4. Health Psychology: Progress and Challenges – Psychology in India, Volume 3

4

Health Psychology: Progress and Challenges

Sagar Sharma and Girishwar Misra

INTRODUCTION

Health psychology is a rapidly growing field and one of the most vibrant specialities within the larger discipline of psychology. It has great potential to enhance our collective understanding of health, bring about health improvements, facilitate high quality care, and inform health policy. The primary vision of professional health psychology is the application of psychological knowledge, methods, and skills to prevent illness, facilitate recovery, and promote health. Facilitating health communication, fostering behaviour change, and reducing barriers to access health provisions are some of the significant concerns of health psychologists. In fact, any psychological activity, process, or intervention, which either enhances or threatens health, becomes a concern to health psychology. Moreover, this sub-discipline has a profound impact on clinical psychology, and has played a major (if not the major) role in developing and vitalizing the interdisciplinary fields like behavioural medicine and behavioural health. While behavioural medicine focusses on the needs of actual patients being treated by physicians, behavioural health is concerned with currently healthy people—helping them remain healthy with an appropriate lifestyle. Clinical psychology is primarily concerned with assessing, predicting, preventing, and alleviating cognitive, emotional, and behavioural disorders, and disabilities; psychotherapy is primarily concerned with the treatment of psychological and psychologically induced disorders by psychological means. All of them share common concern with the applications of psychological principles and methods to the domain of health, illness, and health care.

HEALTH PSYCHOLOGY IN AN ECOLOGICAL CONTEXT

The ecological context of health includes various social systems within which human beings live: families, workplaces, organizations, communities, societies, and cultures (see Marks, 1996; Marks et al., 1998; Palsane & Lam, 1996; Palsane & Ram, 1999). In view of such an interdisciplinary nature of health issues, the social significance of health psychology is better reflected when it addresses the social, economic, cultural, and political contexts in which psychological and health processes, including health variations, are embedded. An interdisciplinary perspective can also facilitate the development of multicultural health psychology, which regards and respects all cultural traditions in their global context (Gergen et al., 1996; Marks, 1996). The culturally informed perspective views health and illness as linked to social beliefs, values, and practices (Joshi, 2000; Misra, 2000). It also sheds light on the reciprocal connections among physical, psychological, and societal worlds of health linking the body, mind, and collectives. Such a study of psychological and socio-cultural influences on health and illness is termed as psychosomatics and sociosomatics, respectively.

The understanding of psychological causes of health and illness has to be seen in the context of corresponding developments both in the fields of health psychology and medical sociology. Health psychology argues for an integration of mind and body, sometimes referred to as holistic or the whole person approach, while medical sociology locates the person within the medical world. The emphasis on psychological causality is illustrated when health psychologists maintain that illnesses are predominantly caused by behaviour, and medical sociologists focus on the role of the social-structural environment because an individual's location in the social world is assumed to determine his/her illness profile. Health psychology, as a discipline, aims at prioritizing psychological causes and acknowledging the role of individual beliefs and behaviours. Medical sociology argues that the main determinants of inequalities in health are present in the material or economic circumstances, lifestyles, and behaviours of social classes that produce differences in exposure and resistance to diseases. Moreover, acknowledgement of local/indigenous understanding of health and health care, the social and cultural structures sustaining them along with the vast potential of cultural and other interventions, have also fostered an appreciation of social anthropological analysis of health beliefs and behaviours (Joshi, 2000). Health psychology, medical sociology, and social anthropology thus, can be seen as complementary and mutually dependent, though each fabricates its boundaries to maintain seperate identity.

In the fourth survey, Dalal (2001) had reviewed and analysed the studies in the area of health psychology. He first identified three broad areas where past research has facilitated the growth of health psychology in India, i.e., yoga and health, the stress phenomenon, and indigenous health traditions. He covered culture-specific (indigenous) meanings of health; causes of illness and suffering; health beliefs and practices; major psychological ‘antecedents’ of health (situational, dispositional, and health-related factors); psychological correlates of recovery from chronic illnesses; disability beliefs and rehabilitation interventions, and community health care. This review makes an effort to integrate and analyse the progress of the subsequent research in health psychology (1993 to 2003), and to identify challenges that need redressal. Effort has been made to organize this review around three questions. First, who becomes sick and why? Second, among the sick who recovers and why? Third, how can illness be prevented, recovery improved, and health promoted? (Adler & Matthews, 1994). Our endeavour to find answers to these questions, nevertheless, necessitated a multidisciplinary search with primary focus on psychological research.

The Meaning of Health

In accordance with the World Health Organization (WHO) definition, health is seen as well-being in its broadest sense, not simply the absence of illness. Expanding the WHO definition, well-being is the product of a complex interplay of biological, socio-cultural, psychological, economic, and spiritual factors. In classical Indian traditions, health is conceptualized as a state of delight or a feeling of spiritual, physical, and mental well-being (prasannatnmendriyamanah), and this conception is closer to the WHO definition of health/well-being (see Dalal, 2001; Sinha, 1990). Analysing the discourse on health, Shukla (2000) draws attention to ‘being in itself’ or autolocus (swastha). But it is not given. It is a search process. Nandy (2000) invites one to attend to the plurality of the notion of health and emphasizes the need to bring to our psychological inquiry ‘something of the sagacity, insights and cumulative wisdom of the people with whom we live’ (p. 111). Drawing from Bhagvadgita, Verma (1998) states that human well-being unfolds at three levels namely, cognitive, conative, and affective. The cognitive level talks about ‘self’ with its lustful inclinations, desires and attachments (asakti, see also Bhusan, 1994; Naidu & Pande, 1999). Well-being at the cognitive level requires self-examination leading to freedom from desires and attachments—anasakti (Naidu & Pande, 1999). At the conative level, well-being lies in the performance of one's duty or karma (Bhusan, 1994, see also Ram, 2000; Verma, 1994, 1998). Lastly, at the affective level, well-being lies in the attainment of freedom from I and mine. In a nutshell, Indian traditional perspective offers an ideal state of human functioning and constitutes health and well-being as a state of mind [somewhat equivalent to the concept of subjective well-being (SWB)] which is peaceful, quiet, serene, and free from conflicts and desires. Undoubtedly, such a conceptualization of health and well-being is significant in its own right. These levels need to be contextualized in contemporary perceptions and experiences of physical and mental health.

The open-ended responses defining health by different social and/or occupational groupings reflect a definite class distinction on this issue. While medical professionals usually distinguish between health and illness in organic terms relying on bodily conditions, lay people rely on subjective and culturally given meanings. Thus, a patient approaches a health professional only when he or she finds the symptoms to be threatening and perceives a need for medical attention. Illness, thus, often understood within the social constructionist framework involves participation of patients, their families, and their kith and kin. The resulting social construction of disease/health may not be congruent with those of the medical professional, but it does influence health-related decisions. Being embedded in a socio-cultural context, people imbibe belief systems that structure the meaning of health and illness. For people of the middle and upper class, health is considered to be a value and a norm (including spiritual striving) in itself, something to be sought and attained, a feeling of being in equilibrium or sama, balance or a state of samyavastha, or the middle path or madhyama marga. However, for the people of the lower social class, health is likely to be appreciated in more utilitarian or physical terms, such as providing means to do things and particularly to be able to work. Further, there are working class preferences for body strength than body shape (see Chamberlain, 1997). Earlier, Chaturvedi and Michael (1993) documented that social-structural factors like habitat (rural-urban) and socio-economic status (SES) influence the nature and localization of somatic complaints. In a sample of rural people, Tripathi (1993) observed that factors of vitality, hardiness, and fitness defined health for these respondents. All these three positive markers of health were, however, defined primarily in terms of their physical manifestations (see also Sharma, 2003b; 2004a). Later, Singh et al. (1999) directed such queries at health practitioners of four systems of medicine. These health professionals conceptualized health more in positive terms than as a default concept—the absence of physical disease. Interestingly, they too expressed relatively less concern for psychological well-being. Also, the absence of emphasis on social and spiritual well-being was striking. Analyzing a qualitative data, Misra (1996) observed an age-differential in the meaning of quality of life (QOL). Regardless of gender, the older people conceptualized QOL in value-laden terms (desirable or undesirable in life), but their younger counterparts cognized in terms of standard of living (materialistic things in life). Further, neither the tribal elderly in Gujrat nor their family members accepted mental problems as illnesses (Patel, 2000).

In an ethnographic study, Priya (2002) has described the general construction of happiness and health in urban area of Kachch (Gujarat) as ‘having material, properties and illness free bodies’. Confirming the unique capacity of contemporary Indians in handling dualities, Wagner et al. (2000) reported the contradictions that coexist in their minds with regard to traditional and Western psychiatric notions of mental illness, their etiology and treatment. They owned both as per the requirements of specific social settings without much dissonance. Using participant observation, focus group discussions and in-depth interviews, Chakraborti et al. (1999) studied the meaning of health in general and mental health in particular from six remote villages of the Sundarban region, West Bengal. Results showed clear differences in the meaning of health according to the SES. The poor and non-educated segment with the least urban influence greatly emphasized physical ability and economic well-being as indicators of good health. Most of them opined that sadness is part and parcel of their highly stressed life, so they did not consider it a special form of any health problem. Their educated, economically better-off counterparts with a certain degree of urban influence emphasized physical and emotional stability as markers of good health, and expressed equal concern for physical and mental health. The pattern of their help seeking also reflected diverse preferences for traditional and modern treatments. These studies on the meaning of health indicate that social class effects are clearly manifested, making a strong case for including the social world of participants and their perspectives in related research.

