t u d e was r e f e r r e d to as mental h e a l t h i n some accounts. The f o l l o w i n g account d e s c r i b e d the b e n e f i c i a l e f f e c t of an ac c e p t i n g , calm mental a t t i t u d e . One p a r t i c i p a n t c a l l e d t h i s a t t i t u d e being "mentally f i n e " . P: I f you are mentally f i n e , I t h i n k i t reduces your s u f f e r i n g s to a great extent t h a t ' s what i t i s . As I sa i d , the way I approach the l i f e , okay, i t had to happen and i t d i d happen, okay. Then now I have to face i t . And then, see i t reduces my s u f f e r i n g s , i t eases the burden on my head. R: So t h i s a t t i t u d e of acceptance? P: A t t i t u d e of acceptance and u l t i m a t e l y t r y to solve the (problem) — form a r e s o l u t i o n to solve the problem. R: So that would be there when you're mentally healthy? P: Yes. That would be there when you're mentally healthy. And i f you're mentally healthy, p h y s i c a l l y you m i qht be s i c k , but s t i l l that (mental a t t i t u d e ) a l s o helps r e c o v er your body. Or i f not recover the body, at l e a s t i t d e f i n i t e l y helps reduce your s u f f e r i n g s . He e l a b o r a t e d on t h i s p e r s p e c t i v e : R: You t a l k e d a l o t about how worry can d i s t u r b your h e a l t h . For i n s t a n c e you s a i d worries over a small p h y s i c a l problem, that mental a t t i t u d e can cause p h y s i c a l problems. P: Yeah. That's r i g h t . Yes. R: Is that the same t h i n g you're t a l k i n g about now? P: Yeah, t h a t ' s e x a c t l y what I'm saying. That yes, i f you 125 are — i f you have some small p h y s i c a l problems a l s o , perhaps you can say, ignore these problems. Ignore in the sense not that you don't go to a doctor, or don't t r y to get i t healed. But what I mean i s that you know what to do with i t , r a t h e r than say, i f you are, i f you don't have c o n t r o l over your mind: "Oh, my god! what have I to do t h i s t h e re". Whereas i f you have a c o n t r o l , a l l that you would do i s okay, go to the doctor you t r y to c o n t r o l the pains or something. Or even i f you have the pains, you know that "okay, t h i s i s the problem, i t has happened". But you have to face i t and you have to br i n g — solve i t subsequently, r a t h e r than j u s t c r y i n g over i t a l l the time. R: "Rather than j u s t c r y i n g over i t a l l the time". So that means worrying about i t ? Or being anxious? P: Yeah. That's r i g h t , yeah. This mental a t t i t u d e was a l s o d e s c r i b e d as a p o s i t i v e view on l i f e . The f o l l o w i n g accounts i l l u s t r a t e t h i s : P: Things happen i n s i d e , and that makes you happy or sad at times. But s t i l l you know, you t r y to something that bothers you, your mind, and you s t i l l , you know, t r y to be happy. Say, look f o r the good sid e of i t , and there's nothing there. Look at your kids and be happy with them. Right? I j u s t f e e l happy with what I've got. I look at my kids, and my mother, and so I, you know, f e e l happy with them. R: You s a i d that in h e a l t h t h i s t h i n k i n g p o s i t i v e was very important. find I was wondering e x a c t l y what you meant by " t h i n k i n g p o s i t i v e l y " ? P: To me t h i n k i n g p o s i t i v e l y means to t r y and see i f t h i n g s are not, you know, always t r y and see what i s going f o r you. What i s okay, I'11 give you an simple example okay? Say i f you had plans to go to a movie with somebody, fit q u a r t e r to seven somebody c a l l s and says " s o r r y . I can't go". find you r e a l l y were loo k i n g forward to i t . Rather than saying, you know, "that's i t , my whole evening i s ruined, you take the op p o r t u n i t y to think, or s i t down and read a book, or, you know. That's what I thin k i s p o s i t i v e t h i n k i n g , i s to make the most of what i s there, r a t h e r than be depressed or d i s a p p o i n t e d with l i f e because of what we don't have. P a r t i c i p a n t s e x p l a i n e d that keeping a happy a t t i t u d e and not being a f f e c t e d by t h i n g s , was another f a c e t of t h i s b e n e f i c i a l mental 126 a t t i t ude. P: St a y i n g happy means that you are not worrying about t h i n g s and you j u s t have a happy a t t i t u d e towards l i f e , and you know. That would — yeah, keep you healthy, i n that s t a t e of h e a l t h . Yeah. You know, you are not worrying about t h i n g s and, l e t t h i n g s happen and not l e t them a f f e c t you, t h a t ' s the idea. P: Well, keeping y o u r s e l f happy, you know, doing your again the same sort of t h i n g comes, you know, doing your r o u t i n e chores and doing your d u t i e s , and keeping y o u r s e l f content and you know. Not l e t anything worry you, the t h i n g s do come that you know, nag at you. But j u s t t r y to keep y o u r s e l f away from i t , and know that they are going to pass away, or whatever. Se v e r a l p a r t i c i p a n t s r e l a t e d t h i s b e n e f i c i a l mental a t t i t u d e to a happy home and f a m i l y environment. Keeping a good atmosphere i n the home was co n s i d e r e d very important i n h e a l t h . P: Home atmosphere i s very important too. P good r e l a t i o n with a l l the f a m i l y members i s a l s o very important - to have good h e a l t h mentally, as well as p h y s i c a l l y . I f th e r e ' s peace and harmony and everybody i s going to be very happy, and, you know, the normal way. But i f there i s any kind of f r i c t i o n in the house, that would b r i n g mental worries and mental — and then i t might — i t could lead to other kind of problems as w e l l . So a l l t h i s does c o n t r i b u t e to being healthy. P: I f you are happy i n a l i f e with your f a m i l y with your c h i l d r e n , that a f f e c t s (health) a l o t too. One p a r t i c i p a n t e x p l a i n e d that i t was often d i f f i c u l t coming to Canada from India, being away from the extended f a m i l y , and having no one to t a l k to about personal problems. D e s c r i b i n g that the worry a s s o c i a t e d with keeping personal concerns b o t t l e d up i n s i d e was d e t r i m e n t a l to h e a l t h , he agreed that a mind f r e e of worries helps to keep a person healthy. R: So then t h i s not being able to t e l l your problems could give r i s e to t h i s worrying? 127 P: Yes. It c o u l d give r i s e to the worrying. It could give r i s e and those worrying a l s o i t — i t d e f i n i t e l y a f f e c t s your body as w e l l u l t i m a t e l y . R: Right. So keeping your mind f r e e of worries, worrying about t h i n g s , w i l l h e lp your p h y s i c a l h e a l t h ? P: Yeah. That's r i g h t . Pbsence of worry (or mental s t r e s s ) was s p e c i f i c a l l y d e s c r i b e d i n one account as something c o n t r i b u t i n g to h e a l t h . The p a r t i c i p a n t d e s c r i b e d the important r o l e of the mind in the h e a l t h experience. R: So you're t e l l i n g me that the body stays healthy as long as the mind doesn't have any s t r e s s in i t ? P: Yes. Ps f a r as the h e a l t h i s concerned. R: "Ps f a r as the h e a l t h i s concerned"? P: Yeah. R: So that means the mind i s r e a l l y i n c o n t r o l of the body's h e a l t h ? P: It i s . R: So f o r you, the mind determines whether the body i s healthy or not? Is that what you're t e l l i n g me? P: Mind does not determine i f the body i s healthy or not. Mind i s the cause which c r e a t e s i t s a f f e c t of h e a l t h on the body. R: Creates (complete) h e a l t h or i l l - h e a l t h ( p a r t i a l - h e a l t h ) ? P: Both ways. R: Both ways? P: Mind i s the cause, the thought process, thought process i s the, I mean — and the s t r e s s i n i t , or not having the s t r e s s i n i t . Okay. Having i t w i l l a f f e c t changes i n the body('s) h e a l t h . In summary, p a r t i c i p a n t s e x p l a i n e d that the mind exerts a two-fold i n f l u e n c e on the three phases of the h e a l t h experience. Worry (often m a n i f e s t i n g as s t r e s s ) was d e s c r i b e d as d e t r i m e n t a l to 128 h e a l t h , while a p o s i t i v e mental a t t i t u d e ( c h a r a c t e r i z e d p r i m a r i l y by freedom from worry) was d e s c r i b e d as having a b e n e f i c i a l i n f l u e n c e on h e a l t h . fts noted p r e v i o u s l y , p a r t i c i p a n t s e xplained that the mind exert s the most powerful i n f l u e n c e on the t o t a l h e a l t h experience. The other i n f l u e n c i n g f a c t o r s d e s c r i b e d i n p a r t i c i p a n t accounts are now d i s c u s s e d i n the con c l u d i n g p o r t i o n of t h i s s e c t i o n . In c o n t r a s t to the mind, which i s viewed as an i n t e r n a l i n f l u e n c i n g f a c t o r , these other f a c t o r s p e r c e i v e d to i n f l u e n c e h e a l t h are r e f e r r e d to as e x t e r n a l f a c t o r s . E x t e r n a l F a c t o r s Diet, e x e r c i s e , sleep, c l e a n l i n e s s and use of medicines, as well as maintaining a r o u t i n e , working o u t s i d e of the home and home atmosphere, were perc e i v e d as other f a c t o r s i n f l u e n c i n g complete h e a l t h , p a r t i a l h e a l t h and si c k n e s s . Although they are r e f e r r e d to as " l e s s e r i n f l u e n c i n g f a c t o r s " ( i n c o n t r a s t to the r o l e of the mind), they were n e v e r t h e l e s s explained as s i g n i f i c a n t i n f l u e n c e s on the h e a l t h s t a t e . Accounts d e s c r i b i n g work outside of the home and home atmosphere were alr e a d y presented i n the previous s e c t i o n i n r e l a t i o n to p o s i t i v e mental a t t i t u d e ; these two f a c t o r s w i l l thus not be presented again i n the cu r r e n t d i s c u s s i o n . The nature of each of the other l e s s e r i n f l u e n c e s w i l l now be d e s c r i b e d through p a r t i c i p a n t accounts. P a r t i c i p a n t s ' d e s c r i p t i o n s of these f a c t o r s r e v e a l the importance of pr e v e n t i v e h e a l t h behaviors. 129 D i e t and E x e r c i s e A f t e r the mind, p a r t i c i p a n t s d e s c r i b e d d i e t and e x e r c i s e as the most s i g n i f i c a n t f a c t o r s i n f l u e n c i n g h e a l t h . Diet and e x e r c i s e were viewed to be very c l o s e l y r e l a t e d to each other, being almost always d e s c r i b e d t o g e t h e r r a t h e r than as i s o l a t e d e n t i t i e s . P: I t h i n k d i e t and e x e r c i s e both should be very c l o s e l y monitored, to ... you know, have good h e a l t h . So j u s t not one or the other, they both should be done. R: The two together, d i e t and e x e r c i s e ? P: That's r i g h t . Because you can eat, you know, r e a l l y h e a l thy food, and yet f e e l s l u g g i s h i f you don't e x e r c i s e . So you have to complement your d i e t with e x e r c i s e . D i e t . P a r t i c i p a n t s saw d i e t as something very important f o r h e a l t h . Improper d i e t was d e s c r i b e d as a major cause of s i c k n e s s . Proper d i e t , on the other hand, was viewed, not only as a f a c t o r i n v o l v e d i n keeping a person healthy and preventing d i s e a s e and si c k n e s s , but a l s o as a i d i n g a person's recovery from s i c k n e s s to h e a l t h . The f o l l o w i n g account d e s c r i b e s how wrong e a t i n g h a b i t s c o n t r i b u t e to s i c k n e s s . P: We learned that most of the d i s t u r b e d , say, p h y s i c a l d i s t u r b a n c e s or whatever i t i s , are due to your i l l d i e t . Okay? So i f your d i e t i s not proper, or you d i g e s t i o n i s not proper, then only most of the i l l n e s s e s you get. He f u r t h e r e x p l a i n e d that, when he was s i c k as a c h i l d , a y u r v e d i c d o c t o r s i n Ind i a s t r i c t l y advised what foods to take and what foods to avoid i n order to heal the body. He spoke of s i c k n e s s in terms of " d i s t u r b a n c e s " i n the body: P: That's why I s a i d that your d i e t a l s o i s r e s p o n s i b l e f o r 130 most of the d i s t u r b a n c e s in your body. find t h a t ' s how i f you avoid those d i e t s (wrong foods), i t helps by i t s e l f (to heal the body). Although the nature of a "proper" d i e t was d e s c r i b e d v a r i o u s l y in the accounts, p a r t i c i p a n t s agreed on b a s i c p r i n c i p l e s . Most p a r t i c i p a n t s e xplained that a proper d i e t was made up of a balance of p r o t e i n s , carbohydrates, f a t s , f r u i t s and vegetables. They were not concerned about s c i e n t i f i c a l l y e s t a b l i s h e d amounts of each food group, but r a t h e r estimated the amounts of each food necessary f o r a balanced d i e t . Both v e g e t a r i a n and non-vegetarian Indian meals were seen as n u t r i t i o n a l l y balanced. Many p a r t i c i p a n t s used Western foods e x t e n s i v e l y i n t h e i r d i e t s . A l l p a r t i c i p a n t s had adequate economic resources to provide the foods r e q u i r e d f o r such a balanced d i e t . The f o l l o w i n g account i l l u s t r a t e s a common p e r s p e c t i v e on proper d i e t . P: A proper healthy d i e t f o r me would be — excess of anything i s not a healthy d i e t . And moderation of anything i s — you Know, — I l i k e to eat a l o t of sweets, or whatever you can c a l l i t , — but a normal amount i s j u s t a l l r i g h t . But i f I s t a r t e a t i n g j u s t sweets and candies everyday, i t s not — i t s going to t e l l on my h e a l t h and my t e e t h and ev e r y t h i n g i n l a t e r years. And that i s not a very healthy d i e t because i t does not, i t does not give you ev e r y t h i n g that you r e q u i r e f o r a healthy body. You must have some meat, you should have some c e r e a l , you should have some milk, you should have f r u i t and f r e s h vegetables — t h a t ' s a proper balanced p o r t i o n of these i s a healthy d i e t . The b e n e f i t s of f a s t i n g , as we l l as l i m i t i n g intake of sugar and s a l t , was d e s c r i b e d by another p a r t i c i p a n t : P: I keep f a s t twice a week (on l i q u i d s and f r u i t s ) j u s t to -- c l e a n , you know, the system. And then I t r y to c o n t r o l sugar and s a l t . I don't take sugar i n my tea. I look a f t e r my h e a l t h . Advocating a n a t u r o p a t h i c p e r s p e c t i v e on d i e t , one p a r t i c i p a n t 131 e x p l a i n e d "proper" d i e t r a t h e r d i f f e r e n t 1 y . To him a proper d i e t meant e a t i n g foods which "the body craved a f t e r " . He f e l t that a person has a n a t u r a l i n c l i n a t i o n to eat the foods which the body needs f o r h e a l t h , as w e l l as a n a t u r a l i n s t i n c t to not overeat. P: When you f e e l an urge to eat something, i t only shows that your body needs those p a r t i c u l a r t h i n g s . Pnd then only you f e e l an urge f o r i t ... But time comes when you f e e l that "oh, hey, t h a t ' s enough, I don't th i n k I need to eat more". But because you l i k e i t s t a s t e , i f you keep e a t i n g i t , that doesn't help you at that time. Pnd then i t a d v e r s e l y a f f e c t s your body. Diet was l i n k e d i n t i m a t e l y to the body's s t o r e of energy. Ps noted p r e v i o u s l y , p a r t i c i p a n t s explained that d i e t needed to be a l t e r e d during s i c k n e s s . P l i q u i d or s e m i - l i q u i d d i e t was recommended f o r the s i c k person, to provide the body with a source of quick energy to promote h e a l i n g , r e c u p e r a t i o n and provide e x t r a energy f o r doing a c t i v i t i e s . S e v e r a l accounts d e s c r i b e d milk as a food of s p e c i a l importance to the d i e t . Milk was d e s c r i b e d as a very wholesome food, and the food of choice d u r i n g s i c k n e s s because i t i s r a p i d l y a s s i m i l a t e d and provides a quick source of energy to the body. The f o l l o w i n g accounts i l l u s t r a t e t h i s pers pect i ve: P: I d e f i n i t e l y b e l i e v e that i t s (milk) a very healthy d i e t , p a r t l y because I don't know why, we have been brought up l i k e t h a t . Pnd we were always t o l d — I t h i n k even in the school i t was taught that you must have a good amount of milk everyday. R: Would you change your d i e t , would you, i f you were s i c k ? P: Yes, I d i e t or supplement with vitamins, and I might dr i n k more milk. I might eat d i f f e r e n t d i e t . It could be s e m i - l i q u i d d i e t . And l i q u i d doesn't mean l i q u o r ! More milk, and d i f f e r e n t , I mean, so e v e r y t h i n g you c o u l d d i g e s t i t b e t t e r . L i k e I won't eat meat, as i t s hard to d i g e s t . 