Health Beliefs and Practices

Dalal (2001) has highlighted a largely unexplored issue of socio-cultural construction of causation of illness and negative affectivity. Based on the analysis of Indian scriptures, for instance, he also identified three types of causality for all kinds of human suffering (see also Ram, 2000). As Dalal (2001) remarks

…health systems and practices in all societies are based on certain shared beliefs about the world, self and human existence. These cultural beliefs provide the necessary framework for defining health, understanding the causes of illness and deciding the modes of treatment (p. 362).

Earlier, Dalal (2000b) had investigated the cultural beliefs about illness among hospital-based patients (suffering from MI-myocardial infarction, cervical cancer, permanent disability through major accidents, and general chronic illnesses), and their psychological adjustment (coping) to such chronic illnesses. It was found that: (i) such patients, and also their family members, consistently attributed illnesses to karma and God's will; (ii) these metaphysical beliefs shaped patients’ treatment-related decisions; but (iii) no consistent linkages were observed between patients’ illness beliefs and their psychological adaptation. These researchers argue that such metaphysical beliefs carry different symbolic meanings when illness and social contexts change (see also Dalal, 1999, 2000a; Dalal & Singh, 1992). Attributing illness to such metaphysical beliefs makes sense in India where these are the core ingredients of people's worldview. When faced with such life crises, even caregivers (such as family members) invoke these cultural beliefs to explain their suffering (Kohli & Dalal, 1998, 1999). Further, Dalal (2000a) emphasized that such indigenous health beliefs and practices continue to form the basis of effective health care in India.

In related studies, Chakraborti et al. (1999) observed use of supernatural factors in the attribution of paediatric illness in the poor and remote villages of West Bengal, and preference for traditional healers (e.g., Ojhas). In an urban slum community, ‘evil spirits’ and ‘evil eyes’ were perceived as adversely affecting the health of the baby (Sahu & Mohanty, 1999). In another study on the tribes of Orissa, Sharma et al. (2001) noted that physical illnesses were attributed primarily to the wrath of a deity or spirits of the dead. For this reason, home treatments were carried out as per ethnomedical perceptions in the community. Singh (2000) also found that rural people attribute mental illness to jadu tona and tantra mantra (indigenous magical and ritualistic practices), and clung to their meanings and attributions of mental illness despite active interventions. Also, there was a strong resistance to change in the health beliefs. Further possession as a powerful health belief system has also been studied by several researchers. In the Dakshina Kannada district of Karnataka, Rao (1998) dealt with the cultural distinctiveness and therapeutic elements of Siri (possession of spirit) cult. He suggests that such an analysis can help health professionals understand the impact of culture on mental illness. A unique form of possession behaviour, Purvaj Syndrome, has been reported by Vagrecha and Asthana (2002). It involves a mediumistic behaviour and entails the impersonation of a recently deceased member of a family (purvaj) rather than a deity or spirit by the medium, as is common in many other forms of possession behaviour. Moreover, the integration of the sick into the community of the healthy continues to be implemented through the practice of possession (Brockman, 2000). In a study on Jaunsari tribe in the central Himalayas, Joshi (2000) notes an intimate relationship between culture, tradition, and health practices (a magico-religious health system). The role of traditional healers of this community entailed bringing the suffering individual close to superhuman forces. They can function as a major resource in providing health services to the local community.

The preceding research highlights the significance of indigenous health beliefs and practices because such beliefs and explanations are most likely to have significant bearing on the health status and health behaviour of such persons, including their social relations, dietary habits, and lifestyle. However, health beliefs may not necessarily be reflected in health behaviour. There is always the possibility of inconsistency between knowledge, beliefs, and behaviour/practice. For instance, Joshi and Lamb (2000) reported that despite their awareness of coronary risk factors and acculturation, South Asians in London persisted with their dietary beliefs/practices and continued to eat food with excess fat content believing it to be a healthy diet.

CONTRIBUTORS TO HEALTH AND ILLNESS

The first question ‘who becomes sick and why’ pertains to the social-structural factors, psychological characteristics of individuals prone to illness, their health-related behaviours, and the mechanisms accounting for the association between these variables and illness. This is the basis for the other two questions and suggests possibilities for prevention. In this section, we examine the related studies in the following three broad domains—(i) the social-structural environment; (ii) the psychosocial environment and dispositions; and (iii) the factors that comprise health-related behaviours or lifestyles. Though somewhat arbitrary, this categorization of variables facilitates the identification of significant contributors to health and illness. It may, however, be emphasized that psychosocial as well as (health) behavioural forces do not exist in a vacuum, but are rooted in the social-structural contexts of people's lives (Chowdhury et al., 1999; Denton et al., 2004). Likewise, health behaviours or lifestyles were influenced by psychosocial factors. In related research, both positive and negative markers of subjective well-being (SWB) have been employed along with medical and behavioural markers of health and illness. The positive markers included self-esteem, ego-strength, optimism, adjustment, life satisfaction—sukh swarup, vitality, contentment (santosh), happiness, QOL. The corresponding negative markers were distress, anxiety, anger/hostility, depression, helplessness, alienation and loneliness (e.g., Agarwal, 2003; Akhani et al., 1999; Joshi, 1998; Mishra & Agarwal, 2003; Sharma 2002, 2003a; Singh & Misra, 2000; Sinha, 1996; Srivastava & Bhatnagar, 1998; Thakar, 1996; Tripathi, 1993; Verma et al., 1998; Wolf, 2001).

Social-Structural Contributors

The importance of the social-structural context of people's lives for health and illness is emerging as a significant focus of research. Studies dealing with such aspects are reviewed in this section.

Socio-Economic Class

In several studies, persons in the lower socio-economic class have been found to display poorer physical and mental health/well-being as indexed by self-report measures of efficacy, adjustment, life satisfaction, coping and QOL (Ahmed, 1998; Akhani et al., 1999; Chaturvedi & Michael, 1993; Chowdhury et al., 1999; Mishra & Agarwal, 2003; Miya & Krishna, 1996; Panjiyar & Rout, 1999; Patel et al., 1998; Patel, V. Ricardo et al., 1999; Sastry, 1999; Sharma et al., 2001; Shirolkar & Prakash, 1996; Srivastava & Bhatnagar, 2000). The chronic preoccupations of very poor illiterates living in the remote villages of West Bengal include livelihood stress, sexual conflicts (extramarital relations), and familial conflicts (Chakraborti et al., 1999). Tribal status also contributes to stress symptoms or poor QOL (Singh, 1993). However, in a correlational study, Agarwal (2003) observed that amassing money as the chief aim of life did not ‘result’ in well-being in the students pursuing medical or engineering course. Earlier, in a study of college students from 31 nations, Diener and Diener (1995) found that financial status (social class) was more strongly correlated with life satisfaction in poorer nations than in the wealthier nations. Thus, in a poorer nation, or for the poor in any nation, the value of money for satisfying needs may be a more critical factor than it is in a nation where most citizens have access to some basic resources for pursuing their goals. With regard to such a link between income inequality and health status, a plausible conceptualization in the domain of health psychology is required to explain how life in a climate of inequality might lead to increased levels of psychological stress, or the initiation and maintenance of behaviours that could be detrimental to individual and community health.

Family Structure

Social relations can be expressed structurally as the extent of social networks, and functionally as the nature of social support. The family or household is probably one of the important social sub-systems of intermediate complexity. Several domains of behaviours are likely to be regulated more directly at the family/household level than at either the individual or community levels. There is also a strong tradition of understanding of psychosomatic illness from the perspective of the family. Some studies have dealt with the efficacy of nuclear and joint families or home environment, vis-à-vis health and illness, with inconsistent outcomes (e.g., Dastidar & Kapoor, 1996; Jagdish & Yadav, 1999; Jha, 2001; Saxena, 1996). Nonetheless, what appears to be significant is not the structure per se but the functional content of family relations. Evans et al. (1998), for instance, highlighted the significance of parent-child conflicts. However, the importance of the family or the household for explaining and promoting health behaviours still remains largely unexplored.

Residential Density and Environmental Hazards

The socio-economic background, largely, determines the residential environment, and lower SES is generally associated with residential crowding and pollution. Living in such a habitat is most likely to have long-term negative consequences for human physical and psychological health and QOL (Aijaz, 1999; Arora & Sinha, 1998; Pandey, 1999, 2003; Sinha, 1999). Environmental hazards are increasingly becoming serious problems. In particular, biological pathogens, physical hazards, chemical pollutants, and shortage of specific natural resources are crucial. The degradation of the environment at national and global levels further complicates the issues. Biological pathogens in the human environment, air, water, soil, etc. takes the greatest toll on health. The incidences of water-borne diseases, respiratory infections, tuberculosis, etc., clearly indicate this. Since food, fuel, and fresh water are central to health the environmental dimension cannot be ignored (Singh & Misra, 2004). In a significant study on 10- to 12-year-old children of lower-middle SES background in Pune city, Evans et al. (1998) found that chronic residential crowding is associated with difficulties in adjustment at school, poor academic achievement, elevated blood pressure, learned helplessness, and impaired parent-child relationship. The gender of children emerged as a moderator variable since residential crowding had a positive relationship with helplessness only among girls and with blood pressure only among boys. Further, perceived parent-child conflict accounted for the various correlates of household crowding among children. The moderator-mediator distinction is a significant feature of this study since it also explains the underlying process.

Age

Chronological age is found to be negatively correlated with indicators of mental health or psychiatric problems (Gunthey & Mathur, 1997; Joshi, 1998; Schimer & Vohra, 1998; Srivastava & Bhatnagar, 2000). With respect to high school students, Sharma (2002) examined Indian studies related to examination (test) anxiety in terms of its socio-cultural genesis, impact on academic performance and general well-being, and the efficacy of diverse interventions to alleviate its impact (see also Singhal, 2004). In three related studies around Pune and Nasik on high school boys and girls, Ganguli (2003) identified social taboos, misconceptions about sex and sexuality, conception and contraception in these vulnerable groups. Based on qualitative data obtained from Delhi-based adolescent girls with three distinct class backgrounds, Ranganathan (2003) interpreted their growing up experiences with respect to puberty, emerging sexuality, and ways they coped with them. The findings revealed that while there were several commonalities in terms of psychological concomitants of puberty and the experiences of sexuality, there were also some variations in the ways these girls from different backgrounds described their sexuality and methods of coping they adopted.

Generally, a discussion on adolescent health deals more with adolescent behaviour—that is, with what these young men and women are actually doing rather than lists of illnesses. The health of adolescents is, in fact, most severely jeopardized by their own risky actions, not by germs, viruses, degenerative diseases, etc. In alarming numbers, adolescents engage in activities inimical to their health (e.g., smoking, substance abuse, dietary fads, unhealthy eating, and unsafe sexual practices). Such lifestyle choices of adolescents have significant implications for their health during later adult life. The sources of their health-damaging lifestyles are mainly located in the prevailing social-structural and psychosocial conditions (Jha, 1994; Kapur, 1999; Thakar, 1996). Sinha (2002) has dealt with mental health and behavioural problems of adolescents along with intervention strategies for their care and cure, including family therapy.

The ageing society is now one of the priority areas of research in health psychology. The impact of poverty, social and family isolation, loneliness, learnt helplessness, etc., are now becoming salient features of Indian society as well. Fear of crime, age discrimination, inadequate access to health and social care are significant barriers to geriatric health and well-being. In the context of social-structural or psychosocial factors, studies have dealt with issues like health and well-being of the elderly assessed in terms of life stress, vulnerability, anxiety, depression, life satisfaction, the impact of institutionalization, elder abuse, cost of elder care, etc. (Dwivedi et al., 1998; Easwaramoorthy, 1993; Gunthey & Mathur, 1997; Gupta, 2002; Hussain & Priyadarshini, 1996; Jamuna & Ramamurti, 2000, 2001; Kanwar & Chadha, 1998; Lalitha & Jamuna, 2003, 2004; Miltiades, 2002; Nathawat & Rathore, 1996; Patel, J. et al., 1999, 2000; Patel & Kamala, 1995; Prakash, 1998; Sharma, S., Krishna, A. et al., 1996; Sinha, 1999; Sushma et al., 2002; Veedon, 2001; Yadava et al., 1997; for earlier reviews see Ramamurti & Jamuna, 1999; Sharma, 1999a and for recent ageing research see Ramamurti and Jamuna in this volume). Mainstream research on ageing in India, by and large, has either focused on social-structural or psychosocial variables. Very few researchers, however, have actually explored the possible linkages and interaction between these two groups of variables in relation to health and ageing.

Gender

Biological differences and entrenched structuring of most aspects of life based on gender clearly create the potential for very different exposures and experiences, both culturally and materially, for men and women. Despite challenges and changes in gender hierarchies over the past few decades, men and women still occupy different places in the job market and have different reproductive roles and expectations. Because of the gendered psychosocial world we inhabit or because of their prevalence, gender-based inequalities are frequently documented in psychological research. In addition, contemporary researchers are paying more attention to specific issues related to women's health, which is clearly more than gynaecology and reproduction, although these are important aspects of women's lives (see also Vindhya, volume four of this survey).

Gender Variation

Compared to their male counterparts, female employees report higher levels of stress and prefer defence-oriented/emotion-focused coping (Deosthalee, 2000; Helode, 2000; Sharada & Raju, 2001). They experience more family-related stresses, while men experience more stresses related to work and society (Sahu & Misra, 1995). Earlier, Agarwal and Dalal (1994) observed gender differences in affective reactions to hospitalization—a stressful event for indoor patients. Female patients exhibited higher levels of anger and anxiety, and lower on disengagement and rationalization (see also Gupta & Saini, 1993). In urban, middle class couples, Andrade et al. (1999) observed that, regardless of work status, women (i.e., wives) experienced less SWB, on such facets like distress, anxiety, and poor QOL. Women of urban poor minorities not only perceived greater economic stress (poverty) and less social support but also expressed greater helplessness, resignation, and fatalism than their male counterparts (Siddiqui & Pandey, 2003).

In a study of low income working people drawn from slums of Allahabad, Srivastava (2003) reported more stress, less resilience as well as unfavourable perception of quality of family life among wives than their husbands. These studies considered both gender and SES together. However, there are also some studies where no variation due to gender has been reported (e.g., Nagartnamma, 1999; Sehgal, 1999). While studying gender variations, one issue often neglected is whether comparisons between men and women assume that differences relate to sex or gender (Lakshmi, 1998). Since gender represents both biological/genetic and social differences, it is likely that the nature of health inequalities/variations between men and women reflect both sex-related biological as well as social factors, and the interplay between them. Differential vulnerabilities and exposures are hypothesized to account for gender-based differences in health and well-being. It could be that high income, working full time, caring for a family, and having social support are more potent predictors of health for women than men (Denton et al., 2004; Mishra & Agarwal, 2003).

Women's Health

Research on the health and well-being of working (professional) women provides inconsistent findings. Compared to non-working women, working women report higher SWB, self-esteem, life satisfaction, and QOL (e.g., Nathawat & Mathur, 1993; Singh & Bawa, 1996; Thakar & Misra, 1999; Vasudeva & Chaudhary, 1998). In contrast, in some studies working women are observed as having poorer SWB/mental health (e.g., Bhusan & Karpe, 1996; Jain & Gunthey, 2001; Mohanty & Bhol, 2000; Srivastava & Bhatnagar, 2000). Recently, Mishra and Agarwal (2003) reported that the socio-economic and working status of women predicted their positive coping and quality humour, which in turn related positively with their SWB (indexed as life satisfaction and happiness). Thus, a joint social and economic empowerment of women appears to be associated with their positive health and well-being via active coping (see also Dubey & Kumari, 1999).

The joint effect of social and economic impoverishment is also reflected in the ill-health of poor, female agricultural and other labourers (Meti et al., 2001; Sididiqui & Pandey, 2003; Srivastava, 2003). In an earlier study, Mishra and Vajpayee (1996) analysed various stressors in the lives of village-based women. As expected, economic pressures and family constraints were not only more stressful but also got reflected in their lower levels of mental health. The researchers argued in favour of social-structural interventions, that is, that an appropriate resource structuring and social support are essential to sustain mental health in a culturally changing society. With respect to marital adjustment, the healthier marital relationship in Bengali couples was traced to women with feminine identity and traditional gender role attitude (Dasgupta & Basu, 1997). However, in a study of upper middle class, educated, urban-based women, Sinha Ray (2000) found marital adjustment and mental health to be independent. The results suggest that marriage implies multiplicity of roles. Though these roles cause stress to people, especially women, they also provide them with ample opportunities for enrichment and escapes from stress in other domains of life.

Another group of studies has addressed itself to the health/well-being consequences of gender-specific stressors like sexual harassment or military induced separation (Kalia, 1999; Thomas & Sudhakar, 1994; Wadkar, 2000); gynaecological problems/sexual health (Evans & Lambert, 1997; Khan et al., 2000; Srivastava, 2002) reproductive rights/manipulating fertility decisions/female infanticide (Hegde, 1999; Karkal, 1993; Mahajan et al., 1999; Yadav & Badari, 1999) and wife abuse (Martin et al., 1999). In discussing the tragedy of female infanticide in south Indian rural communities, Hegde (1999) highlighted the extreme distress of the hapless mother who is placed in the dual role of victim and murderer because of the gender ideology of the community.