132 R: So you're saying these t h i n g s , milk and l i q u i d s , they'd be easy to d i g e s t when you're s i c k ? Is that what you mean? P: Yes. find give you more energy, and f a s t e r energy. "What" foods were eaten and "when" they were eaten was a l s o a point emphasized in many accounts. P a r t i c i p a n t s e xplained that foods should be eaten at set meal times, and i n moderate amounts. P: E a t i n g proper food, yeah, and doing t h i n g s in time too. L i k e lunch time you have to eat i n time, and you know, no matter i f you eat l i t t l e or more — and j u s t take whatever you, and do t h i n g s in time, you know. R: What do you mean "do t h i n g s i n time"? P: Try to do, okay, some people have habit they w i l l get up 11 o'clock, then they w i l l s p o i l t h e i r whole r o u t i n e . So lunch time, they w i l l have b r e a k f a s t , and dinn e r or snack time they w i l l eat lunch! P: Eat a proper d i e t at proper times, and not j u s t eat any time you f e e l l i k e i t — j u s t open the f r i d g e and eat something. P: If you keep e a t i n g i t (a food you f e e l l i k e e a t i n g ) , that doesn't help you at that time. find then i t ad v e r s e l y a f f e c t s your body. It was f e l t that l i g h t e r foods should be taken in the e a r l y part of the day, and that t h i s p a t t e r n of e a t i n g c o n t r i b u t e d to a person's v i t a l i t y . One p a r t i c i p a n t d e s c r i b e d t h i s as f o l l o w s : R: fire there other t h i n g s that you thi n k are important f o r you, to maintain c o n t r i b u t e to t h i s v i t a l i t y t h a t ' s part of h e a l t h ? P: It again comes to e a t i n g h a b i t s . What you eat and when you eat. I mean, I would not eat any meat items before lunch. Okay. On my br e a k f a s t , I'11 have a very l i g h t b r e a k f a s t . Very l i g h t means a cup of tea, or a cup of milk, or a cup of j u i c e and maybe a piece of f r u i t . find lunch w i l l be a l s o very l i g h t — i t s not a big lunch, I mean. R: So a l l these t h i n g s you're doing, having a l i g h t b r eakfast and a moderately l i g h t lunch are c o n t r i b u t i n g to having you 1 3 3 have that f e e l i n g of being e n e r g e t i c ? P: That i s r i g h t . One p a r t i c i p a n t spoke of t a k i n g foods which were in season; t h i s p r a c t i c e stemmed from upbringing in India. R: So you grew up t a k i n g the foods that were in season? P: Yeah. F r u i t s and food what i s in season, and what grows most at the farm, t h a t ' s the main. R: So, here a l s o you tend to take foods that are in season? P: Okay, here habit i s s t i l l that same. Temperature and freshness of foods eaten were d e s c r i b e d as other important aspects of a healthy d i e t . One p a r t i c i p a n t e xplained that a t t i t u d e s about proper d i e t were i n s t i l l e d in him d u r i n g h i s upbringing i n India. He d e s c r i b e d that very c o l d food, or s t a l e food, i s not healthy. Fresh food, i n c o n t r a s t , was d e s c r i b e d as h e a l t h f u l . P: Right from our childhood, we were never given any c o l d s t u f f to eat a l t o g e t h e r . R: Could you d e s c r i b e what you mean by "cold"? P: E i t h e r that i s a c t u a l l y r e f r i g e r a t e d or — one i s r e f r i g e r a t e d — that i s anything that i s extremely c o l d i s never consumed. Secondly, anything that i s s t a l e i s never consumed. R: S t a l e . How would you determine " s t a l e " ? P: Something that i s , something which you s t o r e up i n the f r i d g e or somewhere f o r days together. Or i n a f r e e z e r and put i t f o r days together. Or canned foods and t h i n g s l i k e t h a t , we never knew. E v e r y t h i n g i s f r e s h . He e x p l a i n e d how he s t i l l observed these p r a c t i c e s i n Canada. P: I u s u a l l y don't d r i n k very c o l d water, sometimes I do take these pops and other t h i n g s , but s t i l l i f I have to d r i n k water a l s o , I do take c o l d water but not that very c o l d one. 1 3 4 The f o l l o w i n g accounts i l l u s t r a t e p e r s p e c t i v e s on e x e r c i s e . E x e r c i se. P a r t i c i p a n t s unanimously perc e i v e d e x e r c i s e as e s s e n t i a l to maintenance of h e a l t h . Pccounts v a r i e d , however, in terms of the type of e x e r c i s e advocated. Walking and jogging, as wel l as t r a d i t i o n a l hatha yoga e x e r c i s e s and breathing techniques, were d e s c r i b e d as b e n e f i c i a l to h e a l t h . One p a r t i c i p a n t saw e x e r c i s e as a way of coping with s t r e s s . The accounts presented below i l l u s t r a t e some of these p e r s p e c t i v e s . P: I've always been a c t i v e , and always ... not, not you know, r i g o r o u s e x e r c i s e , j u s t a r e g u l a r balanced ... i n moderation, you know.Go f o r long walks or something, swimming, or whatever. Do something on a r e g u l a r b a s i s . E x e r c i s e was perce i v e d as enhancing the body's v i t a l i t y and r e s i s t a n c e ; with e x e r c i s e i t s e l f viewed as one aspect of a healthy l i f e s t y l e . The importance of i n c r e a s i n g c a r d i a c output through p h y s i c a l and breathing e x e r c i s e s was d e s c r i b e d by one p a r t i c i p a n t : R: You j u s t s a i d that t h i s r e s i s t a n c e comes from doing s e v e r a l t h i n g s , or l i v i n g a c e r t a i n way. P: Yeah. L i v i n g a c e r t a i n s t y l e of l i f e s t y l e . G e n e r a l l y we have been taught i n our s o c i e t y that g e t t i n g up before s u n r i s e and having a bath and c l e a n i n g up, and a l l c l e a n i n g , and then doing a l i t t l e b i t of e x e r c i s e — you can c a l l i t yoga or whatever you can, e x e r c i s e which r e l a t e s to the body. Okay? L i k e breathing e x e r c i s e . R: So when you say " r e l a t e s to the body", you mean using the body? P: Yes, using the body. R: You mean p h y s i c a l e x e r c i s e ? P: Yes. That's r i g h t . Your p h y s i c a l e x e r c i s e , that p h y s i c a l e x e r c i s e a l s o i n c l u d e s b r e a t h i n g . find l i k e , again, i f you want to bri n g , i n c l u d e the medical terms here, I mean the — I ' l l be saying you have to pump up your c a r d i o v a s c u l a r system. 135 R: Okay. Yes, yes. P: But i t s the breathing e x e r c i s e s , in a way, which a l s o does that s i m i l a r l y . find some other e x e r c i s e s , and the same e x e r c i s e s which give you — without that much s t r a i n on your body — s t i l l the same v i t a l i t y . But one e s s e n t i a l part i s , I mean, having, g e t t i n g up before s u n r i s e and having bath before s u n r i s e , gives you e x t e r n a l energy. It was a l s o e x p l a i n e d that people vary in terms of the amount and type of food and e x e r c i s e they r e q u i r e to be healthy. P: Some people could become healthy with l e s s e x e r c i s e than some people, who could, to some i t might take more e x e r c i s e and food, or chemical intake (foods). As compared — t h a t ' s t o t a l l y (dependent) upon your own p h y s i c a l requirements, body requirements. R: And what about these requirements? P: As I s a i d , d i f f e r e n t foods, and more e x e r c i s e , a d i f f e r e n t type of e x e r c i s e . That's again a p h y s i c a l requirement, I mean. R: I know. But I mean why, or how, do you see t h i s being d i f f e r e n t from person to person? What would the reason be? P: Because everybody's body s t r u c t u r e i s d i f f e r e n t . And chemical body, i n t e r n a l l y chemical r e a c t i o n to d i f f e r e n t chemicals i s d i f f e r e n t . R: I see. So some people w i l l need more d i e t and some more e x e r c i se. P: That's r i g h t , yes. Sleep and C l e a n l i n e s s Although p a r t i c i p a n t s mentioned s l e e p and c l e a n l i n e s s only b r i e f l y i n t h e i r accounts, they nonetheless a t t r i b u t e d importance to these two i n f l u e n c e s on h e a l t h . The importance of s l e e p f o r p h y s i c a l and mental h e a l t h was d e s c r i b e d in one account as f o i l o w s : R: So i t seems that s l e e p has an e f f e c t on your p h y s i c a l h e a l t h as well as your mental h e a l t h ? 136 P: It does, yes. It r e s t s my mental — because I'm not t h i n k i n g , maybe unconsciously I am_ dreaming or whatever, I don't know. I can't say about that, I have no idea what goes on — but I f e e l that my b r a i n i s g e t t i n g a l i t t l e b i t of r e s t as well as my body's g e t t i n g r e s t . So next morning when I wake up, the v i t a l i t y i s again back and I can s t a r t work again. Another p a r t i c i p a n t d e s c r i b e d how s l e e p helps a person c a r r y out h i s / h e r d u t i e s : P: I f you don't have a good sleep, n a t u r a l l y , you know, you are not capable of performing your d u t i e s d u r i n g the day. So ... i f you're not s l e e p i n g every night, in case of insomnia or something, you're not going to stay healthy. ... Your d u t i e s that you have to perform the next day ... supposing you have had a good sleep, you know, you're capable of doing (the d u t i e s ) b e t t e r . I f you haven't had i t ( s l e e p ) , you are j u s t doing i t , but not i n a proper way. That's what I th i n k . C l e a n l i n e s s of one's person, as well as the surrounding environment, was d e s c r i b e d as another f a c t o r i n f l u e n c i n g h e a l t h . The f o l l o w i n g accounts e x p l a i n the importance of c l e a n l i n e s s : P: C l e a n l i n e s s . You should keep y o u r s e l f clean, otherwise i t does b r i n g a c e r t a i n kind of maybe i t could b r i n g s k i n d i s e a s e . L i k e d e n t a l h e a l t h i s very important, too. I f you don't wash your h a i r then there can be — c e r t a i n problems co u l d come. So, c l e a n l i n e s s i s very important too, on your person as well as in the house. P: When you get up, you brush your t e e t h , you take a bath, and you change your c l o t h e s everyday. L i k e my c h i l d r e n never wear the same c l o t h e s the next day. It has to be washed before they can wear the same c l o t h e s ... So I thin k that i t i s a n e c e s s i t y to be healthy, because i f you don't brush your te e t h , n a t u r a l l y germs go i n , and that s o r t of t h i n g I b e l i e v e i n . To be f r e s h . Pnd t h a t ' s the way I s t a r t a day f o r myself. Pnd I keep the house c l e a n so that, you know, my kids l i k e to play on the f l o o r so I would l i k e to have the f l o o r c l e a n . So that, I mean, t h a t ' s the way I take h e a l t h as. Use of Medicines Pccounts d e s c r i b e d use of both Western and t r a d i t i o n a l Indian medicines. Some p a r t i c i p a n t s used Western medicines e x c l u s i v e l y , 137 others used both Western and Indian medicines. One p a r t i c i p a n t e x p l a i n e d that herbal medicines were important in maintaining h i s h e a l t h , p a r t i c u l a r l y in r e l a t i o n to preventing c o n s t i p a t i o n and promoting proper d i g e s t i o n of food. R: So you're t e l l i n g me that you f e e l that herbal medicine works much b e t t e r (than Western a l l o p a t h i c medicines)? P: Oh, d e f i n i t e l y much b e t t e r . I have always t r u s t e d these medicines only. He e l a b o r a t e d on the type of herbal medicines he used and why: R: You don't l i k e to take any of these t r a d i t i o n a l Western medicines ( l i k e a s p i r i n ) ? P: Any of those p i l l s . Not only Western, I don't take — and t h a t ' s where the concept of naturopathy comes — I don't take even a y u r v e d i c medicines a l s o so of t e n . I have a few medicines brought over from India. And i t r e a l l y works extremely w e l l . Only a couple of them. One i s known as "harde". Now, t h a t ' s a so r t of l a x a t i v e , okay? but nor a r e a l l a x a t i v e , but i t loosens up your motions, and motion i s r e a l l y good. And that helps you very much. Now t h i s i s one t h i n g which I take o c c a s i o n a l l y . And there i s another one, i t i s known as "sudarshan". That's an extremely b i t t e r powder. And that powder, i f you are having temperature or something, i t helps you a l o t . In cases of f l u or something, i t helps a l o t . Accounts d e s c r i b i n g use of Western medicines, r e f e r r e d almost e x c l u s i v e l y to the use of a s p i r i n as a common way of t r e a t i n g temporary complaints such as headaches, backache and fever . P: L i k e i f I had a headache I j u s t took an a s p i r i n and that would go away. I wouldn't need to go to a doctor f o r that. Or a s l i g h t fever, I could j u s t take an a s p i r i n , and that would be a l r i g h t . M a i n t a i n i n g Routine M a i n t a i n i n g one's usual d a i l y r o u t i n e was d e s c r i b e d as an a d d i t i o n a l f a c t o r i n f l u e n c i n g h e a l t h . The f o l l o w i n g account d e s c r i b e s the importance of keeping a r o u t i n e , or doing t h i n g s 138 r e g u l a r l y . The p a r t i c i p a n t explained maintaining a r o u t i n e of r e g u l a r e x e r c i s e . P: Then, l i k e you do t h i n g s r e g u l a r l y , and eve r y t h i n g . L i k e i f you e x e r c i s e r e g u l a r l y then i t a f f e c t s ; i t doesn't a f f e c t i f you do once a week, or, you know, do maybe, you know, sometime i n the evening and, or, sometime in the morning. Keeping a r o u t i n e i s good t h i n g to become healthy person. Doing "something d i f f e r e n t than the r o u t i n e " was viewed as le a d i n g to s i c k n e s s . The ensuing account d e s c r i b e d t h i s : R: So a c t u a l l y t h i s seems to be important, that to keep your h e a l t h you need to maintain your r o u t i n e s ? P: Maintain your r o u t i n e s i s very important. R: find whatever that r o u t i n e i s you can change i t slowly? P: You can change i t slowly, but you cannot make a sudden change and not f e e l the e f f e c t of i t on your body. R: So, in order to keep healthy you need to maintain the time you get up, and what you eat, and the r o u t i n e of how much e x e r c i s e you have? P: That's r i g h t . R: find when you don't keep that r o u t i n e going, you can get in t o i l l - h e a l t h ( p a r t i a l h e a l t h ) ? P: Yeah. Then body has to react to that change, and then the v i t a l i t y goes down because i t s t r y i n g to cope with that change, energies are d i v e r t e d towards coping (with) that change and a d j u s t i n g towards that change. Because now the body w i l l accept s i m i l a r changes that next time happening. So the energies are going there, so energies are not there f o r other t h i n g s which are happening around the body, in the environment. In summary, p a r t i c i p a n t s d e s c r i b e d d i e t , e x e r c i s e , sleep, c l e a n l i n e s s , use of medicines, maintaining a r e g u l a r r o u t i n e , working ou t s i d e of the home and home atmosphere, as a d d i t i o n a l f a c t o r s i n f l u e n c i n g the three phases of the h e a l t h experience. Diet, e x e r c i s e , sleep, c l e a n l i n e s s , use of medicines, and 1 3 9 maintaining a r e g u l a r r o u t i n e have been d e s c r i b e d through the p a r t i c i p a n t accounts presented in t h i s s e c t i o n . The accounts presented i n the previous s e c t i o n on p o s i t i v e mental a t t i t u d e i n c l u d e d p a r t i c i p a n t s ' d e s c r i p t i o n s of the i n f l u e n c e which working ou t s i d e of the home and home atmosphere exert on h e a l t h . Of these minor i n f l u e n c i n g f a c t o r s , d i e t and e x e r c i s e were given the gre a t e s t importance in p a r t i c i p a n t s ' accounts. Summary This chapter has presented the r e s u l t s of the study in the form of p a r t i c i p a n t s ' accounts of t h e i r experience of h e a l t h . A n a l y s i s of data r e v e a l e d "doing normal a c t i v i t i e s " as the o v e r a l l context w i t h i n which p a r t i c i p a n t s explained the h e a l t h experience, and led to the f i n a l s t r u c t u r i n g of an a n a l y t i c framework which organized the p r e s e n t a t i o n of data in t h i s chapter. Within t h i s o v e r a l l context, p a r t i c i p a n t s o f f e r e d two l e v e l s of d e s c r i p t i o n of h e a l t h . F i r s t l y , they d e s c r i b e d h e a l t h a c c o r d i n g to the three phases of the h e a l t h experience (complete h e a l t h , p a r t i a l h e a l t h and s i c k n e s s ) . Secondly, h e a l t h was de s c r i b e d i n terms of the f a c t o r s perceived to i n f l u e n c e h e a l t h . Health was perceived as a h o l i s t i c phenomenon i n v o l v i n g both body and mind, the two being l i n k e d t ogether as an ins e p a r a b l e whole unit and making up the t o t a l person. P a r t i c i p a n t s d e s c r i b e d the three phases of the h e a l t h experience p r i m a r i l y in terms of the p h y s i c a l body. In c o n t r a s t , d e s c r i p t i o n s of the f a c t o r s i n f l u e n c i n g h e a l t h focused l a r g e l y on the r o l e of the mind, 140 although other minor f a c t o r s (such as d i e t and e x e r c i s e ) were a l s o d e s c r i bed. Complete h e a l t h was explained as a s t a t e where the t o t a l person (both body and mind) was healthy and able to c a r r y out normal a c t i v i t i e s w ell and h a p p i l y . In p a r t i a l h e a l t h , p a r t i c i p a n t s were s t i l l able to c a r r y out d a i l y a c t i v i t i e s , but l e s s well and with more e f f o r t than i n complete h e a l t h . In s i c k n e s s , p a r t i c i p a n t s explained that they could not c a r r y out normal a c t i v i t i e s , and t h e r e f o r e could not f u l f i l l personal d u t i e s and r e s p o n s i b i l i t i e s independently. P a r t i a l h e a l t h was viewed as temporary and bothersome, while s i c k n e s s was d e s c r i b e d as s e r i o u s , permanent (or long term) and worrisome. Energy, r e s i s t a n c e , independence and c o n t r o l were d e s c r i b e d as four c h a r a c t e r i s t i c s of the h e a l t h experience. These fo u r h e a l t h c h a r a c t e r i s t i c s supported i n d i v i d u a l c a p a c i t y f o r doing normal a c t i v i t i e s in each phase of the h e a l t h experience. Health was per c e i v e d and experienced by p a r t i c i p a n t s p r i m a r i l y i n terms of c a p a c i t y f o r normal a c t i o n . Health was d e s c r i b e d i n r e l a t i o n to the three phased continuum making up the t o t a l h e a l t h experience. D e s c r i p t i o n s of the c h a r a c t e r i s t i c s of p a r t i a l h e a l t h and s i c k n e s s c l a r i f i e d the nature of complete h e a l t h . The r e s u l t s of t h i s study c o n s t i t u t e a d e s c r i p t i o n of the e s s e n t i a l meaning of h e a l t h f o r the Indo-Canadians i n v o l v e d i n t h i s i n v e s t i g a t i o n . T h i s d e s c r i p t i o n r e p r e s e n t s the popular domain of Kleinman's explanatory model. The f o l l o w i n g chapter 141 d i s c u s s e s the r e s u l t s of the r e s e a r c h in l i g h t of r e l e v a n t 1i t erat ure. 142 CHAPTER 5 : DISCUSSION OF THE FINDINGS The framework presented in chapter f o u r r e p r e s e n t s the fundamental meaning of h e a l t h f o r the Indo-Canadians who p a r t i c i p a t e d i n t h i s study. The framework i l l u s t r a t e s some of the explanatory models of h e a l t h l o c a t e d w i t h i n the popular sphere of Kleinman's c u l t u r a l system model (see f i g u r e 1). The study f i n d i n g s i n d i c a t e that there i s some agreement between the c o n c e p t u a l i z a t i o n s of h e a l t h h e l d by h e a l t h care p r o f e s s i o n a l s and those held by the Indo-Canadian p a r t i c i p a n t s i n t h i s study. Health was r e v e a l e d as c o n s t r u c t e d in both e t h n o c u l t u r a l and s o c i a l contexts. T h i s i s a s i g n i f i c a n t f i n d i n g of the study. The r e s e a r c h e r s t a r t e d the c u r r e n t study with the i n t e n t of i n v e s t i g a t i n g the i n f l u e n c e which e t h n i c i t y and c u l t u r e exert on h e a l t h d e f i n i t i o n . The data, however, i n d i c a t e that s o c i a l environment a l s o plays an important r o l e in the way people c o n s t r u c t h e a l t h . In t h i s chapter, the study's f i n d i n g s w i l l be d i s c u s s e d and r e l a t e d to r e l e v a n t l i t e r a t u r e . 