Gender variations in health and well-being have seldom been examined for influences by SES and other social-structural and psychosocial factors. As gender SES too continues to structure opportunities and life chances, it is therefore important to examine the intersection between them in the social patterning of health (see Denton et al., 2004; Macintyre & Hunt, 1997). The psychosocial experiences of individuals and their behaviours are significantly patterned by various social-structural variables.

Psychological Contributors

In contrast to social-structural factors, psychosocial contributors of health and illness operate chiefly at the subjective level. In this section, we examine two broadly interrelated categories of psychosocial factors affecting the onset of illness and health promotion: critical life events (stress in various life domains) and psychosocial resources (dispositions, coping, and social factors like social support).

Stress: Critical Life Events

The term ‘stress’ is potentially the most useful device in the conceptual armamentarium of health psychologists. It offers a ready means of describing possible links between the individual and his or her social and physical milieu. Stress, in its various forms, is ubiquitous and leads to the occurrence of a range of dysfunctional behavioural consequences and other negative sequelae leading to cardiovascular and other psychophysiological disorders (see Misra, 1999; Palsane et al., 1999; Pareek, 1993; Pestonjee et al., 1999; Ram, 1998; Sharma et al., 1999; Singh & Srivastava, 1999). Stress emerges in a significant way to begin answering the central question of health psychology: ‘Why do some people fall sick and others stay well’? (Adler & Matthews, 1994). Across various categories based on occupation, social class, gender, age, and habitat, people who experience stress are found to be more susceptible to unhealthy lifestyles; illness and lower well-being (see Dalal, 2001; Naidu, 2001). Subsequent research has further documented that people who are exposed to life-events-stress are at a greater risk of psychological distress (Agarwal & Dalal, 1994; Banerjee & Vyas, 1992; Biswas et al., 1995; Chakravarty & Misra, 1999; Dolke, 2000; Goyal, 1997; Jagdish & Reddy, 2000; Kapur, 1999; Mishra, 1998; Mishra & Vajpayee, 1996; Naidu & Pande, 1999; Pande & Naidu, 1992); poor physical health (Ambrose & Karunanidhi, 1996; Arun et al., 1993; Bansal, 1996; Ghosh, 1999; Mandal et al., 1992; Parveen & Singh, 1994; Rastogi & Kashyap, 2001; Sharma, 2003a, Sharma et al., 2004; Shirali & Bharti, 1993; Singh & Kaushik, 1993; Sinha & Nigam, 1993; Verma & Asthana, 1993); and health damaging behaviour (Ahuja et al., 1998; Singh, 1998; Singh & Prajapati, 1999; Suman & Nagalakshmi, 1995). Further, the number/frequency of critical life events do not appear important. What appears to be significant is the perceived negative impact either directly or through a maladaptive coping (Sharma, 2003a; Sharma et al., 2004).

In addition to focusing on exposure to critical life events, other researchers point to the impact of chronic stressors (i.e., ongoing and difficult conditions of daily life) on health, illness and QOL. Such conditions include stresses related to academic settings, poverty, family, parenting, social life, job, unemployment, hospitalization, acculturation and environmental conditions (Agarwal & Dalal, 1994; Alam et al., 1999; Bhushan & Karpe, 1996; Chakrapani, 1996; Chandrasekhar et al., 1995; Chowdhury et al., 1999; Commons & DeMello, 2000; Dubey & Kumari, 1999; Jagdish & Yadav, 1999; Kalia, 1999; Mathur, 1995; Mukhopadhyay & Kumar, 1999; Pattanayak et al., 1999; Pradhan & Misra, 1995; Prasad, 2001; Rao et al., 2000; Schimer & Vohra, 1998; Sharma, 2002; Siddiqui & Pandey, 2003; Singh, 1993; Singh, 1994; Singhal, 2004; Srivastava, 1995, 1999; Wadkar, 2000). The preceding domain-specific stresses, mostly, are more positively associated with the measures of distress and to a lesser extent, to chronic health conditions.

Psychosocial Resources

Dispositions and personality, and coping styles reflect individual differences in appraisal and response to stressful situations; both these psychological resources have been observed to be associated with the onset and the course of chronic and progressive health problems. Social support is also one of the most significant resources in the battle against stress. It is, perhaps, best thought of as ‘support for coping with stress for well-being’.

Dispositions

Dispositions refer to the personal resources residing in a person. These factors work directly through their association with health and illness, and indirectly by modifying the effects of critical life events or chronic stressors on health and illness. Many personality traits predispose people to emotional distress, such as depression and anxiety, and may lead to maladaptive coping. Research has linked various dispositional factors (e.g., locus of control, field-dependence, ego-strength, optimism, extraversion, thriving, and future orientation) with various indicators of mental health with mixed results (Agarwal, 2003; Ambrose & Karunanidhi, 1996; Hussain & Kumari, 1995; Mishra, 1998; Mookerjee & Mukhopadhyay, 1998; Pareek, 2000; Singh & Prajapati, 1999; Srivastava, 2004). Further, Daftuar and Anjali (1997) found that tamasic disposition generated occupational stress with strong psychological, psychosomatic, and behavioural consequences. Pande and Naidu (1992) examined health consequences of another indigenous dispositional concept anasakti (meaning non-attachment). When faced with stressful life events, those adults who followed anasakti were less distressed and exhibited fewer symptoms of ill-health (see also Naidu & Pande, 1999; Tiwari, 2000). Studies have also demonstrated that type A individuals (i.e., those who are competitive, achievement-oriented, easily-angered, and impatient) are likely to experience greater stress and dysfunctional well-being, with consequences that include coronary heart diseases (CHDs), than their type B counterparts (see Bansal, 1996; Dalal, 2001; Sharma, et al., 1999; Singh & Srivastava, 1999; Thankachan & Misra, 1996b). It is clear that such non-contextualized research focuses primarily on bivariate association between a personal variable and a health or illness variable.

The role of emotions in causation and cure of disease have been examined by Pathak et al. (2000). For instance, the role of trait anger (a component of type A behaviour pattern) and trait anxiety has been investigated vis-à-vis cardiovascular disease (CVD) and non-cardiovascular disease (N-CVD). When compared to patient-controls, higher trait anger (angry temperament and angry reactions) characterized patients with hypertension or peptic ulcer (Ghosh & Sharma, 1998; Sharma, 2003a; Sharma et al., 2004). With respect to modes of anger expression, these patients resorted to greater anger suppression and control of their angry feelings (Ghosh and Sharma, 1998; Sharma, 2003b; Sharma et al., 1995, 2004; Sharma, S., Krishna, A. et al., 1996). Further, both the patients with hypertension and those with peptic ulcer also reported higher trait anxiety (e.g., Chaudhry et al., 1993, 1994; Hoq et al., 1999; Pradhan & Srivastava, 2003; Sharma, 2003a; Sharma et al., 1995, Sharma, S., Krishna, A. et al. 1996; Sharma et al., 2004). In respect of patients with hypertension, Sharma (2003a) further identified trait anger along with modes of anger coping and a situational variable (the negative impact of life events stress) as the most potent discriminator. For peptic ulcer patients, however, trait anxiety (and not trait anger) emerged as the most powerful discriminator along with modes of anger coping and the negative impact of life-events stress (Sharma et al., 2004). The preceding research suggests that life-event stressors, psychological vital signs, such as anger, anxiety, depression, and corresponding behavioural tendencies, can influence the pathophysiology of illnesses like hypertension and peptic ulcer. However, most such cross-sectional research did not control for confounding variables like family history, obesity, smoking, alcohol abuse, bacterium called Helicobacter pylori, the use of non-steriodal anti-inflammatory drugs (NSADs), etc. Nonetheless, these studies highlight the significance of having a perspective with dynamic interaction of dispositional and situational factors.

Coping

Coping is viewed as a cognitive and behavioural effort that may help people in psychosocial adaptation with stressful events. The goal of coping research is to identify the specific ways of coping that are best for managing problems and distressing emotions. This approach has special appeal to researchers and clinicians because it offers scientific foundation for interventions (Mishra & Agarwal, 2003). Coping styles are found to be influenced by family structure, gender bias, type of occupation, etc. (Helode, 2000; Kumar & Murthy, 1995; Pattanayak et al., 1997; Sahu & Misra, 1995). The consistent use of certain coping strategies (dispositional coping) has been systematically related to either good or poor adjustment or well-being (Ambrose & Karunanidhi, 1996; Bhusan & Karpe, 1996). Coping responses to academic and interpersonal stressors of school and college students have been identified as some combination of problem- and emotion-focused strategies including support utilization (Rao et al., 2000; Singhal, 2004). In addition, gender variations have been observed since males use both problem-focused and emotion-focused coping strategies, but their female counterparts utilize emotion-focused coping (Sahu & Misra, 1995; Sharada & Raju, 2001). Moreover, coping strategies of migrants within or outside the country (stress of acculturation) include problem-oriented coping, assimilation, and integration rather than segregation (Nirmala Devi & Krishnamurthy, 2002; Singh & Singh, 1996; Verma, 2001). Recently, Minhas (2003) investigated the coping strategies adopted by Kashmiri migrant children residing in Jammu due to militancy in their native land. They often reported strategies that included daydreaming, compensation, withdrawal, and aggression. All the children largely used emotion-focused coping rather than problem-focused coping. Their coping pathways were similar to those used by their parents, showing the impact of reinforcement by parents. Dispositional coping strategies or coping styles, to the extent they are derivative of higher-level global personality traits are not readily amenable to change. It is for this reason that Dalal and Misra (1999) underlined the need for research to uncover flexibilities in the use of coping strategies. Moreover, collectivistic cultures (e.g., the Asian cultures) lay greater emphasis on social relationships. This has implications for the stress-coping strategies these people employ. However, modern coping research often fails to emphasize this social component, i.e., relationship-focused coping. It is now being increasingly acknowledged that the promise of coping research for providing an empirical basis for clinical intervention has not yet been fully realized.