0 b r i e f examination of the data i n l i g h t of Kleinman's explanatory model framework intr o d u c e s the content of t h i s chapter. The f o l l o w i n g d i s c u s s i o n focuses on three main themes: (1) normalcy and h e a l t h , (2) c o n c e p t u a l i z a t i o n s of h e a l t h , and (3) f a c t o r s i n f l u e n c i n g h e a l t h . These three themes correspond to the three fundamental components of the framework presented in the preceding chapter: namely - doing normal a c t i v i t i e s , the three phases of the h e a l t h experience and 143 f a c t o r s i n f l u e n c i n g the h e a l t h s t a t e (see f i g u r e s 2 & 3). Some of the l i t e r a t u r e c i t e d i n chapter two i s reviewed again in t h i s d i s c u s s i o n of the study's f i n d i n g s . The s i g n i f i c a n c e of s o c i o - c u l t u r a l context in c o n s t r u c t i o n of notions of h e a l t h i s emphasized in t h i s chapter's d i s c u s s i o n . The Explanatory Model Framework Kleinman (1978a,b, 1980, 1984) s t a t e s that s o c i a l and c u l t u r a l context s t r u c t u r e the i n d i v i d u a l ' s explanatory model f o r viewing h e a l t h and i l l n e s s . As i l l u s t r a t e d i n Kleinman's model, each of the three domains ( p r o f e s s i o n a l , popular and f o l k ) has i t s own p e r s p e c t i v e s on h e a l t h and i l l n e s s (see f i g u r e s 2 & 3). E f f e c t i v e communication and h e a l t h care i s encouraged when c l i e n t s and h e a l t h p r o f e s s i o n a l s share s i m i l a r views of h e a l t h and i l l n e s s . On the other hand, d i f f i c u l t i e s i n c l i n i c a l communication and i n e f f e c t i v e h e a l t h care are l i k e l y to e x i s t when lay and p r o f e s s i o n a l p e r s p e c t i v e s remain d i s t a n t from each other. The d e s c r i p t i o n s of h e a l t h presented i n the accounts of p a r t i c i p a n t s represent the popular sphere of the model, and encompass the i n d i v i d u a l and fa m i l y based b e l i e f s , r o l e s and behaviours a s s o c i a t e d with the experiences of h e a l t h and i l l n e s s . P a r t i c i p a n t s ' b e l i e f s r e g a r d i n g the f a c t o r s which i n f l u e n c e h e a l t h , and r e l a t e d h e a l t h promoting l i f e s t y l e s , appear q u i t e s i m i l a r to those h e l d by other groups i n North Pmerican s o c i e t y . These s i m i l a r i t i e s appear to be based on socio-economic s i t u a t i o n r a t h e r than c u l t u r e . Therefore, we cannot say that people's 144 n o t i o n s of h e a l t h and i l l n e s s are c o n s t r u c t e d s o l e l y by e t h n o c u l t u r a l context. Doing Normal A c t i v i t i e s ! Normalcy and Health Study p a r t i c i p a n t s emphasized the term "normal" in t h e i r accounts of h e a l t h . A n a l y s i s of the data showed that p a r t i c i p a n t s employed the term "normal", and concepts of normalcy, in two d i s t i n c t ways: they spoke of (1) doing normal a c t i v i t i e s , and a l s o (2) viewed h e a l t h as a normal s t a t e of being. The f o l l o w i n g s e c t i o n d i s c u s s e s the concept "normal" in terms of normal a c t i v i t i e s in h e a l t h . The S o c i o - C u l t u r a l C o n s t r u c t i o n of Normal A c t i v i t i e s P a r t i c i p a n t s d e s c r i b e d "doing normal a c t i v i t i e s " as the primary c h a r a c t e r i s t i c of h e a l t h . Normal a c t i v i t i e s c ould be c a r r i e d out i n both the complete h e a l t h and p a r t i a l h e a l t h phases of the h e a l t h continuum. Consequently, p a r t i c i p a n t s viewed themselves as healthy in both of these two h e a l t h s t a t e s . P a r t i c i p a n t accounts d e s c r i b e d "normal a c t i v i t y " in four ways: as (1) d u t i e s and r e s p o n s i b i l i t i e s to family, s o c i e t y and occupation; (2) a c t i v i t i e s which one p e r s o n a l l y wished to engage i n ; (3) everyday r o u t i n e s , or a c t i v i t i e s , u s u a l l y c a r r i e d out in the course of day to day l i f e ; and (4) a c t i v i t i e s which do not harm the body, and which a person i s accustomed to doing everyday without adverse e f f e c t . These four meanings of normal are very c l o s e l y r e l a t e d , i f 145 not e s s e n t i a l l y the same, si n c e p a r t i c i p a n t s explained that a c t i v i t i e s c a r r i e d out d a i l y were synonymous with personal d u t i e s r e l a t e d to l i f e r o l e s . Furthermore, the vast m a j o r i t y of p a r t i c i p a n t s d e s c r i b e d these d a i l y d u t i e s as a c t i v i t i e s they p e r s o n a l l y wished to engage i n . P a r t i c i p a n t s most f r e q u e n t l y d e s c r i b e d normal a c t i v i t i e s as d u t i e s , r e s p o n s i b i l i t i e s , or "what I u s u a l l y do". Although i t can be assumed that engaging i n d a i l y l i f e r o l e s and tasks i s a common, i f not u n i v e r s a l , outcome of h e a l t h f o r a l l i n d i v i d u a l s , p a r t i c i p a n t s in t h i s study placed p a r t i c u l a r emphasis on the importance of h e a l t h f o r f u l f i l l i n g personal f a m i l y d u t i e s and r e s p o n s i b i l i t i e s . The f o l l o w i n g d i s c u s s i o n of d u t i e s and r e s p o n s i b i l i t i e s i n Indo-Canadian s o c i e t y i s t h e r e f o r e germane to the study r e s u l t s . Most l i t e r a t u r e in t h i s area i s co n f i n e d to the l i f e context of Indo-Canadian women. Family. Duties and R e s p o n s i b i l i t i e s i n Indo-Canadian S o c i e t y A survey of the l i t e r a t u r e shows that the d u t i e s and r e s p o n s i b i l i t i e s which study p a r t i c i p a n t s d e s c r i b e d as "normal a c t i v i t i e s " are l a r g e l y a s s o c i a t e d with Indo-Canadian f a m i l y s t r u c t u r e and t r a d i t i o n a l c u l t u r a l values. S o c i a l context (most notably socio-economic s t a t u s and ed u c a t i o n a l l e v e l ) a l s o appears to have i n f l u e n c e d p a r t i c i p a n t s ' d e f i n i t i o n of the r o l e s and r e s p o n s i b i l i t i e s that they c o n s i d e r e d important to f u l f i l l in t h e i r d a i l y l i v e s . Many of the r e p o r t s and s t u d i e s on the Indo-Canadian community have focused p r i m a r i l y on women (Anderson,1985a, 1987; 146 Anderson & Lynam, 1987; Khosla, 1981; Majumdar & Carpio, 1988; Naidoo, 1980, 1984) and a t t i t u d e s of Indo-Canadian parents towards t h e i r c h i l d r e n (Yoshida & Davies, 1985). L i t e r a t u r e on the p e r s p e c t i v e s of Indo-Canadian men i s l a c k i n g . Khosla (1981), in a re p o r t of South-Asian women in Canada, d e s c r i b e s the importance of fa m i l y and famil y d u t i e s , or dharma, to the Hindu woman. D e s c r i b i n g c u l t u r a l r o l e expectations, she s t a t e s : Based upon the concept of Dharma, or duty, the Hindu woman i s s o c i a l i z e d to b e l i e v e that her main c o n t r i b u t i o n in s o c i e t y i s to her f a m i l y ; her primary r e s p o n s i b i l i t i e s c o n s i s t i n g of home-making and c h i l d - r e a r i n g . For the married woman, a p p r o p r i a t e r o l e o b l i g a t i o n s d i c t a t e that her ul t i m a t e goal as a wife l i e s i n a t t a i n i n g the st a t u s of a good daughter-in-law. (p. 178-179) Naidoo (1980), in a study of r o l e p e r c e p t i o n s , found s i m i l a r l y that Indo-Canadian women place high value on f u l f i l l i n g t r a d i t i o n a l f a m i l y r o l e s and d u t i e s , and emphasize the importance of a happy f a m i l y l i f e and home atmosphere. The Indo-Canadian women i n Naidoo's (1980) study, a l s o r e p o r t e d r o l e s and a sense of accomplishment stemming from a balance between r o l e s both i n s i d e and outside the home. This view would l i k e l y be endorsed by many Anglo-Canadian women as w e l l . Concurring with the f i n d i n g s of Naidoo (1980) and Khosla (1980), the majority of female p a r t i c i p a n t s i n t h i s study s u b s c r i b e d to the t r a d i t i o n a l p e r s p e c t i v e that l i f e 147 r e s p o n s i b i l i t i e s c e n t e r around the famil y and home. The word "duty" was employed by many of these women in t h e i r accounts of he a l t h . The majori t y of p a r t i c i p a n t s in t h i s study perceived normal a c t i v i t i e s , as well as the a c t u a l c a r r y i n g out of these a c t i v i t i e s , almost e x c l u s i v e l y as fa m i l y centered a c t i v i t i e s , or d u t i e s . The two male study p a r t i c i p a n t s a l s o spoke of the importance of loo k i n g a f t e r t h e i r f a m i l i e s , although they d i d not emphasize t h i s theme i n t h e i r accounts of h e a l t h . Some p a r t i c i p a n t s a l s o r e p o r t e d an i n t e r a c t i o n between contemporary and t r a d i t i o n a l r o l e s , and exp l a i n e d normal a c t i v i t i e s as a c t i v i t i e s c a r r i e d out outside as well as i n s i d e the home. A few female p a r t i c i p a n t s d e s c r i b e d the importance of having a f u l f i l l i n g c a r e e r o u t s i d e of the home. In a l a t e r study, Naidoo (1981) repo r t e d that well-educated, p r o f e s s i o n a l Hindu men and women who had r e s i d e d in Canada f o r approximately 10 years "saw t h e i r r o l e s as continuous with s i m i l a r r o l e s in the home country" (p. 85). Although the p a r t i c i p a n t s in t h i s study possessed s i m i l a r background c h a r a c t e r i s t i c s to Naidoo's (1981) study sample, they f r e q u e n t l y s a i d that l i f e i n Canada r e q u i r e d them to c a r r y out d i f f e r e n t r o l e s than they would have engaged in in India. It i s c l e a r from the data that the s o c i a l circumstances of people's l i v e s i n f l u e n c e how they view h e a l t h . As noted, p a r t i c i p a n t s i n t h i s study f r e q u e n t l y r e l a t e d t h e i r views on h e a l t h to the f a c t that they l i v e in Canada, r a t h e r than i n India. Many p a r t i c i p a n t s d e s c r i b e d independence as a very important part 148 of h e a l t h , e x p l a i n i n g that l i f e in Canada r e q u i r e s them to be independent because they are l a r g e l y , i f not t o t a l l y , removed from the support of extended fam i l y . For example, some female study p a r t i c i p a n t s spoke of the f a c t that they never had a job before coming to Canada; e x p l a i n i n g that in India employment outside of the home would be s o c i a l l y i n a p p r o p r i a t e and/or unnecessary. P a r t i c i p a n t s sometimes r e f e r r e d to h e a l t h as a "normal" s t a t e of experience. Although p a r t i c i p a n t s emphasized "normal a c t i v i t i e s " i n t h e i r accounts of h e a l t h , they a l s o used the concept "normal" to d e s c r i b e the h e a l t h experience i t s e l f . The f o l l o w i n g d i s c u s s i o n of normalcy and n o r m a l i z a t i o n in h e a l t h i s s i g n i f i c a n t to the study's f i n d i n g s . The S o c i o - C u l t u r a l C o n s t r u c t i o n  of Normality and N o r m a l i z a t i o n i n Health P a r t i c i p a n t s d e s c r i b e d themselves as "normal", or in a "normal c o n d i t i o n " , when they were able to carry out normal a c t i v i t i e s . In other words, i t appears that p a r t i c i p a n t s viewed h e a l t h i m p l i c i t l y as a s t a t e of normalcy. In l i n e with the work of Anderson (1981a), the data from t h i s r e s e a r c h r e v e a l "normal" and normality as concepts c o n s t r u c t e d w i t h i n an e t h n o c u l t u r a l and s o c i a l context. T h i s p e r s p e c t i v e d i f f e r s from the view that notions of nor m a l i t y are "culture-bound" (Ahmed, Kolken & Coelho, 1979; O f f e r & Sabshin, 19&6, 1984). O f f e r and Sabshin (1984) advance four p e r s p e c t i v e s of nor m a l i t y . They propose that n o r m a l i t y may be explained as: (1) 149 h e a l t h (reasonable h e a l t h , not optimal h e a l t h ) ; (2) u t o p i a (optimal f u n c t i o n i n g or s e l f - a c t u a l i z a t i o n - an u n a t t a i n a b l e i d e a l ) ; (3) an average ( c o n c e i v i n g of the middle range as normal, and both extremes as d e v i a n t ) ; and (4) normality a t r a n s a c t i o n a l system (or process of change o c c u r r i n g w i t h i n a complex, changing environment). Two of these p e r s p e c t i v e s on normality (normality as reasonable h e a l t h and a t r a n s a c t i o n a l system) are of i n t e r e s t to t h i s d i s c u s s i o n , as they appear somewhat s i m i l a r to the views a r t i c u l a t e d by some p a r t i c i p a n t s in t h i s study. The p a r t i a l h e a l t h s t a t e d e s c r i b e d in t h i s study resembles the "reasonable" h e a l t h s t a t e which O f f e r and Sabshin d e s c r i b e as normal. In p a r t i a l h e a l t h , p a r t i c i p a n t s were s t i l l able to do normal a c t i v i t i e s although they were not completely healthy. In c l e a r c o n t r a s t to O f f e r and Sabshins' (1984) p e r s p e c t i v e s on normality, however, p a r t i c i p a n t s viewed both p a r t i a l and complete h e a l t h as normal s t a t e s of h e a l t h . They a l s o f e l t that complete h e a l t h (the highest s t a t e of health) i s a s t a t e a t t a i n a b l e by a l l people, r a t h e r than an u n a t t a i n a b l e i d e a l . The data a l s o c o n t a i n d e s c r i p t i o n s of normality which bear some s i m i l a r i t y to O f f e r and Sabshins' p e r s p e c t i v e of normality as a t r a n s a c t i o n a l system. One study p a r t i c i p a n t explained that s o - c a l l e d "abnormal a c t i v i t i e s " c ould "become normal" with the passage of time. The data from t h i s study do not support the other two conceptions noted by O f f e r and Sabshin (1984) that normalcy means u n a t t a i n a b l e optimal h e a l t h , or a s t a t i s t i c a l average. 