Social Support

Social support is conceptualized as including both social embeddedness and emotional support that demonstrates to the individuals that they are valued. Social support, either elicited or provided spontaneously, plays an important role in how people deal with life's challenges and threats. Supportive interactions and the presence of supportive relationships in people's lives have been shown to play a major role in their emotional well-being and physical health. Although supportive ties may create dilemmas for both providers and recipients, a sense of belonging to a reliable support system of kin and friends often reduces the risk of disease and enhances recovery from mental and physical illness (e.g., Dalal, 2001; Latha, 1998; Pal et al., 2002; Pradhan & Misra, 1995; Singh & Arora, 1997). Sharma (1999b) has specifically analysed the family as a support system. There are two major mechanisms that explain how social support lessens the negative impact of stress on health and well-being, that is, direct-effect hypothesis and buffering-effect hypothesis. Evidence has been cited suggesting that emotional support would be more likely to have a stress-buffering effect and the connectedness (e.g., network size would be more likely to have direct effects on health and well-being (see Banerjee & Gupta, 1996; Sharma, 1999b; Singh & Srivastava, 1999; Thakar & Misra, 1999). Moreover, the efficacy of social support is likely to be dependent on (i) who is providing the support, (ii) what kind of support is provided, (iii) to whom is the support provided, (iv) the problem for which the support is provided, and (v) when, and for how long, is the support provided (see Sharma, 1999b). Such issues are partly reflected in a recent study by Miltiades (2002) where the effect on the psychological well-being of India-based parents was examined whose adult children had migrated to the USA. It was seen that the availability of alternative support systems (the extended family support, the hired help) did not alleviate the feelings of ‘loss’, depression, and loneliness in such parents. Thus, the appropriateness of a special kind of support seems to be dependent on the match between the type of support and the nature of problem encountered at a point in life course, as also on who provides that support.

Behavioural Contributors

During the last decade or so, there has been increasing awareness of the critical role that behaviour plays in determining the risk of illness or promotion of health. This generated a great deal of interest in understanding the antecedents and consequences of health-related behaviours/lifestyles. Health behaviour pertains to behaviour which has health (or ill-health) as a consequence, not necessarily as a goal. A possible mechanism by which social-structural and psychosocial factors might influence subsequent health is by influencing health behaviours. The following section summarizes the available evidence on the social-structural and psychosocial linkages to health behaviour, and also regarding health-related awareness.

Social-Structural and Psychosocial Linkages of Health Behaviour

Some individuals try to offset stress-induced emotional distress by engaging in health-damaging behaviours/lifestyles. Studies elucidate the cognitive and affective factors associated with specific health-related behaviours including alcohol intake, smoking, substance abuse, diet, etc. Also, because social support reduces adverse effects of stress such individuals are less likely to engage in health-damaging behaviours. Psychosocial links to health-related behaviour are further demonstrated when highly stressed male executives were observed to have higher caffeine and poor dietary intake (Ahuja et al., 1998).

Research has documented the role of stress and/or dysfunctional family as the precursor to alcoholism (e.g., Jiloha & Soni, 1994; Rajendran & Cherian, 1992; Saini & Khan, 1997; Singh & Prajapati, 1999; Stanley, 1998; Suman & Nagalakshmi, 1995) and accident behaviour (Singh, 1998). Further, those with low income and other social indicators are more likely to be drug addicts or drug peddlers (Sen & Pande, 1993, 1994). Individual characteristics, especially externalizing behaviours, are central to the development of substance use and abuse. The general psychosocial profile of alcoholics and/or substance abusers comprises psychological distress, sensation-seeking, dependence, loneliness, depression, anxiety, alienation, negative self-belief, life dissatisfaction, unrealistic life expectations, anomie, acute/chronic stress, gender-privileges, and a relatively lower location in social class (e.g., Bhargava & Bhargava, 1999; Dey & Ray, 1993; Dubey, 1993; Hussain & Vadra, 1992; Maqbool & Hussain, 1993; Mitra & Mukhopadhyay, 2000; Mukhopadhyay & Bose, 1995; Nimmagadda, 1999; Sen & Pande, 1993). Dispositional variables such as locus of control, neuroticism, extraversion, and depression are also found to be important factors affecting alcohol-related intervention outcomes (Saini & Khan, 1997). Further, the most common relapse precipitants for alcoholics include reduced cognitive vigilance as also unpleasant mood state, sensation seeking, difficulty in decision-making and lower social support as evidenced in greater interpersonal conflicts with spouse and other family members (e.g., Malhotra et al., 1999; Singhal & Nagalakshmi, 1992). One consequence of alcohol-related behaviour is the negative impact on marital dynamics and spouse's well-being. Wives of alcoholics report less affectional expression, marital satisfaction, and higher incidence of verbal aggression and violence (Stanley, 1998).

Health Awareness and Behaviour

Health behaviour is influenced by health-related cognitions especially their awareness dimension. Awareness studies are significant since they provide information on the current status of knowledge of people, about etiology of a disease, and lifestyle factors in illness prevention (Parasher, 2000). Moreover, in respect of coronary patients, Latha and Suresh (2002) observed that knowledge and health behaviours/practices are significantly related to each other. Earlier, Jejeebhoy (1998) reviewed research concerning sexual and reproductive behaviour including reproductive morbidity, abortion-seeking and reproductive choice. Other studies have examined the role of factors like religiosity, value orientation, fatalism, women empowerment, and future orientation in family planning behaviour. (Kumar et al., 1997; Pandey & Singh, 2001; Roth et al., 2001; Sinha & Javed, 1996–1997; Sinha & Mishra, 1998; Sinha et al., 1996–1997).

Sex-related myths and unsafe sexual behaviour are seen as precursors to marital distress and life threatening diseases. A large gap has been documented between actual and desired knowledge, belief and practices about reproductive health (Kumar, 1995; Kumar et al., 2000; Tickoo, 1997). Among the out-of-school slum adolescents in Anand district of Gujarat, Biswas and Daftuar (2000) observed gender variation in awareness and concerns about reproductive and sexual health, with males being more aware and concerned about such issues than the females (see also Saini & Sharma, 1999). Also, Suchdeva (1998) observed that female university students rejected the repressive traditional Indian sexual standards relating to pre-marital and non-procreative sex. Further, a widespread lack of basic knowledge in the area of fertility, maternal health, and sexually transmitted disease (STD) has been observed in slum, rural and/or tribal groups (see Bloom et al., 2000; Collumbien & Hawkes, 2000). The major concerns of such men relate to matters of their own psychosexual disorders while health communicators focused on STDs.

Acquired Immune Deficiency Syndrome (AIDS) has affected millions of people worldwide, both through actual infection by the human immunodeficiency virus (HIV) and because of the threat it presents due to ease of transmission through unsafe sexual and other behaviours, attendant physical and psychological degeneration, and its fatal consequences. As no accepted ‘cure’ for this disease has yet been identified, greater attention has been paid towards developing effective prevention through increasing awareness of the virus and promoting low-risk behaviours. A varying degree of a wareness about HIV/AIDS has been observed (e.g., Agarwal & Kumar, 1996; Suchdeva, 1998; Veeraraghavan & Singh, 1999). In a recent study, Chatterjee et al. (2001) found relatively low degree of awareness about HIV/AIDS not only in school boys but in their teachers as well. More than 50 per cent of students and their teachers expressed that ‘isolation of persons suffering from HIV/AIDS would prevent the spread of the disease’. Such a faulty notion might deny the needed support to the AIDS sufferer (see also Kumar et al., 1997). In the context of prisons and a Kolkata slum, perceptions about high-risk sexual behaviour and HIV/AIDS have also been investigated (Poddar et al., 1996; Sundar et al., 1995). Using a qualitative approach with young and adult men and women, Bharat (2000) examined how HIV/AIDS is perceived and interpreted in low income communities of Mumbai city; in spite of high familiarity with HIV/AIDS, several misconceptions and fears about it were observed. A significant gender difference was seen where men, compared to women, conveyed not only greater awareness but also more misconceptions about HIV/AIDS. This study also reconfirmed several HIV/AIDS metaphors and symbols are used in other cultural settings. These included the perception of HIV/AIDS as dreaded, shameful, invited, and ‘othered’ (i.e., not personalized or perceived as a problem of their community despite the prevalence of risk behaviour in their own community); a disease, strongly associated with sex and sex workers, with fatal outcome and andocentric focus. As can be seen, Indian studies that simultaneously link stress, disposition, and social support to health-related behaviours constitute a narrow cut through the vast literature on behaviour and health in Western settings. All the studies reviewed in this section share the correlational and cross-sectional approach. On this account, we cannot delineate the complex causal pathways to health. What can be suggested is that social-structural, psychosocial factors, and health behaviours are all contributors to health. To understand the relative contribution of each, it is necessary to consider their ‘effects’ as net of the other factors, preferably through a prospective research design.