150 Every s o c i e t y has "acceptable standards" of what i s regarded as "normal" h e a l t h . Frequently, what a c u l t u r a l or s o c i a l group values i s con s i d e r e d as "normal" (Miles, 1978). The p a r t i c i p a n t s in t h i s study d e f i n e d h e a l t h in terms of a valued c a p a c i t y f o r "doing normal a c t i v i t i e s " . They viewed complete h e a l t h and p a r t i a l h e a l t h as "normal" s t a t e s ; s i c k n e s s , in c o n t r a s t , was de s c r i b e d as "abnormal". This view appears q u i t e s i m i l a r to biomedical p e r s p e c t i v e s on normalcy and h e a l t h (Redlick, 1976; Sebag, 1979). P a r t i c i p a n t s ' p e r s p e c t i v e s on "normal" s t a t e s of h e a l t h are s i m i l a r to Twaddle's (1974) view that a range of l e s s than p e r f e c t h e a l t h e x i s t s which may be d e f i n e d as normal. Although complete h e a l t h and p a r t i a l h e a l t h were recognized as two d i s t i n c t phases of the h e a l t h continuum, p a r t i c i p a n t s nonetheless perceived them to be the same, or "normal", i n the sense that the i n d i v i d u a l could s t i l l engage i n normal a c t i v i t i e s i n both s t a t e s . Furthermore, when a s t a t e of complete h e a l t h was regained a f t e r a per i o d of p a r t i a l h e a l t h or si c k n e s s , p a r t i c i p a n t s s t a t e d that they were "back to normal". In c o n t r a s t , s i c k n e s s was seen as "not normal" because they could not c a r r y out normal a c t i v i t i e s at that time. The p e r s p e c t i v e s of p a r t i c i p a n t s i n t h i s study are not u n l i k e views presented in the l i t e r a t u r e that s o c i e t y g e n e r a l l y views h e a l t h as an experience which i s not t o t a l l y "symptom-free". According to Mi l e s (1978) and Zola (1966), each s o c i e t y c o n s i d e r s c e r t a i n u b i q u i t o u s c o n d i t i o n s as part of normal h e a l t h . In some Western c u l t u r e s , f o r example, backache, l o s s of h a i r and tooth decay may be c o n s i d e r e d w i t h i n the parameters of normal h e a l t h , r e f l e c t i n g a p a r t i c u l a r s o c i o - c u l t u r a l norm of h e a l t h . In other s o c i o - c u l t u r a l contexts i t might be otherwise. Within some contexts, minor aches and pains may not be considered as " d e v i a t i o n s from h e a l t h " or as a f f e c t i n g o v e r a l l h e a l t h s t a t u s . Rather, these common complaints may be seen "as compatible with good h e a l t h ... (and) part of normally accepted ' h e a l t h ' " (Miles, 1978, p. 10-11). P a r t i c i p a n t s i n t h i s study viewed the minor complaints a s s o c i a t e d with p a r t i a l h e a l t h as "normal", and considered themselves to be healthy i n t h i s s t a t e . Even when they were s u f f e r i n g from a c o l d or fever, p a r t i c i p a n t s f e l t that they were " s t i l l h ealthy", and explained that l i f e was s t i l l going on normally because they were able to continue with t h e i r normal a c t i v i t i e s . These p e r s p e c t i v e s appear s i m i l a r to the views h e l d by much of North Pmerican s o c i e t y . Consequently, i t seems that Indo-Canadians, with s o c i o - c u l t u r a l backgrounds s i m i l a r to the p a r t i c i p a n t s i n t h i s study, p e r c e i v e h e a l t h in much the same way as many other North Pmerican groups. The extent to which symptoms d i s r u p t normal a c t i v i t i e s i s another determinant of t h e i r c o m p a t i b i l i t y with conceptions of normal h e a l t h . M i l e s (1978) s t a t e s that people "tend to accept symptoms as part of normal h e a l t h " as long as they f a l l w i t h i n " s o c i a l d e f i n i t i o n " , and "the more so i f the symptoms are minor, do not a r i s e suddenly and do not d i s r u p t everyday a c t i v i t i e s " (p. 15E 37). T h i s i s a s i g n i f i c a n t point. The data i n d i c a t e that the meaning which p a r t i c i p a n t s assigned to symptoms was often r e l a t e d to l i f e context. Some p a r t i c i p a n t s in t h i s study explained that the same symptoms have d i f f e r e n t meaning, depending upon the i n d i v i d u a l ' s l i f e r e s p o n s i b i l i t i e s and the d u t i e s a s s o c i a t e d with h i s / h e r a g e - r e l a t e d l i f e r o l e s and f a m i l y s t a t u s . For example, one p a r t i c i p a n t explained that what i s c a l l e d " h e a l t h " and " s i c k n e s s " changes ac c o r d i n g to a person's age and l i f e s i t u a t i o n . She explained that breaking a leg was more s e r i o u s f o r her now as a wife and mother than when she was a c h i l d , because now she "had so many r e s p o n s i b i l i t i e s " ; as a c h i l d she had no r e s p o n s i b i l i t i e s apart from school work. She a l s o s t a t e d that a common c o l d was more s e r i o u s f o r her mothei—in-law than f o r h e r s e l f , because o l d e r people are " f e e b l e " and any small s i c k n e s s makes them "a l o t s i c k " and puts them in bed. According to t h i s study p a r t i c i p a n t , what i s viewed as " s i c k n e s s " at one point in the l i f e c y c l e , may "not be viewed as s i c k n e s s " at another point in the l i f e c y c l e . Normality cannot be viewed as an absolute. Anderson (1981b) e x p l a i n s that "normal" and "abnormal" are not given f a c t s or given s t a t e s . She proposes that the two concepts cannot be o b j e c t i v e l y i d e n t i f i e d or d e f i n e d , and cannot be c l e a r l y d i s t i n g u i s h e d from one another because any d i s c u s s i o n of normality makes i m p l i c i t r e f e r e n c e to concepts of abnormality. According to Anderson (1981b), notions of "normal" and "abnormal" are " i n t e r p r e t i v e schemes" which allow us to adjudge, evaluate, and give meaning to everyday l i f e events. She f u r t h e r d e s c r i b e s t h i s p e r s p e c t i v e as 153 f o i l o w s : We know from our everyday experience that although we cannot d e f i n e what no r m a l i t y i s , i t i s c o n s t a n t l y o p e r a t i n g as an i n t e r p r e t i v e schema in our l i v e s . Notions of 'normal' and 'abnormal' are deeply embedded in the n a t u r a l a t t i t u d e of d a i l y l i f e , in our ways of seeing the world, and in our ways of managing ou r s e l v e s so that we can d i s p l a y conduct which can be read as evidence of our c u l t u r a l competence. (Anderson, 1981b, p. 235) The data show that p a r t i c i p a n t s in t h i s study used the term "normal" in the common sense of " u s u a l " or "everyday". Recent r e s e a r c h on p e r c e p t i o n s of c h r o n i c i l l n e s s (Anderson, 1981a; Anderson & Chung, 1982) and normal and d i s t u r b e d f a m i l y dynamics (Anderson, 1981b) has r e p o r t e d s i m i l a r usage of the term. Normali zat i on N o r m a l i z a t i o n i s a concept l i n k e d c l o s e l y to notions of normalcy. A b r i e f d i s c u s s i o n of the n o r m a l i z a t i o n process i s r e l e v a n t to the study r e s u l t s f o r three reasons. F i r s t l y , study p a r t i c i p a n t s d e s c r i b e d the a c t i v i t i e s which they could c a r r y out in h e a l t h , as "normal a c t i v i t i e s " . Secondly, they d e f i n e d both complete and p a r t i a l h e a l t h as "normal", or healthy, c o n d i t i o n s because they were able to c a r r y out t h e i r normal a c t i v i t i e s i n these two s t a t e s . F i n a l l y , some p a r t i c i p a n t s explained that they never saw themselves as s i c k even though they experienced p h y s i c a l sympt oms. According to Anderson (1981a), n o r m a l i z a t i o n i s a process 154 which emphasizes normality and "deconstructs", or removes, the d i s e a s e l a b e l by making a p a r t i c u l a r event or c o n d i t i o n "normal". In the n o r m a l i z a t i o n process, c o n d i t i o n s are seen as "normal", or usual, and part of the everyday s c e n a r i o . Anderson (1981a) d e s c r i b e d n o r m a l i z a t i o n in terms of t r e a t i n g a c h r o n i c a l l y i l l c h i l d as a "normal c h i l d " , and coming to view c h r o n i c i l l n e s s as non-deviant and part of normal d a i l y l i f e . Wo 1fensberger (1972), advances a c o n t r a s t i n g view on n o r m a l i z a t i o n . He d i s c u s s e s n o r m a l i z a t i o n p r i m a r i l y with r e f e r e n c e to i n s t i t u t i o n a l context, and speaks of n o r m a l i z i n g (or humanizing) the l i v i n g c o n d i t i o n s in i n s t i t u t i o n s and s o c i e t a l a t t i t u d e s towards persons considered by s o c i e t y as deviant. Wo 1fensberger equates the term normative with " t y p i c a l or c o n v e n t i o n a l " (p. 28), and speaks of s i c k n e s s as a deviance from normalcy. The f i n d i n g s of t h i s study suggest that p a r t i c i p a n t s normalized t h e i r e x p l a n a t i o n s of p a r t i a l h e a l t h and s i c k n e s s . For example, p a r t i c i p a n t s d e s c r i b e d the p a r t i a l h e a l t h s t a t e as " s t i l l normal" and nothing to worry over or be concerned about, even though they experienced some d e v i a t i o n from the complete h e a l t h s t a t e . Although p a r t i c i p a n t s d e s c r i b e d having a small p h y s i c a l complaint (such as a c o l d , the f l u , fever, backache or headache) in the p a r t i a l h e a l t h s t a t e , they considered themselves as " e s s e n t i a l l y h e a l t h y " or " s t i l l h e a l t h y " at t h i s time, r a t h e r than s i c k . T h i s view that p a r t i a l h e a l t h was s t i l l h e a l t h , and t h e r e f o r e s t i l l normal. i s explained by the f a c t that p a r t i c i p a n t s 155 cou l d s t i l l carry out normal a c t i v i t i e s in the p a r t i a l h e a l t h s t a t e , although not as well or as h a p p i l y , and with more e f f o r t than in complete h e a l t h . •ne p a r t i c i p a n t emphasized that "he never saw hi m s e l f as i l l or s i c k " , but r a t h e r "always f e l t that he was h e a l t h y " d e s p i t e e x p e r i e n c i n g minor p h y s i c a l symptoms. He informed the r e s e a r c h e r that " i f you t h i n k you are healthy, you are healthy". He always s a i d he was " f i n e " , and f e l t that he had never r e a l l y been s i c k . T h i s account provides one i l l u s t r a t i o n of how study p a r t i c i p a n t s c o n s t r u c t e d the no t i o n of normal. The f o l l o w i n g s e c t i o n w i l l address the second major theme of t h i s chapter: c o n c e p t u a l i z a t i o n s of h e a l t h . The d i s c u s s i o n emphasizes l i t e r a t u r e d e s c r i b i n g the h e a l t h - s i c k n e s s continuum and dimensions of h e a l t h , s i n c e study p a r t i c i p a n t s c o n c e p t u a l i z e d h e a l t h as a two dimensional experience i n v o l v i n g (1) a three phase continuum (complete h e a l t h , p a r t i a l h e a l t h and sickness) and (2) the i n f l u e n c e of the mind and other f a c t o r s . T h i s d i s c u s s i o n i l l u s t r a t e s how study p a r t i c i p a n t s ' views on the h e a l t h - s i c k n e s s continuum are both s i m i l a r to and d i f f e r e n t from the p e r s p e c t i v e s o f f e r e d i n the l i t e r a t u r e . The uniqueness of p a r t i c i p a n t s ' h e a l t h d e s c r i p t i o n s l i e s in the emphasis they placed on "doing" i n h e a l t h , as well as t h e i r c o n c e p t u a l i z a t i o n s of h e a l t h as a multidimensional phenomenon. P a r t i c i p a n t s ' d e s c r i p t i o n s of h e a l t h i n c l u d e a unique arrangement of many of the h e a l t h dimensions d e s c r i b e d i n the l i t e r a t u r e . 156 C o n c e p t u a l i z a t i o n s of Health The Health-Sickness Continuum ft review of l i t e r a t u r e examining c o n c e p t u a l i z a t i o n s of h e a l t h as a continuum i s p e r t i n e n t to t h i s d i s c u s s i o n , as i t provides f u r t h e r i n s i g h t i n t o the unique manner in which study p a r t i c i p a n t s viewed h e a l t h . The h e a l t h - i l l n e s s continuum has been c o n c e p t u a l i z e d v a r i o u s l y in the l i t e r a t u r e (ftntonovsky, 1987; F i s k Matsal, 1980; Lerner, 1973; Rogers, 1970; Roy, 1976; Seedhouse, 1986; Smith, 1981; Tripp-Reimer, 1984c; Winstead-fry, 1980). The work of some of these authors i s d i s c u s s e d here. (The l i t e r a t u r e g e n e r a l l y r e f e r s to i l l n e s s , r a t h e r than sic k n e s s , as the p o l a r opposite of h e a l t h - the two terms are used interchangeably i n t h i s d i s c u s s i o n ) . Conceptions of the continuum d i f f e r i n terms of whether h e a l t h and i l l n e s s are viewed as dichotomous v a r i a b l e s , or i n t e r f a c i n g , continuous concepts l i n k e d together by a range of v a r i o u s combinations of h e a l t h / i 1 l n e s s along the continuum. Smith (1981) d e s c r i b e s the c h a r a c t e r i s t i c s of the h e a l t h - i l l n e s s continuum as f o l l o w s : ft continuum i s an unbroken sequence of t h i n g s arranged so that between any two p o i n t s there i s always an intermediate point. The v a r i a t i o n s between h e a l t h and i l l n e s s are smooth. There are no d i s c r e t e p o i n t s . Health then becomes a comparative term, r a t h e r than a c l a s s i f i c a t o r y ( e i t h e r / o r ) term. (p. 44) Roy (1976) o f f e r s a d i f f e r e n t view. E x p l a i n i n g the h e a l t h - i l l n e s s 157 continuum in terms of a d a p t a t i o n and holism, she c o n c e p t u a l i z e s a continuum made up of seven d i s t i n c t stages: (1) peak wellness, (2) high l e v e l wellness, (3) good h e a l t h , (4) normal h e a l t h , (5) poor h e a l t h , (6) extreme poor h e a l t h , and (7) death. Roy holds that an i n d i v i d u a l may be l o c a t e d anywhere along the continuum at any given time, and that a d a p t a t i o n occurs as the i n d i v i d u a l moves in e i t h e r d i r e c t i o n along t h i s continuum. In l i n e with t h i s p e r s p e c t i v e , p a r t i c i p a n t s in t h i s study explained that they could move in both d i r e c t i o n s along the continuum. However, they c o n c e p t u a l i z e d three phases, or stages, w i t h i n the continuum r a t h e r then the seven o u t l i n e d by Roy. P a r t i c i p a n t s d e s c r i b e d h e a l t h as a s t a t e r e g a i n a b l e from s i c k n e s s . They d e s c r i b e d two p o s s i b l e outcomes of s i c k n e s s : (1) r e t u r n to h e a l t h and (2) c h r o n i c i l l n e s s and death. Os p a r t i c i p a n t s ' accounts contained only i m p l i c i t r e f e r e n c e to c h r o n i c i l l n e s s , i t i s u n c l e a r whether they perceived the p o s s i b i l i t y of a r e t u r n to h e a l t h a f t e r c h r o n i c i l l n e s s (see f i g u r e 3). Tripp-Reimer's (1984c) d e s c r i p t i o n of h e a l t h as a continuum v a r i a b l e mentions death as one consequence of i l l n e s s , and r e f l e c t s other aspects of the views held by study p a r t i c i p a n t s . She s t a t e s : Although the continuum may c o n s i s t of a sequence of s t a t e s ranging from h e a l t h to i l l n e s s (or sometimes death) i t i s e s s e n t i a l l y a b i p o l a r c o n s t r u c t i o n . Absence of p a t h o l o g i c a l symptoms c o n s t i t u t e one pole and abnormality ( v a r i o u s l y termed disease, s i c k n e s s , i l l n e s s or non-health) c o n s t i t u t e s 158 the other, (p. 102) P a r t i c i p a n t s d i d not see h e a l t h as an i s o l a t e d e n t i t y . They r a t h e r d e f i n e d the t o t a l h e a l t h experience in terms of a three phased continuum. Within t h i s continuum, p a r t i c i p a n t s d e s c r i b e d v a r y i n g degrees of h e a l t h (complete h e a l t h and p a r t i a l health) in r e l a t i o n to s i c k n e s s . Health and s i c k n e s s were c o n c e p t u a l i z e d as continuous, p o l a r concepts on the h e a l t h - i l l n e s s continuum, and p a r t i c i p a n t s g e n e r a l l y d e s c r i b e d h e a l t h i n terms of i t s opposite, s i c k n e s s . These views are s i m i l a r to c u r r e n t p e r s p e c t i v e s found in the l i t e r a t u r e d e s c r i b i n g h e a l t h i n terms of a range of h e a l t h / i 1 l n e s s s t a t e s along the continuum (Kass, 1981; Roy, 1976; Seedhouse, 1986; Smith, 1981; Tripp-Reimer, 1984c; Twaddle, 1974). P a r t i c i p a n t s ' views are c o n s i s t e n t with Tripp-Reimer's (1984c) p o s i t i o n that the i n d i v i d u a l "may range along t h i s continuum in v a r i o u s combinations of h e a l t h / i 1 l n e s s " (p. 102). By e n v i s i o n i n g h e a l t h as a comparative concept, i t becomes p o s s i b l e to "speak of more or l e s s h e a l t h , of an i n d i v i d u a l being h e a l t h i e r at one time than at another, or of one i n d i v i d u a l being h e a l t h i e r than another" (Smith, 1981, p. 44). The gradations of h e a l t h l o c a t e d along the continuum are s t r u c t u r e d by the p a r t i c u l a r human c o n d i t i o n s or t r a i t s under e v a l u a t i o n at a given time. These va r i o u s ways of c o n c e i v i n g the h e a l t h - i l l n e s s continua, or gradations, are models of h e a l t h (Smith, 1981). The p a r t i c u l a r gradations on the continuum d e s c r i b e d i n p a r t i c i p a n t s ' accounts of h e a l t h are in terms of c a p a c i t y f o r doing normal a c t i v i t i e s , and the u n d e r l y i n g h e a l t h c h a r a c t e r i s t i c s 159 (energy, r e s i s t a n c e , independence and c o n t r o l ) . These gradations c o n s t i t u t e , or form, the three phases of the h e a l t h experience: complete h e a l t h , p a r t i a l h e a l t h and sic k n e s s . Lerner's (1973) d e s c r i p t i o n of h e a l t h sheds a d d i t i o n a l l i g h t on the f i n d i n g s of t h i s study. Lerner proposes that i n d i v i d u a l s place d i f f e r e n t values, or weights, qn various p o i n t s w i t h i n the continuum. This point i s s i g n i f i c a n t in view of the f a c t that concepts of normality are c o n s t r u c t e d in terms of s o c i o - c u l t u r a l values. Lerner d e s c r i b e s the s u b j e c t i v e v a l u i n g of the h e a l t h experience as f o l l o w s : ... human beings s u b j e c t i v e l y a t t r i b u t e d i f f e r e n t weights to vario u s p o i n t s along that continuum; that i s , l i f e at d i f f e r e n t ages or at i t s v a r i o u s stages appears to have d i f f e r e n t 'meanings' to people, and t h e r e f o r e d i f f e r e n t values or weights. Further, that meaning, value, or weight v a r i e s a c c o r d i n g to c u l t u r a l f a c t o r s and value systems and i s t h e r e f o r e s o c i a l l y d e f i n e d . (Lerner, 1973, p. 9) The work of Majumdar and Carpio <19Q8) was di s c u s s e d e a r l i e r in chapter two. Aspects of t h e i r q u a n t i t a t i v e study are presented here to provide a d d i t i o n a l i n s i g h t i n t o how the h e a l t h accounts of p a r t i c i p a n t s in t h i s study resemble those d e s c r i b e d by other Indo-Canadians. Indo-Canadian and Other E t h n i c Canadian P e r s p e c t i v e s Majumdar and Carpio (1988) found that Indo-Canadian women's p e r s p e c t i v e s on h e a l t h were both s i m i l a r to and d i f f e r e n t from the h e a l t h p e r s p e c t i v e s of (Euro-)Canadian, and P h i l i p i n o and L a t i n 160 women l i v i n g i n Canada. ft b r i e f account of the h e a l t h images provided by the Indo-Canadian women in Majumdar and Car p i o s ' study i s of i n t e r e s t , s i n c e the p a r t i c i p a n t s in t h i s study expressed s i m i l a r , although much broader, views on the h e a l t h experience. Majumdar and Carpio found that Indo-Canadian women d e f i n e d h e a l t h p r i m a r i l y in terms of mental h e a l t h (55%). P h y s i c a l h e a l t h (27.8%) and s o c i a l h e a l t h (16.7%) were viewed as l e s s important dimensions of h e a l t h . L i f e s t y l e was not inc l u d e d as a dimension of these women's pe r c e p t i o n s of h e a l t h . L i f e s t y l e , however, was given the most importance (61.9%) in d e s c r i p t i o n s of h e a l t h maintenance. S o c i a l h e a l t h (14.3%) and p h y s i c a l h e a l t h (23.8%) were emphasized l e s s in t h i s area, and mental h e a l t h not at a l l . C o n c e p t u a l i z a t i o n s of di s e a s e c a u s a t i o n i n c l u d e d a l l the four c a t e g o r i e s of h e a l t h d e f i n i t i o n ( l i f e s t y l e , s o c i a l , mental and p h y s i c a l ) , with l i f e s t y l e (50%) and p h y s i c a l aspects (33.3%) being emphasized the most i n these women's d e s c r i p t i o n s (Majumdar & Carpio, 1988). In support of Majumdar and Carpios' (1988) research, the f i n d i n g s of t h i s study r e v e a l p h y s i c a l h e a l t h , mental h e a l t h , and s o c i a l f a c t o r s as components of the Indo-Canadian h e a l t h experience. In c o n t r a s t to Majumdar and Carpios' (1988) f i n d i n g s , however, p a r t i c i p a n t s i n t h i s study included l i f e s t y l e f a c t o r s i n t h e i r p e r c e p t i o n s of h e a l t h , and a l s o emphasized the important r o l e which the mind plays i n both the maintenance and r e g a i n i n g of he a l t h , as well as c a u s a t i o n of si c k n e s s . The r e s u l t s of t h i s study concur with Majumdar and Carpios' 161 (1988) f i n d i n g that s o c i a l h e a l t h i s a component (described as fam i l y o r i e n t a t i o n ) of Indo-Canadian c o n c e p t u a l i z a t i o n s of h e a l t h maintenance and expla n a t i o n s of dis e a s e c a u s a t i o n . P a r t i c i p a n t s in t h i s study d e s c r i b e d the importance of a happy, harmonious fa m i l y l i f e and home atmosphere f o r maintenance of h e a l t h . On the other hand, they considered an unhappy, s t r e s s f u l f a m i l y l i f e and home environment d e t r i m e n t a l to h e a l t h , as well as something which c o n t r i b u t e s to p a r t i a l h e a l t h and s i c k n e s s . Yoshida and Davies (1985), in t h e i r i n v e s t i g a t i o n of c h i l d b e a r i n g and c h i l d r e a r i n g among immigrant Canadian f a m i l i e s , found that Indo-Canadian parents d e s c r i b e d healthy c h i l d r e n as en e r g e t i c , happy and well nourished. In c o n t r a s t , these Indo-Canadian parents d e s c r i b e d a s i c k c h i l d as unhappy and i r r i t a b l e , with l o s s of a p p e t i t e . The data from t h i s study concur with p e r c e p t i o n s of h e a l t h as a s t a t e where the i n d i v i d u a l i s e n e r g e t i c and happy (Yoshida & Davies, 1985). P a r t i c i p a n t s i n t h i s study, however, d e s c r i b e d four c h a r a c t e r i s t i c s of the h e a l t h experience: energy, r e s i s t a n c e , independence and c o n t r o l . The f o l l o w i n g s e c t i o n examines four conceptions, or models, of h e a l t h . P r e s e n t a t i o n of these four models i l l u s t r a t e s aspects of the h e a l t h experience d e s c r i b e d by the p a r t i c i p a n t s in t h i s study, and a s s i s t s the reader in a p p r e c i a t i n g the uniqueness of the p a r t i c i p a n t s ' h e a l t h images. Four Conceptions of Health Smith (1981), L a f f r e y (1986) and Woods and coworkers (1988) provide c o n c e p t u a l i z a t i o n s of h e a l t h based upon four fundamental 162 models of h e a l t h : (1) Eudaimonistic, (2) Adaptive, (3) Role-performance and (4) C l i n i c a l . Each of these four models re p r e s e n t s one way of c o n c e p t u a l i z i n g the h e a l t h - i l l n e s s continuum, and has a d i s t i n c t "health extreme" and " i l l n e s s extreme". According to Smith (1981), these various dimensions of h e a l t h are conceived to overlay the b a s i c h e a l t h - i l l n e s s continuum. Arranged h i e r a r c h i c a l l y , they encompass a l l the various ideas and conceptions of the h e a l t h phenomenon. An overview of the b a s i c c h a r a c t e r i s t i c s of each model i s warranted. The e u d a i m o n i s t i c model, d e r i v e d from the work of Maslow (1968, 1970), i s a s s o c i a t e d with notions of general w e l l - b e i n g , and s e l f - r e a l i z a t i o n , and presents a h o l i s t i c view of the human being. Health i s c o n c e p t u a l i z e d as a person's r e a l i z i n g h i s / h e r f u l l e s t inner p o t e n t i a l . The h e a l t h extreme of the h e a l t h - i l l n e s s continuum i s "exuberant w e l l - b e i n g " , and the i l l n e s s extreme i s "enervation and l a n g u i s h i n g d e b i l i t y " (Smith, 1981, p.45). The adaptive model i s based on the work of Dubos (1959). The h e a l t h extreme of the continuum i s seen as a b i l i t y to f u n c t i o n using adaptive mechanisms, and e f f e c t i v e p h y s i c a l and s o c i a l f u n c t i o n i n g . Conversely, the i l l n e s s extreme of the continuum i s i n a b i l i t y to cope with the changing environment, and subsequent f a i l u r e i n a d a p t a t i o n . Drawn p r i m a r i l y from the work of Parsons (1979), the role-performance model emphasizes performance of s o c i a l r o l e s . The h e a l t h extreme of the continuum i s "performance of expected r o l e s with maximum expected output", and nothing 163 impeding e f f e c t i v e performance of i n d i v i d u a l r o l e s . Pt the other end of the h e a l t h - i l l n e s s continuum, the i l l n e s s extreme i s c o n c e p t u a l i z e d as " f a i l u r e i n performance of one's r o l e " (Smith, 1981, p. 46). C r i t i c i z e d as being the most narrow in i t s p e r s p e c t i v e , the c l i n i c a l model focuses on f a m i l i a r biomedical views of p h y s i c a l and mental no r m a l i t y or abnormality. The h e a l t h extreme of the continuum i s "absence of signs or symptoms of disease or d i s a b i l i t y as i d e n t i f i e d by medical s c i e n c e " . The i l l n e s s extreme i s "conspicuous presence of these signs or symptoms" (Smith, 1981, p. 46). Smith (1981) proposes that these four models provide a l t e r n a t e , although not mutually e x c l u s i v e , h e a l t h images that view the i n d i v i d u a l "within broader and broader contexts". The e u d a i m o n i s t i c model i s h o l i s t i c and most i n c l u s i v e , embracing the concepts found in the other three models (Smith, 1981, p. 47). In terms of Smith's (1981) h i e r a r c h y of h e a l t h models, p a r t i c i p a n t s in t h i s study presented e x p l a n a t i o n s of h e a l t h f o c u s i n g p r i m a r i l y on the role-performance model. Normal a c t i v i t i e s approximate concepts of h e a l t h as role-performance. P a r t i c i p a n t s ' r i c h d e s c r i p t i o n s of h e a l t h , however, a l s o embraced ideas of h e a l t h advanced by the c l i n i c a l , adaptive and e u d a i m o n i s t i c models. B u i l d i n g on the work of Smith (1981), L a f f r e y (1986) provides d e s c r i p t i o n s of h e a l t h which more c l o s e l y approximate the f i n d i n g s of the c u r r e n t study. L a f f r e y (1986) r e p o r t e d d e s c r i p t i o n s of h e a l t h i n c o r p o r a t i n g h e a l t h dimensions from each of the four h e a l t h models, or 164 conceptions. U t i l i z i n g the four models of h e a l t h (Smith, 1981), L a f f r e y (1986) developed four conceptions of h e a l t h : (1) c l i n i c a l h e a l t h conception, (2) f u n c t i o n a l / r o 1 e performance conception, (3) adaptive h e a l t h conception, and (4) eu d a i m o n i s t i c h e a l t h conception. She found that one dimension of h e a l t h can "stand out" i n peoples' d e s c r i p t i o n s of h e a l t h . T h i s was the case in the h e a l t h d e s c r i p t i o n s of p a r t i c i p a n t s in t h i s study. They focused on h e a l t h as f u n c t i o n a l c a p a c i t y , although t h e i r accounts a l s o i n c l u d e d d e s c r i p t i o n of other h e a l t h dimensions. Many of L a f f r e y ' s (1986) s t r u c t u r a l items ( a s s o c i a t e d with these f o u r conceptions of health) are supported by the data in t h i s study. For example, p a r t i c i p a n t s in t h i s study d e s c r i b e d "not having to take medicines" and "not being s i c k " as aspects of h e a l t h . These d e s c r i p t i o n s are c o n s i s t e n t with some of the s t r u c t u r a l items noted i n L a f f r e y ' s r e s e a r c h ( f o r example, "do not r e q u i r e p i l l s f o r i l l n e s s " and "not s i c k " a s s o c i a t e d with the c l i n i c a l h e a l t h conception) (p. 111). Some of the f u n c t i o n a l r o l e performance h e a l t h conceptions c i t e d in L a f f r e y ' s research were a l s o supported by the f i n d i n g s of t h i s study: ( f o r example, " f u l f i l l d a i l y r e s p o n s i b i l i t i e s " , "able to do what I have to do", "able to c a r r y out d a i l y r e s p o n s i b i l i t i e s " , and " f u l f i l l r o l e r e s p o n s i b i l i t i e s " ) (p. 35). P a r t i c i p a n t s i n t h i s study d e s c r i b e d h e a l t h in terms of what L a f f r e y c a l l s the c l i n i c a l h e a l t h p e r c e p t i o n when e x p l a i n i n g that h e a l t h means "nothing i s wrong", and s i c k n e s s means "something i s wrong" in the body or mind. Study p a r t i c i p a n t s a l s o e xplained 165 h e a l t h in terms s i m i l a r to L a f f r e y ' s (1986) f u n c t i o n / r o l e performance conception when emphasizing h e a l t h as a b i l i t y to do normal a c t i v i t i e s . A c o n s i d e r a t i o n of L a f f r e y ' s (1986) d e s c r i p t i o n s of c o n t r o l , or coping, as a f u r t h e r c h a r a c t e r i s t i c of the h e a l t h experience, suggests that p a r t i c i p a n t s ' views on h e a l t h to some extent r e f l e c t adaptive h e a l t h conception. P a r t i c i p a n t s ' d e s c r i p t i o n s of h e a l t h in terms of f e e l i n g s of happiness, contentment, harmony and enthusiasm f o r l i f e , resemble the eu d a i m o n i s t i c view of h e a l t h d e s c r i b e d by both L a f f r e y (1986) and Smith (1981). Woods and coworkers (1988) combined the four models of h e a l t h proposed by Smith (1981) with the conceptions of h e a l t h o f f e r e d by L a f f r e y (1986), to d e s c r i b e the meaning of h e a l t h to ftsian, white, Black, North American Indian and H i s p a n i c women in the P a c i f i c North West. Many of the h e a l t h images d i s c u s s e d in the re s e a r c h of Woods and coworkers appear q u i t e s i m i l a r to the d e s c r i p t i o n s of h e a l t h presented by p a r t i c i p a n t s i n t h i s study (see Appendix F f o r a l i s t of the h e a l t h images d e s c r i b e d by Woods and coworkers which p a r t i c i p a n t s i n t h i s study i n c l u d e d i n t h e i r accounts of the h e a l t h e x p e r i e n c e ) . When speaking of the absence of disease, the doing of normal a c t i v i t i e s , and being happy, p a r t i c i p a n t s i n t h i s study i n c o r p o r a t e d the "negating", "doing" and "being" dimensions d e s c r i b e d i n Woods and coworkers' (1988) study. These terms ("negating", "doing" and "being") represent the dominant dimensions of the c l i n i c a l , r o l e performance and eudia m o n i s t i c 166 h e a l t h images r e s p e c t i v e l y . The s i m i l a r i t y between the h e a l t h images d e s c r i b e d by the p a r t i c i p a n t s in t h i s study and those presented in the re s e a r c h of Woods and coworkers (1988), suggests that some dimensions of h e a l t h may transcend both c u l t u r a l and s o c i a l d i f f e r e n c e s . T h i s f i n d i n g was a l s o an outcome of Woods and coworkers' (1988) research. Ps p a r t i c i p a n t s n a r r a t e d t h e i r p e r c e p t i o n s of he a l t h , i t became i n c r e a s i n g l y c l e a r that t h i s group of Indo-Canadians view h e a l t h as an i n t e g r a t e d experience i n v o l v i n g both the body and mind. This i s an important f i n d i n g of the study. P a r t i c i p a n t s d e s c r i b e d the fundamental, u n i t a r y r e l a t i o n s h i p between the body and mind, and a l s o d e s c r i b e d the body and mind in r e l a t i o n to e x t e r n a l f a c t o r s (such as d i e t , e x e r c i s e and sleep) which i n f l u e n c e h e a l t h . The ensuing s e c t i o n b r i e f l y d i s c u s s e s the h o l i s t i c view of h e a l t h o f f e r e d by the study p a r t i c i p a n t s . Holism: Body and Mind Together P a r t i c i p a n t s ' p e r c e p t i o n s of h e a l t h , as a uni t y of body and mind, r e f l e c t t r a d i t i o n a l Indian views that h e a l t h i s an experience where the d i f f e r e n t aspects of the human being are in a s t a t e of harmony and balance (Obeyeskere, 1977, 1978; Vora, 1986). Current h o l i s t i c h e a l t h l i t e r a t u r e expresses s i m i l a r views of the nature of the i n d i v i d u a l , and the experiences of h e a l t h and si c k n e s s ( Flynn, 1980; K r e i g e r , 1981; S a r k i s & Skoner, 1987). Study p a r t i c i p a n t s c l e a r l y i d e n t i f i e d the i n s e p a r a b i l i t y of mind and body, and d e s c r i b e d the meaning of t h i s t o t a l (body-mind) unit i n h e a l t h and s i c k n e s s . Harmony and balance of the whole 167 person, w i t h i n h i m / h e r s e l f and with the environment, was a major theme a r i s i n g from p a r t i c i p a n t s ' accounts of h e a l t h . P a r t i c i p a n t s emphasized h e a l t h as a p o s i t i v e q u a l i t y , or s t a t e , s t r u c t u r e d in two dimensions and framed by the o v e r a l l context of doing normal a c t i v i t i e s . Health as the absence of disease was only one minor facet of p a r t i c i p a n t s ' d e s c r i p t i o n s of h e a l t h . Study p a r t i c i p a n t s presented a h o l i s t i c v i s i o n of he a l t h , with m u l t i f a c e t e d d e s c r i p t i o n of the environmental, s o c i a l and personal f a c t o r s which i n f l u e n c e the t o t a l h e a l t h experience. In the next s e c t i o n , some of the f a c t o r s which p a r t i c i p a n t s viewed as i n f l u e n c i n g the h e a l t h experience are presented i n l i g h t of r e l e v a n t l i t e r a t u r e . These f a c t o r s c o n s t i t u t e the second dimension of h e a l t h d e s c r i b e d i n p a r t i c i p a n t accounts (see f i g u r e s 2 & 3). This d i s c u s s i o n focuses on the r o l e of the mind in hea l t h , and f u r t h e r r e v e a l s the h o l i s t i c nature of the study p a r t i c i p a n t s ' views on h e a l t h . Factors Inf luencing Health Some study p a r t i c i p a n t s explained that f a c t o r s such as d i e t , e x e r c i s e and mental a t t i t u d e were under t h e i r personal c o n t r o l to some degree. These i n f l u e n c i n g f a c t o r s were seen as th i n g s they could "do something about", or th i n g s "they could c o n t r o l " . In c o n t r a s t , d isease and s i c k n e s s were sometimes de s c r i b e d as being under D i v i n e c o n t r o l . Although l i m i t e d data were gathered on p a r t i c i p a n t s ' views of c o n t r o l in he a l t h , the r e s u l t s of t h i s study are s i m i l a r to 168 Majumdar and Carpio's (1988) f i n d i n g s that Indo-Canadian women expressed g r e a t e s t f e e l i n g s of c o n t r o l over t h e i r h e a l t h in the area of h e a l t h maintenance, mental and s o c i a l h e a l t h . P h y s i c a l h e a l t h d e f i c i t s were viewed as something the i n d i v i d u a l had l i t t l e c o n t r o l over (Majumdar & Carpio, 1988). P a r t i c i p a n t s in t h i s study d e s c r i b e d the mind as the most important f a c t o r i n f l u e n c i n g h e a l t h . Ps d i s c u s s e d in chapter four, the mind was viewed as having both a p o s i t i v e and negative e f f e c t on h e a l t h . The Mind and Health The vast majority of p a r t i c i p a n t s d e s c r i b e d a p o s i t i v e mental a t t i t u d e , ( c h a r a c t e r i z e d by absence of worry and s t r e s s , calmness and c o n t r o l over the emotions, and a c t u a l l y " t h i n k i n g one i s h e a l t h y " ) , as b e n e f i c i a l to the maintenance and improvement of he a l t h , as well as recovery from i l l n e s s . On the other hand, they viewed a mental a t t i t u d e c h a r a c t e r i z e d by worry, s t r e s s and " t h i n k i n g one was s i c k " , as e x e r t i n g a d e t r i m e n t a l e f f e c t on h e a l t h and a c t u a l l y l e a d i n g to s i c k n e s s . The f o l l o w i n g s e c t i o n d i s c u s s e s v a r i o u s aspects of the i n t e r a c t i o n between the body and mind. L i t e r a t u r e on the r e l a t i o n s h i p between the mind, s t r e s s and immune response i s r e l e v a n t to the study f i n d i n g s s i n c e t h i s theme was given importance i n some p a r t i c i p a n t s ' accounts of h e a l t h . Mind, the Immune System and Resistance The mind i s seen as both a "h e a l e r " and a " s l a y e r " , c r e a t i n g e i t h e r h e a l t h or s i c k n e s s (Wolf, 1986). Ps d i s c u s s e d above, study 169 p a r t i c i p a n t s d e s c r i b e d t h i s