COPING WITH CHRONIC ILLNESS AND EVENTS OF MASS DESTRUCTION

Our second question is among the sick, who suffers, who recovers faster and why. The concept of ‘suffering’ means the experience of pain or agony in crisis situations, which is assumed to be shaped by cultural belief systems pertaining to illness and health (Dalal, 2001; Palsane & Ram, 1999). In addition, ‘healing’ has been conceptualized as gradual recovery from an experience of pain or agony (Priya, 2002, 2004). The consequences of suffering from a chronic illness or events of mass destruction (natural or man-made disasters) may be studied from the perspective of a stressful situation. This stress perspective on a chronic illness or a disaster predicts that the way those affected cope with such chronic and acute micro and macro stressors influence health and well-being expressed in terms of suffering, adaptation, recovery, and QOL (Kothari & Agarwal, 1999). This section examines research related to such issues.

Chronic Illness: Coping and Recovery

Living with chronic illness makes great demands on the capacity of the individual to adapt: preserving a reasonable emotional balance, sustaining relationships with family and friends, and dealing with suffering (pain and other debilitating symptoms, etc.). A chronic illness can be viewed as a major stressful event which is the starting point of stressful conditions characterized by a large number of ‘minor’ events with strong negative (well-being) consequences (Subramanian, 1998).

A group of researchers has addressed the issue of coping with chronic paediatric illnesses (e.g., epilepsy, asthma, conversion disorder, thalassemia, cardiac illness, juvenile rheumatoid). Compared to children from general population, children suffering from epilepsy have a lower psychological well-being or more psychological difficulties such as depression, behavioural problems and conflicts, lower satisfaction, lower self-esteem and less happy. The rate of psychiatric disturbance in children with physical disorders involving brain (e.g., epilepsy) is markedly higher than those with other physical disorders (Malhi, 2000, 2003b; Malhi & Singhi, 1999; Pal et al., 2002; Pradhan et al., 2003; Tripathi & Agarwal, 2000). Also, children with asthma have higher incidence of psychosocial adaptation problems (Agarwal & Pandey, 1998; Malhi & Singhi, 1999; Malhi & Singh, 2002b; Tripathi & Agarwal, 2003). However, children with well-controlled asthma have a relatively good overall QOL (see Malhi & Singh, 2002b). Likewise, children with conversion disorder have significantly higher childhood psychopathology and lower level of adjustment (Malhi, 2003a; Malhi & Singhi, 2003). Other related studies on chronic paediatric illness and well-being outcomes include those on thalassemia (Pradhan et al., 2003), juvenile rheumatoid arthritis (Malhi & Singh, 2002a), kidney and cardiac illness (Tripathi & Agarwal, 2000).

With respect to paediatric health care, the following issues need attention: First, the negative dispositions of the mother caregivers are manifested in greater symptom reporting about their children or the prediction of well-being of the child. The study by Tripathi and Agarwal (2000) highlighted the issue of accepting mother's symptom reporting of their children with chronic illness as influenced by their own degree of neuroticism. Second, the management of medically unexplained symptoms in children requires a collaborative team approach between the primary care physician and the mental health professional (Malhi & Singh, 2002b). Third, enhancing the child's social support network and improving the family functioning (such as expressiveness) to promote mastery reduce the psychosocial impact of chronic illness on the child (Malhi, 2000, 2003a, 2003b). Further, diabetes is a demanding chronic illness that necessitates extensive responsibility from patients for carrying out the treatment. Reviewing evidence of the psychological distress of diabetes, Sudhir et al. (2000) listed patients’ major concerns like future complications, interference in work and social life. Sangeetha and Kalanidhi (1995) and Agarwal et al. (2002) identified coping strategies that are effective in reducing suffering/discomfort among diabetic patients. Further, the major symptoms following the diagnosis of AIDS included depressive mood, adjustment disorder, and cyclothymias (Prasad, 1997).

Cancer is a complicated and chronic stressor; it is not a single event, but a series of stressful illness and treatment-related situations and problems that vary in duration and intensity. Somerfield (1997) provided a multilevel conceptualization of cancer-related stress, i.e., at the levels of diagnosis, treatment, and survivorship. To cope with impending crisis and sustaining the hope of recovery, patients with life-threatening illness like cancer first of all seek causal explanations of their illness and suffering. Through a semi-structured interview, Kohli and Dalal (1998) addressed this question in a study of hospitalized adult cervical cancer patients with rural backgrounds. The findings revealed that these patients often attributed their illness and/or suffering to existing metaphysical factors: fate, God's will, and karma rather than to other factors. Thus, women patients looked for causes which reinforced their existing personal and cultural beliefs. Expected anxiety or generalized anxiety disorders are also noted in cancer patients (Chandra et al., 1998; Dhyani & Patel, 2000; Satapathy & Das, 1997). Patients with breast cancer who were undergoing mastectomy experienced psychosocial strains like socio-emotional, sexual problems, and perceived rejection (Dubey & Agarwal, 2004; Khan et al., 2000). The suffering of patients with leukemia is reflected in their psychiatric morbidity characterized by depressive episodes, generalized anxiety disorder, obsessiveness with illness and other related symptoms (Asthana & Verma, 1998; Satapathy & Das, 1997). Mehrotra and Mrinal (1997) showed that perceived reduction in physical distress and depression (i.e., suffering) in cancer patients was associated with their information processing style of blunting (cognitive avoid).

Studies have also addressed the question of healing and psychological recovery. Gaur (2003) contends that the ‘faith-bond’ between patient and the health professional is a significant factor in healing/recovery. Kohli and Dalal (1998) assert that the acceptance of suffering is the first step towards its cognitive reconstruction and a process of healing. Using narratives, Anand et al. (2001) and Anand (2004) demonstrated how despite a chronic illness or other major life crisis, persons can work through their emotional pain and facilitate psychological healing, which may lead to self-transformation. However, we know very little about the underlying mechanisms by which various healing traditions bring about the intended transformation within the person. As indicated, cervical cancer patients attributed their illness to metaphysical beliefs like karma, fate, and God's will (Kohli & Dalal, 1998). In the same study, however, no clear linkage of such metaphysical beliefs was seen with psychological recovery. Rather, psychological recovery was negatively correlated with attributions to poor family conditions, physical weakness, and stress. The patients rated their doctor as a major factor in recovery. Thus, even if metaphysical beliefs were important as causal explanations for the disease like cancer, they were not associated with recovery beliefs. Nonetheless, the findings of such culturally sensitive studies can form the basis for effective health interventions.

In recent studies on patients with cancer, diabetes, and cardiovascular illness, Agarwal (2003), Dubey and Agarwal (2004), Tripathi and Agarwal (2003), and Upadhyay (2002) found that future-orientation, optimism, perceived control, and relationship with family were associated with greater feeling of ‘wellness’ and life satisfaction. In the context of chronic illness, perceived control and future-oriented outlook have relevance because of the positive focus they create and enable the person to find a meaningful life in adverse circumstances. That is why patient's positive life orientation also emerged as an important factor in psychosocial and medical recovery from MI (Agarwal & Dalal, 1993; Agarwal et al., 1994). Such studies do provide some insights about the possible mechanism by which positive thinking influences recovery from cardiovascular and other illnesses. Agarwal et al. (1994) argued that positive life orientation contributes to high expectation of recovery, sense of personal control, and a positive mood state in an adverse situation. These are the preconditions for mobilizing the internal sources of the patients, and play an active role in recovery process. Along with such dispositional factors, the economic status of the patient positively predicts recovery (Upadhyay, 2002), thereby highlighting an interface between psychological and social-structural variables.

Chronic illnesses need long-term and sustained treatment and care which is mostly home-based (Kausar & Illyas, 2000). A chronic illness affects and is affected by the family context, especially in Indian settings. Thus, family relationships are essentially the most important source of support a chronically ill person can have (Dalal, 1995). As the care providers are mostly women, there is a tremendous emotional and physical cost to caring. Bharat (1995) examined various studies dealing with the acute and chronic psychological pressures that family members, especially spouses, of HIV/AIDS patients undergo. She argued that female partners are more vulnerable than the HIV/AIDS patients themselves are, because the females have to struggle not only as potential AIDS casualities but also as survivors. The presence of disability or chronic illness in children can pose a threat to the well-being of mothers (e.g., Bhan et al., 1998; Dalal & Pande, 1997; Gambhir, 1993; Gupta, 2002; Tangri & Verma, 1992; Tripathi & Agarwal, 2000); parental psychological adaptation to such a chronic illness is dependent on the severity of a child's illness, satisfaction with available social support and the strength of religious beliefs (e.g., Pal et al., 2002). Chakrabarti et al. (1992) and Prema and Kodandaram (1998) have highlighted the severity of the burden experienced by family members (especially the females) of caring for patients in the family suffering major affective disorders. Earlier, Dalal (1995) observed that certain families are themselves in need of support in crisis situations. He emphasized the need to identify such families and to involve professionals in building realistic expectations about the disease and its ramifications. Finally, the individual-based focus of much of such research tends to ignore the gender inequality that is perpetuated by an assumption that family caregiving is naturally the work of women. While reviewing mostly Western evidence on burden of caregiving, Lee (1999) has argued for psychological research that also addresses issues of public policy, rather than the individual woman and her personal capacity to cope. For example, gender inequalities in family caregiving cannot be considered independently from broader issues of gender role socialization.

Coping with Events of Mass Destruction: Disaster

Catastrophic disasters (e.g., earthquakes, communal violence, and cyclones) are traumatic and emotionally overwhelming events of mass destruction with strong and long-lasting negative consequences for health and well-being at the level of individuals and collectives. It is only recently that some attention has been paid to the ‘psychological’ sequelae of such disasters and the required community psychosocial support intervention for the survivors.

In a study of 200 forcibly displaced people for the construction of Tihri dam, Pirta and Agrawal (2000) observed that a majority of these oustees (76 per cent to 96 per cent) had lower psychological well-being in terms of loss of mental peace, increased stress, unsecurity, isolation, loss of identity, etc. Gandevia (2000) studied the earthquake victims in Latur Killari. Reduced family and community support/care contributed to the emotional reactions of the survivors. Lakshminarayana (2003) compiled studies documenting the psychological consequences of disasters in India. These events of mass destruction included the Bhopal gas tragedy (of 1984), the Bombay riots (between December 1992 and January 1993), the Marathwada earthquake (in 1993), the Baripada fire (in 1997); the Gujarat cyclone (in 1997); the Yamuna Pusta fire (in 1999), the Orissa supercyclone (in 1999), the Gujarat earthquake (in 2001), and the Gujarat riots (in 2002). In all these studies, the common theme of psychological distress of the victims/survivors comprised a state of shock, heightened anger, anxiety, depression, helplessness, obsessional paranoid symptoms, post-traumatic stress disorder (PTSD), and other psychiatric disorders. Many such consequences often manifest shortly after such disaster strikes.

Recently, Suar (2004) examined such links between disaster and emotions. Earlier, with respect to the Orissa supercyclone, Suar et al. (2002) identified health and psychosocial problems of survivors in a post-disaster phase which included psychosomatic symptoms, sleep disturbances, new family strains and conflicts, increased interpersonal violence, pessimism, decline in perceived social support, and increased health damaging behaviours like consumption of alcohol and drug abuse. Direct ‘exposure’ to or witnessing a disaster aroused stronger negative emotions of anxiety, terror, disgust, dejection, and grief. When consistently reactivated during the post-disaster period, such emotions found expression in PTSD, depression, and bodily symptoms. In addition to this ‘exposure’ perspective on disaster, Suar (2004) also considered its ‘resource’ perspective. He cites evidence to demonstrate that women, the elderly, the challenged and other disadvantaged sections of Indian society with fewer resources are the most vulnerable and are the worst sufferers in the aftermath of events of mass destruction (see Misra & Jain, 1996–1997). Such social-structural variables provide antecedent conditions for developing PTSD, anxiety, and depression among the survivors (see Bhatt, 2001; Parasuraman & Acharya, 2000; Parasuraman & Unnikrishnan, 2001; Saxena et al., 2003; see also National Centre for Disaster management, 2002, p. 39). Considering Indian psychological wisdom, Suar (2004) also outlines the situational attributes of disasters, negative emotions, and emotional expressions (bhava). He further observes that post-disaster traumatic stress can be captured by adding a symptom cluster of depression to the conventional symptom clusters of intrusion, numbing, and hyperarousal.

In an ethnographic investigation, Priya (2002, 2004) also looked at the emotional, cognitive, behavioural, and social aspects of the impact on 18 families comprising rural and urban survivors of the Bhuj-Kachch earthquake in 2001. He also examined the role of cultural beliefs that influenced the subjective experiences of suffering and healing among these survivors. Priya (2002) found that ten months after the earthquake, its psychological impact was deep and serious in 70 per cent to 80 per cent of the urban families compared to 10 per cent of rural families. It was seen that the belief in the faith that discharging their duties (karma) would lead them to peace and harmony with nature resulted in better healing of rural survivors than their urban counterparts whose life is guided more by the materialistic goals. The author argues that urban life appears not to have provided people with any constructive philosophy or belief system about life to lead them to a ‘cognitive reconstruction’ of the trauma they may face. Priya (2002) also questioned the universal applicability of the diagnosis of PTSD as it is based on the Western cultural discourse, that is, stress or ill-health is an outcome of loss of control over nature. In the later phases of this study, post-earthquake socio-economic changes constituted the context of suffering and healing. Priya (2004) observed that males continued to have higher suffering/lower recovery levels than the females. Such gender variation in coping with disaster indicated that not only were male members in most families frustrated due to economic deprivation (non-receipt of relief package) and the collapse of the social network, but there was a general apathy among them towards the members of their families and the community. The nature of suffering altered as several post-earthquake socio-economic changes in the region added estrangement to loss-induced grief. Thus, Priya (2004) demonstrates how social-structural changes in the post-disaster phase can alter the nature and intensity of suffering and impede the healing process.

ILLNESS PREVENTION AND HEALTH PROMOTION

Health psychology is more than a field of inquiry, it is also intended to promote health and well-being. Given the emphasis on alterations in current lifestyles and behaviour of people, health psychology has the potential to make a unique contribution to health care and rehabilitation through behavioural interventions. Therefore, the third question addressed in this discipline pertains to: how illness can be prevented and health promoted, This section examines the role and contribution of health psychology in this context. The nature, quality, and availability of primary health care services can be an important factor in the success of such illness prevention and health promotion efforts (see Babu et al., 2000). From the point of view of cost effectiveness health professionals also underscore the desirability of integrating mental health interventions with primary care (Ponnuswami, 2000). Illness prevention and health promotion initiatives include—(i) individual-based interventions, and (ii) community-based interventions. The latter targets health-related cognitions, behaviour/lifestyles, and also the changes necessary in the social and physical environment. Thus, effective community-based intervention can also directly counter socio-economic disparity and deprivation through structural approaches. Nonetheless, health psychology focuses on awareness and behaviour change efforts for health promotion. There have been innovations in both individual and community (public health) approaches addressing such concerns.

Individual-Based Interventions

Investigators have documented the benefits for recovery/healing and health of various individual-based interventions such as yoga (Aminabhavi, 1996; Palsane, 1998; Telles & Vani, 2002; Verma, 1996–1997; Wolf, 2001), sports (Joshi, 2002), biobehavioural therapies (Mehta, 1992; Thankachan & Misra, 1996b), and various relaxation and self-exploration techniques (Anjana & Sreedhar, 2000; Krishnaveni & Devi, 1998; Pandya, 1999; Parashar, 1998). Such studies show that much in the Western psychological literature are relevant to issues of mental health in India. Nonetheless, there appears to be little that is immediately and directly applicable to the promotion of positive mental health and well-being. Moreover, lessons from cross-cultural psychology and transcultural psychiatry remind us that culturally insensitive therapeutic help may not be help at all (see Neki; 2000; Sharma, 1994; Veeraraghavan, 2000). It is now well accepted that programmes aimed at prevention of illness and promotion of health must be based on an understanding of traditions, belief systems, patterns of family and community interactions, and other such indigenous resources. Further, indigenous systems of health care are holistic in nature, focus on social construction of health and illness, and are based on the principle of unity of mind and body. Joshi (2000), amongst others, recommends: (i) cooperation between traditional healers and modern practitioners; (ii) treating local resources as assets rather than obstacles to health care; and (iii) paying proper attention to the sacred domains of health care (see also Balodhi, 1991; Rammohan et al., 2002; Sharma, 2004c). The last concern is seen to be a movement toward positive health and well-being (Kapur, 2002; Raghuram et al., 2002; Sridevi & Krishna Rao, 1996).