twofold c a p a c i t y of the mind in t h e i r accounts of h e a l t h . Many p a r t i c i p a n t s d e s c r i b e d t h e i r p e r c e p t i o n that the mind i n f l u e n c e s the body's r e s i s t a n c e to si c k n e s s . They s p e c i f i c a l l y r e l a t e d s t r e s s to increased s u s c e p t i b i l i t y to sic k n e s s . P a r t i c i p a n t s explained that s t r e s s , or worry, has a damaging e f f e c t on immune f u n c t i o n and r e s i s t a n c e to disease. T h e i r d e s c r i p t i o n s of the e f f e c t which mental s t a t e exerts on the body and immune f u n c t i o n , appear s i m i l a r to current views on h e a l t h and s i c k n e s s (Ornstein & Sobel, 1987; Selye, 1979a,b; Shaver, 1985). The r o l e of the mind i n r e s i s t a n c e and s u s c e p t i b i l i t y to i l l n e s s has been well documented i n recent h e a l t h l i t e r a t u r e f o c u s i n g on the f i e l d of psychoneuroimmuno1ogy (a s y n t h e s i s of p s y c h i a t r y and immunology) (Najman, 1980; Risenberg, 1986; Rogers, Dubey, & Reich, 1979; Selye, 1979a,b; Shaver, 1985). Some re s e a r c h e r s propose that s t r e s s exerts an immunosuppressive e f f e c t and thus i n c r e a s e s v u l n e r a b i l i t y to disease (Rogers, Dubey & Reich, 1979; Selye, 1979a,b), and that the i n d i v i d u a l i s able to i n f l u e n c e the immune system to some degree (Risenberg, 1986). Mood s t a t e s and p s y c h o l o g i c a l experience ( e s p e c i a l l y s t r e s s ) , as well as such v a r i a b l e s as age, sex, prolonged s l e e p l e s s n e s s , race, pregnancy, and c i r c a d i a n rhythms, have been l i n k e d to a l t e r a t i o n s i n immune f u n c t i o n . Depression and bereavement, f o r example, have been a s s o c i a t e d with decreased immune competence. Conversely, f e e l i n g s of c o n t r o l over one's l i f e , and happy a f f e c t , are 170 p e r c e i v e d to p o s i t i v e l y i n f l u e n c e immune f u n c t i o n . The importance of the i n d i v i d u a l ' s sense of c o n t r o l over s t r e s s f u l s i t u a t i o n s has been emphasized in the l i t e r a t u r e (Rogers et a l . , 1979). A number of study p a r t i c i p a n t s l i n k e d mental a t t i t u d e with r e s i s t a n c e to d i s e a s e and promotion of h e a l t h , d e s c r i b i n g the e f f e c t s of p s y c h o l o g i c a l s t r e s s r a t h e r than p h y s i c a l s t r e s s . It i s of i n t e r e s t that t h e i r p e r s p e c t i v e s are s i m i l a r to those advanced in the w r i t i n g s of Selye (1979a,b) and other authors (Risenburg, 1986; Shaver,1985). P o s i t i v e Mental A t t i t u d e Selye (1979b) contends that the s t r e s s a s s o c i a t e d with any p a r t i c u l a r s i t u a t i o n i s l a r g e l y determined by the way s t r e s s o r agents are "perceived, i n t e r p r e t e d , or a p p r a i s e d " by the i n d i v i d u a l (p. 60). According to Shaver (1985) and Risenburg (1986), c o g n i t i v e response to the e x t e r n a l environment i s an important modulator of s t r e s s and immune f u n c t i o n . The way that the i n d i v i d u a l responds, or r e a c t s , to e x t e r n a l s i t u a t i o n s i n f l u e n c e s h i s / h e r experience of s t r e s s . A number of p a r t i c i p a n t s in t h i s study d e s c r i b e d the importance of c u l t i v a t i n g a n o n - reacting mental a t t i t u d e to combat or remove s t r e s s , and thus promote and maintain h e a l t h and a s s i s t in recovery from i l l n e s s . They r e f e r r e d to t h i s process v a r i o u s l y as " t r a i n i n g the b r a i n " , "not worrying" about l i f e s i t u a t i o n s and small h e a l t h concerns, " t h i n k i n g p o s i t i v e l y " and "not l e t t i n g f e e l i n g s c o n t r o l you". T h e i r p e r c e p t i o n s are in l i n e with Selye's (1979b) comments on "a mind-ovei—body approach" to d e a l i n g with 171 s t r e s s . He s t a t e s : S t r e s s i s a matter of pe r c e p t i o n and, that being the case, that the body can be i n s t r u c t e d to react at a proper l e v e l by educating the mind. It i s becoming i n c r e a s i n g l y evident that the human body i s p l i a b l e , changeable, and capable of being a l t e r e d through mental c o n d i t i o n i n g . (1979b, p. 76) In t h i s study, p a r t i c i p a n t s r e l a t e d f a m i l y support with development of a p o s i t i v e mental a t t i t u d e . A b r i e f d i s c u s s i o n of the importance of f a m i l y support in prevention of s t r e s s (or worry) and promotion of h e a l t h i s presented next. Family: a moderator of l i f e s t r e s s . S o c i a l support has been d e s c r i b e d as a moderator, or b u f f e r , which p r o t e c t s the i n d i v i d u a l from the e f f e c t s of s t r e s s (Cobb, 1976; Hammer, 1983). In t h i s study, p a r t i c i p a n t s emphasized the importance of a happy fami l y atmosphere and the support of extended fam i l y in the h e a l t h experi ence. The views expressed by the p a r t i c i p a n t s in t h i s study are supported by l i t e r a t u r e d e s c r i b i n g the importance of s o c i a l support networks in promoting the h e a l t h of immigrant groups i n Canadian s o c i e t y (Lynam, 1985). As noted e a r l i e r , f a m i l y network has been emphasized as an important support system in Hindu Indo-Canadian c u l t u r e (Ahmad, 1981; Khosla, 1981; Naidoo, 1980, 1981). In t h e i r p r e v i o u s l y noted study, Yoshida and Davies (1985) found that Indo-Canadian and other e t h n i c Canadian f a m i l i e s valued f a m i l y support h i g h l y and d e s c r i b e d the l o s s of t r a d i t i o n a l f a m i l y support systems ( a s s o c i a t e d with immigration) as a source of 172 s t r e s s . Imbalances in personal, f a m i l y and s o c i a l l i f e , and s p i r i t u a l l i f e have been d e s c r i b e d as c o n t r i b u t i n g to mental d i s o r d e r s in Hindu c u l t u r e in both India and Canada (Ananth, 1984; Singh, 1985). The accounts provided by many study p a r t i c i p a n t s d e s c r i b e d r e l a t i o n s h i p s with extended f a m i l y , and the importance of these r e l a t i o n s h i p s i n the h e a l t h experience. P a r t i c i p a n t s explained that the l o s s of support from extended f a m i l y often leads to worry, or s t r e s s , because (1) the i n d i v i d u a l i s unable to express h i s / h e r concerns and f e e l i n g s to f a m i l y members, and (2) lacks help with the c a r r y i n g out of d a i l y tasks i f he/she were to become s i c k . P a r t i c i p a n t s d e s c r i b e d these s i t u a t i o n s as n e g a t i v e l y a f f e c t i n g t h e i r h e a l t h , and making "being s i c k " more of a problem. These s i t u a t i o n s c o n t r i b u t e d to t h e i r view that sickness means dependency, and h e a l t h means independent a c t i v i t y . P few p a r t i c i p a n t s in t h i s study f e l t that Indo-Canadians growing up in Canadian s o c i e t y might be s o c i a l i z e d d i f f e r e n t l y (than those growing up i n I n d i a ) , and t h e r e f o r e might not f i n d such a need f o r c o n f i d i n g t h e i r concerns e x c l u s i v e l y to c l o s e f a m i l y members. Hence, the importance of fa m i l y support in h e a l t h d e s c r i b e d by study p a r t i c i p a n t s (who were f i r s t generation Indo-Canadians), might not prove so important to second generation Indo-Canadians i f t r a d i t i o n a l f a m i l y s t r u c t u r e s are not maintained. Other F a c t o r s A f f e c t i n g Health As noted, one of the main f i n d i n g s of t h i s study i s that the 173 way the p a r t i c i p a n t s e x p l a i n h e a l t h i s s i m i l a r in many ways to how other people speak about h e a l t h - i n c l u d i n g h e a l t h p r o f e s s i o n a l s . The f o l l o w i n g d i s c u s s i o n r e l a t e s to t h i s f i n d i n g . It has been mentioned that socio-economic and ed u c a t i o n a l context play a s i g n i f i c a n t r o l e i n the c o n s t r u c t i o n of h e a l t h . The p a r t i c i p a n t s in t h i s study were g e n e r a l l y well educated, and the vast m a j o r i t y were l i v i n g a c c o r d i n g to Western upper-middle c l a s s standards. Indo-Canadians who do not speak E n g l i s h , who are uneducated and working in menial jobs, may very l i k e l y hold views on h e a l t h which are d i f f e r e n t from those d e s c r i b e d by the p a r t i c i p a n t s i n t h i s study. In l i g h t of t h i s , the curr e n t d i s c u s s i o n of f a c t o r s i n f l u e n c i n g the h e a l t h of study p a r t i c i p a n t s becomes more meaningful. P a r t i c i p a n t s in t h i s study d e s c r i b e d s e v e r a l f a c t o r s , i n a d d i t i o n to the mind, which they p e r c e i v e d to i n f l u e n c e the h e a l t h experience. This s e c t i o n b r i e f l y examines l i t e r a t u r e d i s c u s s i n g a few of these i n f l u e n c i n g f a c t o r s . N u t r i t i o n , s t r e s s management and e x e r c i s e have been d e s c r i b e d as the most common themes i n Indo-Canadian d e s c r i p t i o n s of l i f e s t y l e f a c t o r s (Majumdar & Carpio, 1988). The r e s u l t s of t h i s study concur with these f i n d i n g s and a l s o expand on t h i s d e s c r i p t i o n of " l i f e s t y l e f a c t o r s " , or f a c t o r s which i n f l u e n c e h e a l t h . In a d d i t i o n to d i e t and e x e r c i s e , p a r t i c i p a n t s in t h i s study d e s c r i b e d mental a t t i t u d e , c l e a n l i n e s s , sleep, use of medicines and maintenance of r o u t i n e , as well as work outside of the home and home atmosphere as a d d i t i o n a l f a c t o r s i n f l u e n c i n g 174 h e a l t h . Ps d i s c u s s e d in chapter four, some h e a l t h accounts d e s c r i b e d mental a t t i t u d e as i t r e l a t e s to c o n t r o l of s t r e s s , or worry; hence, the p a r t i c i p a n t s ' views on mental a t t i t u d e in h e a l t h may be somewhat s i m i l a r to what Majumdar and Carpio (1988) c a l l " s t r e s s management". P d i s c u s s i o n of a l l the f a c t o r s which study p a r t i c i p a n t s d e s c r i b e d as i n f l u e n c i n g h e a l t h i s beyond the scope of t h i s d i s c u s s i o n . In the c o n c l u d i n g s e c t i o n s of t h i s chapter maintenance of r o u t i n e , d i e t and e x e r c i s e , and the use of medicines i n the h e a l t h experience of Indo-Canadians and other c u l t u r a l groups w i l l be b r i e f l y examined. Maintenance of Routine Shaver (1985) d e s c r i b e d the f a c t that d i s r u p t i o n of usual body rhythms by environmental or mental f a c t o r s , i s l i n k e d to changes in behaviour, a f f e c t and c o g n i t i o n . P a r t i c i p a n t s i n t h i s study expressed the r a t h e r s i m i l a r p e r s p e c t i v e that i t i s important f o r a person to keep a s u i t a b l e , f i x e d d a i l y schedule of a c t i v i t i e s . They d e s c r i b e d t h i s p r a c t i c e as "maintenance of d a i l y r o u t i n e ( 5 ) " . T h i s was one f a c t o r they d e s c r i b e d as i n f l u e n c i n g the h e a l t h experience (see f i g u r e s 2 & 3). P a r t i c i p a n t s e xplained that a person should s t i c k to e s t a b l i s h e d d a i l y schedules to keep healthy and avoid i l l n e s s . One p a r t i c i p a n t explained that he caught a c o l d because he had run ou t s i d e without a j a c k e t and omitted h i s usual p r a c t i c e of t a k i n g a short r e s t a f t e r work - these were t h i n g s he "didn't u s u a l l y do". 175 Diet and E x e r c i s e Food and proper n u t r i t i o n were other aspects of the p a r t i c i p a n t s ' h e a l t h accounts which, to a large extent, bear s t r i k i n g s i m i l a r i t y to the views of Western h e a l t h care p r o f e s s i o n a l s d e s c r i b e d w i t h i n Kleinman's framework (see f i g u r e 1). It should not be concluded, however, that a l l of the study p a r t i c i p a n t s ' d e s c r i p t i o n s of d i e t mirrored e s t a b l i s h e d Western p e r s p e c t i v e s - they d i d not. Pis i l l u s t r a t e d i n the accounts presented in chapter four, study p a r t i c i p a n t s sometimes expressed views on d i e t which more c l o s e l y approximate the t r a d i t i o n a l Ayurvedic and na t u r o p a t h i c p e r s p e c t i v e s of India, and c l a s s i c a l Chinese p e r s p e c t i v e s . Some study p a r t i c i p a n t s saw d i e t very much as a way of t r e a t i n g disease and i l l n e s s and promoting healt h , r a t h e r than j u s t a source of n u t r i t i o n . The use of food to t r e a t and prevent disease has been d e s c r i b e d w i t h i n t r a d i t i o n a l Chinese c u l t u r e (Anderson & Anderson, 1978; Koo, 1984), Indian c u l t u r e (Obeyesekere, 1977), Vietnamese and Cambodian c u l t u r e (Fishman, Evans & Jenks, 1988) and Malaysian c u l t u r e s (Dunn, 1978). T r a n s c u l t u r a l nursing l i t e r a t u r e has a l s o focused on the r e l a t i o n s h i p between d i e t and h e a l t h ( L e i n i n g e r , 1970b; 1988). Diet and e x e r c i s e have been d e s c r i b e d as l i f e s t y l e f a c t o r s i n f l u e n c i n g the h e a l t h / w e l l n e s s s t a t u s of i n d i v i d u a l s (Shaver, 1985). L e i n i n g e r (1988) e x p l a i n s the c l o s e r e l a t i o n s h i p between food and c u l t u r e . She proposes that promotion of h e a l i n g , treatment of 176 d i s e a s e , maintenance of h e a l t h and prevention of i l l n e s s through c u l t u r a l l y determined food p r a c t i c e s and d i e t a r y regimens, i s a u n i v e r s a l p r a c t i c e across c u l t u r e s ( L e i n i n g e r , 1970b). S p e c i a l foods are used dur i n g i l l n e s s to a s s i s t in f a s t e r recovery to h e a l t h (Koo, 1984). In Chinese c u l t u r e , i l l h e a l t h i s r e l a t e d to energy imbalance and concomitant lowered r e s i s t a n c e , l e a d i n g to g r e a t e r s u s c e p t i b i l i t y to d i s e a s e . Convalescing Chinese p a t i e n t s are given c e r t a i n foods to promote recovery; c e r t a i n foods are seen as b e n e f i c i a l and others as d e t r i m e n t a l to h e a l t h (Koo, 1984). The data from t h i s study i l l u s t r a t e that p a r t i c i p a n t s regarded food as very important i n h e a l t h maintenance and d i s e a s e p r e v e n t i o n and treatment. P a r t i c i p a n t s explained the need f o r d i e t a r y m o d i f i c a t i o n s during times of s i c k n e s s to provide i n c r e a s e d energy and " f a s t e r energy" f o r promotion of h e a l i n g and recovery. " F a s t e r energy" was explained as the energy r e s u l t i n g when foods are e a s i l y d i g e s t e d and r a p i d l y absorbed i n t o the c i r c u l a t o r y system. Consumption of a n u t r i t i o u s d i e t and avoidance of o v e r e a t i n g were themes emphasized in p a r t i c i p a n t s ' e x p l a n a t i o n s of d i e t as a f a c t o r i n f l u e n c i n g h e a l t h . F a s t i n g , and d i e t a r y supplementation were a l s o d e s c r i b e d as behaviours which exert a p o s i t i v e i n f l u e n c e on h e a l t h , prevent s i c k n e s s and a i d i n recovery from s i c k n e s s . R number of study p a r t i c i p a n t s a l s o mentioned the importance of a v o i d i n g excess q u a n t i t i e s of sugar, f a t and s a l t to keep healthy. Although b e l i e f s i n the i n t r i n s i c hot and c o l d p r o p e r t i e s of 177 foods, treatments and h e a l t h c o n d i t i o n s are common in India (Parker et a l . , 1978), and have been documented in previous d e s c r i p t i o n s of h e a l t h e l i c i t e d from the Indo-Canadian community (Yoshida & Davies, 1985), p a r t i c i p a n t s in t h i s study d i d not support t h i s p e r s p e c t i v e i n t h e i r accounts of the h e a l t h experience. Study p a r t i c i p a n t s r e f e r r e d only to the a c t u a l p h y s i c a l temperature of foods, r a t h e r than "hot" and " c o l d " as i n t r i n s i c q u a l i t i e s i n the sense t r a d i t i o n a l l y d e s c r i b e d in Ayurvedic medicine (Obeyesekere, 1977) or Indo-Chinese and Vietnamese c u l t u r e (Ahern, 1974; Fishman, Evans & Jenks, 1988; Koo, 1984). P a r t i c i p a n t s ' d e s c r i p t i o n s of e x e r c i s e a l s o resemble Western views to a c o n s i d e r a b l e extent. Although a few p a r t i c i p a n t s d e s c r i b e d engaging in hatha yoga ( p h y s i c a l e x e r c i s e s and breathing t e c h n i q u e s ) , the m a j o r i t y of study p a r t i c i p a n t s mentioned walking, j o g g i n g and other r e c r e a t i o n a l a c t i v i t i e s t y p i c a l of Western middle c l a s s s o c i e t y . Use of Medicines The views presented by study p a r t i c i p a n t s on the use of medicines in h e a l t h and s i c k n e s s a l s o r e f l e c t s o c i o - c u l t u r a l context. T h e i r h e a l t h accounts i l l u s t r a t e t r a d i t i o n a l Indian p e r s p e c t i v e s as well as p e r s p e c t i v e s endorsed by Western h e a l t h care p r o f e s s i o n a l s . One p a r t i c i p a n t emphasized the n e c e s s i t y of a r e g u l a r y e a r l y check-up with her f a m i l y p h y s i c i a n , and placed c o n s i d e r a b l e importance on the r e s u l t s of the medical t e s t s conducted at that 178 time. The major i t y of study p a r t i c i p a n t s s t a t e d that they would "go to the do c t o r " f o r treatment, or i f they suspected that they were g e t t i n g s i c k . P a r t i c i p a n t s d i d not f e e l that they needed to go to a doctor i f they were j u s t s u f f e r i n g from a c o l d or other minor h e a l t h complaints (such as d e s c r i b e d in the p a r t i a l h e a l t h s t a t e ) . It i s of i n t e r e s t that p a r t i c i p a n t s never d e s c r i b e d seeking the s e r v i c e s of nur s i n g p r o f e s s i o n a l s . Other study p a r t i c i p a n t s presented a d i f f e r e n t view on the use of medicines and the h e a l t h care system, supporting s e l f care p r a c t i c e s r a t h e r than the use of Western medical treatment. The two male p a r t i c i p a n t s s t r o n g l y advocated use of t r a d i t i o n a l Indian remedies f o r the prevention and treatment of s i c k n e s s and promotion of h e a l t h . Some of the l i t e r a t u r e d i s c u s s i n g s e l f care p r a c t i c e s in Indian c u l t u r e i s mentioned here i n c o n c l u s i o n . N i c h t e r (1978) in h i s study of s e l f care p r a c t i c e s i n r u r a l India, noted the frequent use of s p e c i a l d i e t s and home and ready-made medicines ( l a x a t i v e s , vitamins and t o n i c s ) f o r treatment of common ailments such as c o l d s and upset stomach. Parker, Shah, Plexander and Neumann (1979), i n other s t u d i e s of s e l f care p r a c t i c e s in India, a l s o found that s p e c i a l d i e t s , f a s t i n g and d i e t a r y supplements were used by r u r a l p o p u l a t i o n s i n India. Yoshida and Davies (1985) repo r t e d the use of herb and f o l k remedies by Indo-Canadian f a m i l i e s to r e l i e v e common di s c o m f o r t s during pregnancy and the post partum period, as we l l as f o r t r e a t i n g t h e i r c h i l d r e n . P a r t i c i p a n t s in t h i s study s i m i l a r l y d e s c r i b e d a number of these s e l f care p r a c t i c e s in t h e i r 179 accounts of the h e a l t h experience. Summary In t h i s chapter the study's f i n d i n g s have been d i s c u s s e d in r e l a t i o n to r e l e v a n t l i t e r a t u r e . The d i s c u s s i o n centered on three main themes: normalcy and h e a l t h , c o n c e p t u a l i z a t i o n of h e a l t h and f a c t o r s i n f l u e n c i n g h e a l t h . These three themes of d i s c u s s i o n are d e r i v e d from the three main components of the o r g a n i z i n g framework presented in the preceding chapter (see f i g u r e s 2 & 3). As d e t a i l e d i n chapter four, p a r t i c i p a n t s explained h e a l t h as a two dimensional phenomenon framed by the o v e r a l l concept of doing normal a c t i v i t i e s . Health was d e s c r i b e d as a means to doing normal a c t i v i t i e s . Being able to do normal a c t i v i t i e s was viewed as the goal, or outcome, of being healthy. P a r t i c i p a n t s d e s c r i b e d normal a c t i v i t i e s as everyday d u t i e s , r e s p o n s i b i l i t i e s or rout ines. The uniqueness of the p a r t i c i p a n t s ' h e a l t h d e s c r i p t i o n s r e s t e d i n t h e i r emphasis on "doing normal a c t i v i t i e s " as the hallmark of h e a l t h , and t h e i r d e s c r i p t i o n s of the four c h a r a c t e r i s t i c s of the h e a l t h experience (energy, r e s i s t a n c e , independence and c o n t r o l ) . Previous s t u d i e s have not r e p o r t e d s i m i l a r d e s c r i p t i o n of these four c h a r a c t e r i s t i c s u n d e r l y i n g a c t i v i t y in h e a l t h . The f i n d i n g s of t h i s study i l l u s t r a t e that h e a l t h i s c o n s t r u c t e d in both e t h n o c u l t u r a l and s o c i a l contexts. A major f i n d i n g of the study i s the f a c t that the h e a l t h p e r s p e c t i v e s 180 p a r t i c i p a n t s are s i m i l a r in many r e s p e c t s to the views held by Western middle c l a s s s o c i e t y . T h i s s i m i l a r i t y i s p a r t i c u l a r l y evident i n p a r t i c i p a n t s ' d e s c r i p t i o n s of d i e t and e x e r c i s e , and t h e i r p e r s p e c t i v e that h e a l t h i s not t o t a l l y "symptom f r e e " . The p a r t i c i p a n t s ' c l e a r d e s c r i p t i o n s of h e a l t h as a h o l i s t i c experience i n v o l v i n g a u n i t y of body and mind i s another important f i n d i n g of t h i s r e search. P a r t i c i p a n t s i n t h i s study used the term normal in the sense of "usual", "common", or "everyday". Being healthy was regarded as "being the way one u s u a l l y i s " , and doing normal a c t i v i t i e s was explained "as doing what one u s u a l l y does". Previous r e s e a r c h has d e s c r i b e d s i m i l a r use of the term "normal" in s i t u a t i o n s i n v o l v i n g c h r o n i c i l l n e s s and f a m i l y i n t e r a c t i o n (Pinderson, 1981a; Anderson & Chung, 1982). In support of previous r e s e a r c h on h e a l t h c o n c e p t u a l i z a t i o n , p a r t i c i p a n t s d e s c r i b e d h e a l t h in terms of v a r i o u s h e a l t h dimensions o v e r l a y i n g the h e a l t h - s i c k n e s s continuum. P a r t i c i p a n t s viewed h e a l t h as a continuum comprised of three d i s t i n c t , yet continuous phases. Within t h i s continuum, complete h e a l t h and s i c k n e s s were seen as p o l a r concepts, (the h e a l t h and i l l n e s s extremes), with opposing c h a r a c t e r i s t i c s . Health was equated p r i m a r i l y with s o c i a l h e a l t h and f u n c t i o n a l r o l e c a p a c i t y , although p a r t i c i p a n t s ' accounts i n c l u d e d aspects of a l l four h e a l t h conceptions d e s c r i b e d p r e v i o u s l y by Smith (1981), L a f f r e y (1986) and Woods and coworkers (1988). Complete h e a l t h was d e s c r i b e d as the acme of h e a l t h , and u n l i k e 181 previous conceptions of optimal h e a l t h as an u n a t t a i n a b l e utopia, complete h e a l t h was seen as a f u l l y r e a l i z a b l e s t a t e . P a r t i c i p a n t s d e s c r i b e d p a r t i a l h e a l t h as a d i s t i n c t h e a l t h phase l o c a t e d between the two continuum extremes. These views support e a r l i e r r e s e a r c h f i n d i n g s d e s c r i b i n g a range of h e a l t h / i 1 l n e s s phases along the continuum (Roy, 1976; Tripp-Reimer, 1984c; Twaddle, 1974). P a r t i a l h e a l t h was con s i d e r e d as part of h e a l t h , r a t h e r than as part of si c k n e s s . The h e a l t h images e l i c i t e d from p a r t i c i p a n t s in t h i s study r e f l e c t the values of Indo-Canadian s o c i e t y i n general, as well as some aspects of t r a d i t i o n a l Indian h e a l t h p e r s p e c t i v e s . P a r t i c i p a n t s emphasized the importance of personal d u t i e s and r e s p o n s i b i l i t i e s to f a m i l y and s o c i e t y , viewing these a c t i v i t i e s as the essence of normal a c t i v i t i e s . The c l o s i n g chapter of the t h e s i s w i l l provide a summary of the study, and s t a t e c o n c l u s i o n s to be drawn from the data. I m p l i c a t i o n s f o r nur s i n g p r a c t i c e , education and re s e a r c h w i l l a l s o be presented. 182 CHAPTER 6: SUMMPRY, CONCLUSIONS PND IMPLICPTIONS OF THE STUDY Summary and Conclusions of the Study Summary This study has i n v e s t i g a t e d the meaning of h e a l t h to Indo-Canadians. Plthough c r o s s - c u l t u r a l l i t e r a t u r e and re s e a r c h are f o c u s i n g i n c r e a s i n g l y on the h e a l t h p e r s p e c t i v e s held by vari o u s c u l t u r a l groups, very l i t t l e i n f o r m a t i o n i s a v a i l a b l e on Indo-Canadian p e r c e p t i o n s of h e a l t h . Q u a l i t a t i v e r e s e a r c h in t h i s area i s p a r t i c u l a r l y l a c k i n g . The Indo-Canadian p e r c e p t i o n of h e a l t h was chosen as the focus f o r t h i s r e s e a r c h because i t i s important that h e a l t h care p r o f e s s i o n a l s b e t t e r understand the unique p e r s p e c t i v e s on h e a l t h h e l d by t h i s c u l t u r a l group. For f e d e r a l government p o l i c i e s advocating h e a l t h f o r a l l Canadians to be s u c c e s s f u l and t r u e to formal p o l i c i e s of mu1ticu1tura1ism, continued i n v e s t i g a t i o n of the d i s t i n c t p e r c e p t i o n s on h e a l t h held by Canada's various c u l t u r a l p o p u l a t i o n s i s imperative. Ps Canadian s o c i e t y becomes i n c r e a s i n g l y m u l t i c u l t u r a l in nature, r e s e a r c h on the meaning of h e a l t h i s c r i t i c a l i f Canadian h e a l t h care i s to be e f f e c t i v e and c u l t u r a l l y r e l e v a n t . Health promotion programs are r e a l i z a b l e f o r a l l segments of Canadian s o c i e t y only when h e a l t h i s a p p r e c i a t e d as a concept i n e x t r i c a b l y l i n k e d to the h i s t o r i c a l , s o c i a l and c u l t u r a l f a c t o r s in the i n d i v i d u a l l i f e context. The background to the problem presented i n chapter one 183 emphasized the r e a l i t y of continued immigration i n t o Canada in the f u t u r e , and focused on Indo-Canadians as a s i g n i f i c a n t c u l t u r a l group w i t h i n the Canadian mosaic. The r e s e a r c h problem addressed in t h i s study arose from c o n s i d e r a t i o n of h e a l t h as a m u l t i d i m e n s i o n a l , c u l t u r a l l y grounded phenomenon, and r e c o g n i t i o n that h e a l t h care p r o f e s s i o n a l s need to become aware of the v a l i d i t y and uniqueness of the Indo-Canadian h e a l t h experience. L i t e r a t u r e was reviewed in chapter two to provide the background f o r viewing the c u r r e n t research. Three major areas were examined in the l i t e r a t u r e review: t h e o r e t i c a l p e r s p e c t i v e s on h e a l t h and i l l n e s s o f f e r e d by a u t h o r i t i e s w i t h i n the d i f f e r e n t branches of l e a r n i n g , India's t r a d i t i o n a l b e l i e f s on h e a l t h and i l l n e s s , and l i t e r a t u r e on Indo-Canadians. The review i l l u s t r a t e d the lack of i n f o r m a t i o n a v a i l a b l e on Indo-Canadian h e a l t h concerns and p e r c e p t i o n s on h e a l t h . The s o c i o - c u l t u r a l l i t e r a t u r e and r e s e a r c h reviewed c o n s t i t u t e d p a r t i c u l a r l y s i g n i f i c a n t background info r m a t i o n f o r the study, i l l u s t r a t i n g h e a l t h as a c o n s t r u c t d e f i n e d and d e s c r i b e d v a r i o u s l y w i t h i n d i f f e r e n t s o c i a l and c u l t u r a l contexts. These s t u d i e s i n d i c a t e the current discrepancy between the p e r s p e c t i v e on h e a l t h held by most h e a l t h care p r o f e s s i o n a l s , and that held by c l i e n t s from various s o c i o - c u l t u r a l backgrounds. As l i t e r a t u r e on the Indo-Canadian p e r s p e c t i v e on h e a l t h was e s s e n t i a l l y u n a v a i l a b l e , a number of r e s e a r c h s t u d i e s i n v e s t i g a t i n g how other c u l t u r a l groups view h e a l t h and i l l n e s s were d i s c u s s e d . Chapter three presented the methodology of the study. 184 Kleinman's explanatory model (1978a,b, 1980, 1984) was the b a s i c framework supporting t h i s research. Kleinman's explanatory model proposes that the p r o f e s s i o n a l , f o l k and popular domains e x p l a i n phenomena d i f f e r e n t l y , and that problems can a r i s e in c l i n i c a l communication when there i s c o n f l i c t between the p e r s p e c t i v e s of these three domains. Kleinman's framework d i r e c t e d the r e s e a r c h e r to u t i l i z e the phenomenological r e s e a r c h approach to i n v e s t i g a t e the meaning of h e a l t h to Indo-Canadians. Phenomenology was an e f f e c t i v e and a p p r o p r i a t e research methodology f o r t h i s study, where the aim was to d e s c r i b e and e x p l a i n the i n d i v i d u a l experience of h e a l t h . P a r t i c i p a n t s were r e c r u i t e d through an informal network of c o l l e a g u e s and acquaintances. P r i o r to the formal research, a p i l o t study was conducted with two informants to determine the s u i t a b i l i t y of t r i g g e r questions to be used in the i n t e r v i e w s to e l i c i t in-depth d e s c r i p t i o n of h e a l t h . T h e o r e t i c a l sampling methods r e s u l t e d in a f i n a l study sample comprised of eight informants (6 women and 2 men). Data were c o l l e c t e d through 15 open-ended, s e m i - s t r u c t u r e d i n t e r v i e w s conducted in the p a r t i c i p a n t s ' homes. P a r t i c i p a n t s were Indo-Canadian a d u l t s between the ages of 28 and 56, who had r e s i d e d i n Canada f o r 6 1/2 to 21 years. Most p a r t i c i p a n t s were in t h e i r mid-40's, and had r e s i d e d i n Canada f o r approximately 12 years at the time of the study. P a r t i c i p a n t s were of a s i m i l a r socio-economic s t a t u s , and the majority possessed p r o f e s s i o n a l l e v e l s of education. P a r t i c i p a n t s were a l l 185 of comfortable means, and f o r the most part t h e i r l i v i n g environment approximated that of m i d d l e - c l a s s Canadians. The vast ma j o r i t y of p a r t i c i p a n t s had come to Canada d i r e c t l y from India. Interviews were conducted by the r e s e a r c h e r in E n g l i s h . fill i n t e r v i e w s were tape-recorded on an audio-recorder, and t r a n s c r i b e d verbatim. The phenomenological method of G i o r g i (1975) and C o l a i z z i (1978), as d e s c r i b e d by Knaack (1984), guided the a n a l y s i s of re s e a r c h data. Data c o l l e c t i o n and a n a l y s i s were simultaneous and ov e r l a p p i n g (Lofland, 1971). Data a n a l y s i s began as soon as data were c o l l e c t e d , i n accordance with the process of constant comparative a n a l y s i s inherent to the phenomenological method. T r a n s c r i p t s were read and re-read during the i n i t i a l steps of a n a l y s i s to provide the r e s e a r c h e r with a general v i s i o n of the p a r t i c i p a n t s ' e x p l a n a t i o n s of h e a l t h . During data a n a l y s i s , n a t u r a l meaning u n i t s formed c l u s t e r s of data themes and c a t e g o r i e s . Ps these c a t e g o r i e s and themes were r e f i n e d , a d e f i n i t i v e a n a l y t i c framework evolved from the data. T h i s a n a l y t i c framework organized the p r e s e n t a t i o n of the r e s u l t s of the study, and represented the e s s e n t i a l meaning of h e a l t h to Indo-Canadians. This d e s c r i p t i o n of h e a l t h c o n s t i t u t e d the popular domain of Kleinman's explanatory model. In chapter four, the e s s e n t i a l s t r u c t u r e of h e a l t h f o r Indo-Canadians was d e s c r i b e d w i t h i n the o v e r a l l context of doing normal a c t i v i t i e s . No d i f f e r e n c e s were evident in men and womens' d e s c r i p t i o n s of h e a l t h . Male and female p a r t i c i p a n t s provided 186 s i m i l a r accounts of the phenomenon, although s p e c i f i c d e t a i l s v a r i e d a c c o r d i n g to i n d i v i d u a l l i f e c ontexts. P a r t i c i p a n t s viewed h e a l t h as a h o l i s t i c phenomenon, with body and mind i n s e p a r a b l y l i n k e d together. Health was d e s c r i b e d in two dimensions. F i r s t l y , h e a l t h was seen in terms of a three phase continuum comprised of complete h e a l t h , p a r t i a l h e a l t h and sic k n e s s , r e p r e s e n t i n g the t o t a l h e a l t h experience. Energy, r e s i s t a n c e (to dis e a s e and environmental change), independence and c o n t r o l (over one's l i f e and p h y s i c a l c o n d i t i o n ) were d e s c r i b e d as four c h a r a c t e r i s t i c s of the h e a l t h experience u n d e r l y i n g a c t i o n in each phase of the continuum. Secondly, h e a l t h was perceived in terms of f a c t o r s i n f l u e n c i n g h e a l t h . In complete h e a l t h , p a r t i c i p a n t s d e s c r i b e d being able to c a r r y out normal a c t i v i t i e s w ell and ha p p i l y , and t h e r e f o r e being able to f u l f i l l the r e s p o n s i b i l i t i e s and d u t i e s a s s o c i a t e d with personal l i f e r o l e s . Health in t h i s phase was c h a r a c t e r i z e d by abundant energy, r e s i s t a n c e , independence and c o n t r o l . In complete h e a l t h , p a r t i c i p a n t s d e s c r i b e d f e e l i n g happy, f u l l of energy, o p t i m i s t i c about l i f e , c h e e r f u l , not worried about anything, and f e e l i n g l i k e they could do anything they wanted to do. In p a r t i a l h e a l t h , p a r t i c i p a n t s explained that they c o u l d s t i l l c a r r y out normal a c t i v i t i e s , but l e s s well (at a lower l e v e l of e f f i c i e n c y ) and with more e f f o r t than i n complete h e a l t h . The p a r t i a l h e a l t h experience covered minor complaints such as c o l d s and the f l u , and was d e s c r i b e d as temporary and bothersome. 187 P a r t i a l h e a l t h was viewed as temporary because the minor h e a l t h problem l a s t s f o r only a few days, going away by i t s e l f , or with minimal i n t e r v e n t i o n . P a r t i a l h e a l t h was d e s c r i b e d as bothersome because p a r t i c i p a n t s found i t annoying that t h e i r a b i l i t y to do normal a c t i v i t i e s was i n t e r r u p t e d , or hindered t e m p o r a r i l y . In t h i s phase, decreased c a p a c i t y f o r doing normal a c t i o n was a s s o c i a t e d with decreased energy and r e s i s t a n c e , and decreased independence and c o n t r o l . P a r t i c i p a n t s d e s c r i b e d lack of enthusiasm and lack of motivation f o r doing a c t i o n ; b a s i c a l l y not f e e l i n g l i k e doing anything, and having to drag themselves through d a i l y a c t i v i t i e s . P a r t i c i p a n t s viewed s i c k n e s s as a s t a t e i n which one would be t o t a l l y unable to c a r r y out normal a c t i v i t i e s , and could not f u l f i l l ones r e s p o n s i b i l i t i e s independently. Sickness was viewed as s e r i o u s , worrisome and permanent (or long term). P a r t i c i p a n t s f r e q u e n t l y a s s o c i a t e d s i c k n e s s with "something wrong" in the body. The very l i m i t e d a c t i o n i n s i c k n e s s was a s s o c i a t e d with low l e v e l s of energy and r e s i s t a n c e , dependency and lack of c o n t r o l . P a r t i c i p a n t s d e s c r i b e d f e e l i n g that they d i d not want to do anything, and a l s o could not do anything. They f e l t that the s i c k body needed to l i e down, to r e s t and heal. On the second dimension of h e a l t h d e s c r i p t i o n , the mind was expl a i n e d as the most s i g n i f i c a n t f a c t o r i n f l u e n c i n g h e a l t h . Worry was perceived as d e t r i m e n t a l to h e a l t h , while a p o s i t i v e mental a t t i t u d e was perce i v e d as b e n e f i c i a l to he a l t h . Diet, e x e r c i s e , s l e e p and c l e a n l i n e s s , use of medicines, maintaining l a a r e g u l a r r o u t i n e s , working ou t s i d e of the home, and home atmosphere, were a l s o d e s c r i b e d by p a r t i c i p a n t s as f a c t o r s i n f l u e n c i n g h e a l t h . Research f i n d i n g s were d i s c u s s e d in l i g h t of r e l e v a n t l i t e r a t u r e i n chapter f i v e . T h i s d i s c u s s i o n h i g h l i g h t e d the f a c t that h e a l t h and si c k n e s s are c o n s t r u c t e d in both e t h n o c u l t u r a l and s o c i a l contexts. The h e a l t h p e r s p e c t i v e s of the Indo-Canadians in t h i s study were found to be q u i t e s i m i l a r to those held by Western middle c l a s s s o c i e t y . The l i t e r a t u r e reviewed supported t h i s f i n d i n g . For the p a r t i c i p a n t s , normal a c t i v i t i e s meant the "usu a l " or "everyday" r o u t i n e s and work a s s o c i a t e d with c u l t u r a l l y d e f i n e d l i f e r o l e s and r e s p o n s i b i l i t i e s . P a r t i c i p a n t s ' views of h e a l t h emphasized "doing normal a c t i v i t i e s " . T h e i r h e a l t h d e s c r i p t i o n s i n c l u d e d images of the h e a l t h - s i c k n e s s continuum and h e a l t h dimensions d i s c u s s e d in recent l i t e r a t u r e ( L a f f r e y , 1986; Smith, 1981; Woods et a l . , 1988). Cone1 us i ons Three main c o n c l u s i o n s can be drawn from t h i s study. F i r s t l y , the p a r t i c i p a n t s emphasized "doing normal a c t i v i t i e s " as the primary f e a t u r e of h e a l t h . Secondly, they viewed h e a l t h as a h o l i s t i c experience where body and mind are in s e p a r a b l y l i n k e d together, and i n f l u e n c e d by personal and environmental f a c t o r s . T h i r d l y , t h e i r c o n c e p t u a l i z a t i o n s of h e a l t h were c o n s t r u c t e d w i t h i n s o c i a l and c u l t u r a l contexts. 189 I m p l i c a t i o n s of the Study This study i n v e s t i g a t e d the unique p e r s p e c t i v e s on h e a l t h held by Indo-Canadians of the Hindu f a i t h , with the purpose of c o n t r i b u t i n g to h e a l t h care p r o f e s s i o n a l s ' understanding of t h i s view on h e a l t h . The f i n d i n g s of t h i s study have important i m p l i c a t i o n s f o r nursing p r a c t i c e , education and research. These areas are d e s c r i b e d below. I m p l i c a t i o n s f o r Nursina P r a c t i c e The f i n d i n g s of t h i s study have s p e c i f i c i m p l i c a t i o n s f o r nursing p r a c t i c e . In accordance with the p r i n c i p l e s of c r o s s - c u l t u r a l theory, t h i s study supports c r o s s - c u l t u r a l knowledge of h e a l t h and i l l n e s s as e s s e n t i a l to p r o v i s i o n of t h e r a p e u t i c , c u l t u r a l l y r e l e v a n t n u r s i n g care. The study f i n d i n g s a l s o i n d i c a t e that the i n f l u e n c e which the c l i e n t ' s s o c i a l circumstances exerts on h e a l t h p e r c e p t i o n need to be given equal r e c o g n i t i o n . In terms of s p e c i f i c s k i l l s , nurses need to understand c l i e n t s ' unique, s o c i o - c u l t u r a l l y determined explanatory models of h e a l t h and s i c k n e s s , and s t r u c t u r e n u r s i n g care and h e a l t h promotion programs in accordance with these p e r s p e c t i v e s . The nurse r e q u i r e s knowledge of Indo-Canadian p e r s p e c t i v e s on h e a l t h , as well as the s k i l l s to e f f e c t i v e l y i n c o r p o r a t e t h i s knowledge i n t o everyday p r a c t i c e . According to the p a r t i c i p a n t s of t h i s study, h e a l t h means being able to do d a i l y a c t i v i t i e s and f u l f i l l the r e s p o n s i b i l i t i e s a s s o c i a t e d with l i f e r o l e s . The study f i n d i n g s d i r e c t the nurse to be s e n s i t i v e to the d i s t i n c t 190 Indo-Canadian views on h e a l t h when a s s e s s i n g , planning and implementing n u r s i n g care with Indo-Canadian c l i e n t s . The nurse cannot assume that a l l Indo-Canadian c l i e n t s hold that same views on h e a l t h and i l l n e s s . The r e s u l t s of t h i s study show that Indo-Canadians of comfortable s o c i a l circumstances, and possessing h i g h e r l e v e l s of education, may hold views on h e a l t h which are s i m i l a r to Western middle c l a s s s o c i e t y in general. Indo-Canadians from d i f f e r e n t s o c i a l environments, however, may hold d i s s i m i l a r h e a l t h images although they share a common c u l t u r a l background with other Indo-Canadians. Health promotion and prevention programs f o r the Indo-Canadian community may be more e f f e c t i v e and r e l e v a n t i f s o c i o - c u l t u r a l p e r s p e c t i v e s on h e a l t h are i n c o r p o r a t e d into a l l aspects of program planning. The study p a r t i c i p a n t s ' d e s c r i p t i o n s of h e a l t h imply that the success of h e a l t h promotion programs f o r the Indo-Canadian community may be enhanced i f h e a l t h i s recognized as an important resource f o r doing d a i l y a c t i v i t i e s , f u l f i l l i n g r e s p o n s i b i l i t i e s , and b e i n g happy. Health was c o n c e p t u a l i z e d in the study as a two dimensional phenomenon embracing both the three phases of the h e a l t h experience and f a c t o r s i n f l u e n c i n g h e a l t h . The importance p a r t i c i p a n t s placed on d i e t , e x e r c i s e , c l e a n l i n e s s and sleep, medicines and maintaining d a i l y r o u t i n e s , suggests that nurses might e f f e c t i v e l y i n c o r p o r a t e these f a c t o r s i n t o the content of program plans f o r promoting h e a l t h in the Indo-Canadian community. According to Tripp-Reimer (1984b) " i t i s no longer s u f f i c i e n t f o r 191 i n v e s t i g a t o r s to s t a t e that the nurse should be s e n s i t i v e to the c u l t u r e of the c l i e n t " , r a t h e r " i t must be made c l e a r how c r o s s - c u l t u r a l n u r s i n g r e s e a r c h f i n d i n g s (can) be a r t i c u l a t e d with the f u n c t i o n s of assessment, d i a g n o s i s and i n t e r v e n t i o n " (p. 254). Given nursing's fundamental v a l u i n g of the c l i e n t as a unique human being of u n c o n d i t i o n a l worth, i n s e p a r a b l e from h i s / h e r personal h i s t o r i c a l , s o c i a l and c u l t u r a l background, growing r e c o g n i t i o n of the c l i e n t ' s explanatory models of h e a l t h i s an i n e v i t a b l e and c r u c i a l aspect of f u t u r e n u r s i n g care. The f o l l o w i n g i m p l i c a t i o n s f o r n u r s i n g education a r i s i n g from the study f i n d i n g s , are a s s o c i a t e d with the need to f o s t e r development of c r o s s - c u l t u r a l knowledge in the nursing p r o f e s s i o n . I m p l i c a t i o n s f o r Nursing Education The primary i m p l i c a t i o n f o r nursing education a r i s i n g from t h i s study i s that nursing students need to be exposed to c r o s s - c u l t u r a l theory and p r i n c i p l e s . Pis n u r s i n g students are taught how to care f o r c l i e n t s from v a r i o u s backgrounds, they need to be educated concerning c l i e n t s ' unique perceptions on world phenomena. Nurse educators need to design n u r s i n g programs which recognize the explanatory models on h e a l t h and i l l n e s s held by Indo-Canadians and other c u l t u r a l groups w i t h i n Canadian s o c i e t y . Nursing programs need to be designed to provide care which i s safe, e f f e c t i v e and c u l t u r a l l y r e l e v a n t to the c l i e n t . In order to meet t h i s goal, c r o s s - c u l t u r a l content needs to be i n c l u d e d in both undergraduate and graduate nursing c u r r i c u l a . T h i s 192 p e r s p e c t i v e has been supported i n recent nursing l i t e r a t u r e (Branch & Paxton, 1976; L e i n i n g e r , 1978; Morse & E n g l i s h , 1986; Muri11o-Rodhe, 1978; Drque et a l . , 1983). E d u c a t i o n a l programs a l s o need to focus on h e a l t h and i l l n e s s as phenomena c o n s t r u c t e d w i t h i n s o c i a l , as well as c u l t u r a l , context. Nursing r e s e a r c h guides nursing p r a c t i c e and education. The i m p l i c a t i o n s f o r nursing r e s e a r c h a r i s i n g from t h i s study are presented below in the f i n a l s e c t i o n of t h i s chapter. I m p l i c a t i o n s f o r Nursing Research This study has c o n t r i b u t e d to nursing knowledge about how Indo-Canadians view h e a l t h . Plthough c r o s s - c u l t u r a l i n v e s t i g a t i o n of the meaning of h e a l t h i s i n c r e a s i n g , f u r t h e r r e s e a r c h in t h i s area i s necessary. P t t e n t i o n a l s o needs to be given to f u r t h e r e x p l o r a t i o n of the ways that s o c i a l context i n t e r a c t s with c u l t u r e to c o n s t r u c t p e r s p e c t i v e s on h e a l t h . In l i g h t of the f i n d i n g s of t h i s study, the a d d i t i o n a l f o l l o w i n g areas are suggested f o r fu t u r e r e s e a r c h : (1) R e p l i c a t i o n of the cur r e n t study to gain deeper i n s i g h t i n t o the meaning of h e a l t h f o r Indo-Canadians of the Hindu f a i t h . For example, the r e l a t i o n s h i p between c h r o n i c i l l n e s s and h e a l t h (with p a r t i c u l a r focus on s p e c i f i c outcomes of c h r o n i c i l l n e s s ) i s an area which warrants a d d i t i o n a l i n v e s t i g a t i o n . (2) F u r t h e r research on the two dimensions of h e a l t h d e s c r i b e d by the p a r t i c i p a n t s i n t h i s study, as core aspects of the Indo-Canadian explanatory model f o r h e a l t h . (3) I n v e s t i g a t i o n of the meaning of h e a l t h to Indo-Canadians using 193 a l l male and a l l female sample populations, to f u r t h e r c l a r i f y i f p e r c e p t i o n s of h e a l t h are i n f l u e n c e d by gender d i f f e r e n c e s . (4) I n v e s t i g a t i o n of the p e r c e p t i o n s of h e a l t h held by non-Hindu Indo-Canadians, and other c u l t u r a l groups making up Canada's m u l t i c u l t u r a l s o c i e t y . (5) F u r t h e r r e s e a r c h on the meaning which d i f f e r e n t c u l t u r a l groups a s c r i b e to the v a r i o u s terms used to d e s c r i b e the h e a l t h experience (such as h e a l t h , wellness, s i c k n e s s , i l l n e s s , d i s e a s e ) , and the d i f f e r e n c e s which c u l t u r a l groups p e r c e i v e between the meaning of e n g l i s h terms and e q u i v a l e n t " n a t i v e language" terms. L e i n i n g e r (1985) provides us with a f u t u r i s t ' s view on q u a l i t a t i v e r e s e a r c h and the n u r s i n g p r o f e s s i o n : The t u r n i n g point has been reached f o r nurses and e s p e c i a l l y nurse r e s e a r c h e r s to chart new d i r e c t i o n s and methods f o r a l t e r n a t i v e ways to know and understand human beings. More and more, we s h a l l see that q u a l i t a t i v e r e s e a r c h w i l l become the method of choice to f u l l y know the h e a l t h , care and general l i f e w a y s of people. Nurse r e s e a r c h e r s must awaken to the importance of q u a l i t a t i v e methods in order to develop a d i s t i n c t and r e l e v a n t body of s u b s t a n t i v e knowledge in nursing, (p. 24). It i s hoped that L e i n i n g e r ' s p r e d i c t i o n s become a r e a l i t y . Ongoing q u a l i t a t i v e r e s e a r c h w i l l continue to r e v e a l the i n s e p a r a b l e and fundamental r e l a t i o n s h i p between c u l t u r e and h e a l t h . Phenomenology i s one a p p r o p r i a t e r e s e a r c h methodology f o r such enquiry, and ought to c l a i m a primary p o s i t i o n in f u t u r e nursing r e s e a r c h . Given the r e s u l t s of t h i s study, and the supporting d i s c u s s i o n of extant l i t e r a t u r e and r e s e a r c h presented i n t h i s t h e s i s , there i s undeniable argument f o r ongoing and emphasized enquiry i n t o the s o c i o - c u l t u r a l context of h e a l t h . 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American S o c i o l o g i c a l  Review. 31. 615-630. 210 Appendices: 211 Appendix A Information r e g a r d i n g the Study My name i s Robyn Thompson. I am a r e g i s t e r e d nurse working towards my Master's degree i n nur s i n g at the U n i v e r s i t y of B r i t i s h Columbia. I am i n t e r e s t e d i n l e a r n i n g about what h e a l t h means to Indo-Canadians, so that h e a l t h care p r o f e s s i o n a l s may b e t t e r understand Indo-Canadian h e a l t h b e l i e f s and p r a c t i c e s and provide b e t t e r h e a l t h care. The purpose of my study i s to l e a r n how you view h e a l t h and how you experience being healthy. I am i n v i t i n g you to p a r t i c i p a t e i n t h i s study. I f you agree to p a r t i c i p a t e , I would l i k e to i n t e r v i e w you i n your home so that I can le a r n about your v i ews. Each i n t e r v i e w w i l l be tape-recorded so that I can pay f u l l a t t e n t i o n to what you are t e l l i n g me. Each i n t e r v i e w w i l l l a s t f o r approximately one hour. I would l i k e to i n t e r v i e w you 2-3 times so that both of us can d i s c u s s your views in d e t a i l . Interviews w i l l be arranged at times which are mutually convenient to both of us. The i n t e r v i e w s I hold with you w i l l be d i s c u s s e d only with my teachers at the U n i v e r s i t y of B r i t i s h Columbia. Your name w i l l not be i d e n t i f i e d in any c o n v e r s a t i o n or w r i t t e n m a t e r i a l . Your d e c i s i o n to p a r t i c i p a t e or not in t h i s study, WILL NOT AFFECT ANY MEDICAL OR NURSING CARE THAT YOU MAY RECEIVE. I f you decide to p a r t i c i p a t e in t h i s study, YOU MAY WITHDRAW FROM THE STUDY AT ANY TIME WITHOUT ANY CONSEQUENCES TO CARE PROVIDED TO YOU 214 Appendix C I n i t i a l T r i g g e r Questions These i n i t i a l t r i g g e r questions were r e v i s e d subsequent to the p i l o t study. 1) What does h e a l t h mean to you? ... What i s the experience l i k e f o r you? 2) What do you do to gain a sense of ease and wholeness? 3) When do you c o n s i d e r y o u r s e l f to be healthy? 4) What t h i n g s are important to you i n l i f e ? 5) When you are healthy, what t h i n g s are you able to do and accompli sh? fe) What i s your experience i n everyday l i f e when you are not s i c k or s u f f e r i n g from any i l l n e s s ? 215 Appendix D F i n a l T r i g g e r Questions 1) What do you think about h e a l t h ? 2) What does h e a l t h mean to you? ... What i s the experience l i k e f o r you? 3) When do you c o n s i d e r y o u r s e l f to be healthy? 4) What th i n g s are important to you i n l i f e ? 5) When you are healthy, what t h i n g s are you able to do and accompli sh? 6) What i s your experience i n everyday l i f e when you are not s i c k or s u f f e r i n g from any i l l n e s s ? 217 Appendix F Health Images in c l u d e d i n the Health D e s c r i p t i o n s  of P a r t i c i p a n t s in t h i s Study (Adapted a f t e r Wood and Coworkers. 1988) C I i n i c a l -No t i r e d n e s s -Not i l l or s i c k , d i s e a s e f r e e -No pain -NORMAL -Not bedridden -NOT SUSCEPTIBLE TO DISEASE Adapt ive -Don't l e t t h i n g s get you down -ACCEPTANCE OF LIFE'S SITUATION(S) - A b i l i t y to cope -ABLE TO TAKE ANYTHING MENTALLY -IN CONTROL -CONTROL OVER LIFE -CONTROL OVER MIND, AND BODY -Se1f-d i s c i p l i n e Role Performance -ABLE TO DO WORK, DO USUAL FUNCTIONS -ABLE TO PERFORM -ABLE TO DO THINGS -Able to f u n c t i o n without f a t i g u e - P r e d i c t a b l y being able to do t h i n g s -Able to be as a c t i v e as you want A c t u a l i z i n g S e l f -Able to achieve goals P r a c t i c i n g Healthy L i f e Ways -EXERCISING -EAT BALANCED DIET -good n u t r i t i o n P o s i t i v e Self-Concept - F e e l good about s e l f C o g n i t i v e F unction -Think r a t i o n a l l y - C l e a r headed Body Image -Look good P o s i t i v e A f f e c t -POSITIVE MENTAL ATTITUDE -Sense of w e l l - b e i n g -HAPPY - C h e e r f u l - F e e l good S o c i a l Involvement -Involved i n commun i t y -Able to enjoy fam i 1 y F i t n e s s -Strength -Able to be act ive -ENERGETIC 218 Harmony -Cal m -In harmony - L i f e in balance -NO WORRIES -Peace of mind -BODY/MIND IN HARMONY -Cont ent NOTE: The h e a l t h images which p a r t i c i p a n t s in t h i s study emphasized the most are shown i n c a p i t a l i z e d terms. 

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