The concern for sacred domains of health care relates to the topic of spirituality and religion—a relatively overlooked topic in health psychology. Some authors, of late, have emphasized that at least some segments of population are eager for changes in approaches to health behaviour that are based on or are at least consistent with their religious and spiritual beliefs (Smith, 2001). Like health, religion and spirituality are complex and multidimensional concepts. The similarities and differences between them may vary depending on how they are conceptualized and operationalized. Religion is viewed as ‘denominational, external, cognitive, behavioural, ritualistic, and public’ and the spiritual as ‘universal, internal, affective, spontaneous, and private’ (see Richards & Bergin, 1997: 13). Viewed this way religion is an organized social entity, and can be seen primarily as the external manifestation of spiritual experience. Spirituality for some is an attribute of the individual, and pertains to his/her private and affective experiences. Further, various authors agree that these concepts are probably, but not always, interrelated and often are used in an interchangeable manner. Sharma (2004c) examined the efficacy and the complementary nature of certain religious/spiritual interventions (meditation, prayer, and service—volunteering) for health and well-being. Though an essential part of the oriental traditions (the various forms of Hinduism, Buddhism, and Sufi systems), meditation may exist in religious/spiritual forms or even in a non-religious form (e.g., transcendental meditation, TM). Meditation as a primary intervention variable is observed not only as a relief from suffering, but as also providing power over thinking and emotions, not by repressive self-control but by enhanced self-understanding and self-acceptance (e.g., Aruna, 1998; Bhawuk, 2000; Jain, 2003; Khurana, 1996; Kiran Kumar & Raj, 1999; Sridevi & Krishna Rao, 1996; see also Kapur, 2002; Sharma, 2004c).

Healing (recovery) is also seen as a spiritual experience involving an inner sense of well-being, balance, harmony, and peace (Anand et al., 2001; Taylor, 1997). A healing narrative of a middle-aged woman with a major life crisis, was generated by Anand (2004). The process by which the woman worked through her emotional pains was identified. It was observed that progress in healing culminated in self-transformation. Some practitioners also favour the use of meditation as an adjunct to conventional psychotherapy, including the use of psychoanalysis. For example, Kakar (2003) analysed the theory and practice of healing in eastern (oriental) spiritual traditions. He observes that the eastern healing discourse (e.g., meditative practice) goes considerably beyond most traditional psychoanalytic formulations on the nature of empathy in analytic situation. In view of this, Kakar (2003) argues for a place for meditative practice in psychoanalytic education and practice. Prayer is an inherently spiritual or religious activity, and is another self-help health-enhancing activity. Richards and Bergin (1997) cited preliminary evidence suggesting that different forms of prayer (for oneself, others, and for all) may have different associations with outcome variables like life satisfaction and overall well-being. Recently, Anjana and Raju (2002) found that the recitation of the Bhagvadgita (a prayer) contributes positively to personality functioning and QOL. However, the usefulness of prayer either as an independent intervention or as an adjunct to a therapy remains almost uninvestigated. Further, service or volunteering can have both religious/spiritual or non-religious forms. It can also be individual or a collective/community volunteerism. Unselfish actions inspired by religion commonly aim to benefit specific individuals, the community as a whole, or both (Sinha, 1984). Self-less service to others is seen as a way to transcend the egoistic desires promoted by today's consumer culture, and thus can be a predictor of positive health and well-being. Unfortunately, no study has examined service or volunteerism as a significant disease prevention or health promotion variable. Sharma (2004c) further argues that meditation, prayer, and service have a complementary relationship among themselves. Together these interventions can cultivate positive emotions that have the effect of undoing negative emotions and enhance physical and mental health through more adaptive coping (see also Pargament, 1997; Smith, 2001).

Community-Based Interventions

Interventions targeted at and through community not only comprise extensive health awareness programmes but also involve the community per se as an active partner in providing psychosocial care. This section covers macro-level studies on health communication and community psychosocial support (see also Dalal in this volume).

Health Communication

Health care and health promotion are complex human endeavours that demand sophisticated and coordinated use of the message and meaning process. While communication research focuses on messages, psychological research focuses on meanings. Health psychology deals with the issue of how messages and meanings interrelate in the pursuit of health and well-being. Thus, the success of any health programme is contingent upon the efficacy of health communications and ‘informed self-care’ (Dua et al., 2000; Gupta, 1996; Gupta et al., 2001). Recently documented epidemics of communicable diseases like HIV/AIDS resurgent strains of tuberculosis and hepatitis underscore the importance of communication protocols for motivating people to take actions or change behaviours to prevent these highly contagious diseases. Mere health-related ‘awareness’ is not enough (Kapoor et al., 1995); the extent of such ‘awareness’ can provide an indicator of the effectiveness of existing community-health interventions (Ahuja et al., 1998; Bloom et al., 2000; Collumbien & Hawkes, 2000). Surveys among various groups show variations in the levels and nature of sex-related myths, taboos, and misconceptions (Agarwal & Kumar, 1996; Ganguli, 2003; Gomber et al., 1996; Jejeebhoy, 1998; Kumar, 1995; Suchdeva, 1998; Verma et al., 2001). Although a relatively larger proportion of population in poor urban areas knows the most common modes of how HIV is transmitted, there are greater misconceptions related to how the virus cannot be transmitted (Bharat, 2000; Bharat & Aggeleton, 1999). Such misconceptions of causal HIV transmission can be remedied by increasing the level of correct knowledge through information campaigns. The messages should also depict realistic and safe social interaction among ordinary people and HIV-infected persons so that they are reassured that no negative consequences would occur.

Some investigators have studied the efficacy of certain health interventions. The research relates to the impact of (i) sex education on adolescents’ view of human sexuality (Saksena & Saldanha, 2003); (ii) knowledge of mothers on home management of diarroeal and other paediatric illnesses (Mangala et al., 2001); (iii) timely utilization of health services like immunization (Dwivedi & Sundaram, 2001; Singhi et al., 1999); (iv) training competence of rural-based health professionals (Chandra & Sharma, 1998), and (v) the inculcation of healthy lifestyles (Karthikeyan et al., 1998). Following the Indian science of life Ayurveda, Parasher (2000) suggests the adoption and monitoring of a general healthy lifestyle comprising ahara (food), vihara (recreation), achara (routine) and vichara (thinking) to achieve a state of positive health and well-being. Such social analysis of indigenous/local knowledge, attitudes and practices with regard to health and illness should normally precede health campaigns. Kapur and Mukundan (2000) have discussed health care for children from the Indian perspective. They have presented the principles and practices of child care (kaumarbhrtya) on the basis of textual and empirical sources. However, the psychological analysis, for example, of inconsistencies between health awareness, attitudes and behaviour is infrequent (see Agarwal, 1995; Joshi & Lamb, 2000; Kumar et al., 2000; Latha & Suresh, 2002; Suchdeva, 1998).

Television serves as an excellent medium to reach the public with health messages such as campaigns addressing HIV/AIDS. Given television's ability to entertain, inform, and enlighten in a pro-social fashion, it is not an intrinsically evil medium that critics have labelled it. Based on a comprehensive study conducted in 28 villages of Uttar Pradesh, Bihar, and Madhya Pradesh, Agarwal (1995) identified significant issues in the use of mass media for prevention of disease, recognition of symptoms, and health promotion. She also examined the role of mass media and other psychological factors in the formation of intention to acquire health-related information and of actual health behaviours. It was found that the impact of mass media is reinforced when seen in conjunction with factors like social participation in community, reinforcement through interpersonal communication, anticipating changes in life situations, and taking initiatives by the acceptors. Given such findings, Agarwal (1995) cautions that an excessive reliance on mass media without the coordinated support of formal and informal systems in the community may not be suitable for the promotion of health behaviour in rural India. The significance of community involvement in health education programmes is also emphasized by Poddar et al. (1996) and Sukhramani (1998) in their respective studies on AIDS in slum and rural areas (see also Veeraraghavan & Singh, 1999). While suggesting a core activity status for health communication, Gupta (1996) also recommends an optimum mix of various channels of communication (interpersonal, folk and mass media) for delivery of health messages.

Psychosocial Care

Psychosocial care is a broad range of community-based intervention that promotes the restoration of social cohesion and infrastructure, as well as the independence and dignity of individuals and groups. Considered as a highly significant component of disaster management, psychosocial care alleviates suffering, prevents pathological developments, facilitates recovery and long-term rehabilitation of survivors (Aarts, 2000; Murthy et al., 2003). Mental health interventions in disasters offered by institutions in India have been reviewed by Lakshminarayana (2003). The various facets of such psychosocial care include psychiatric rehabilitation, psychosocial first aid (PFA), and training of community level workers. One reason why more stress is experienced post-disaster is that the traditional social network/support is disrupted. The Indian Red Cross Society (IRCS) has developed a model of a psychological support programme (Disaster Mental Health/Psycho-Social Care Programme—DMN/PC), which is grounded in the ‘Continuum of Disasters’ (Ramalingam, 2003). Since the emotional memory of disaster underpins PTSD and depression, a straight social and economic support effort would not be efficacious in reducing them (Suar et al., 2002). This necessitates a comprehensive support intervention programme that includes the provision of emotional, tangible, and information support or some combination thereof (Suar, 2004).

Recently, Perwitt Diaz et al. (2004) put forth a model of psychological support for events of mass destruction in the Indian context. This model provides steps in the delivery of health care, while it also discusses the challenges in providing efficient psychosocial care services. Further, a list of 12 psychosocial manuals has been provided which addresses the psychosocial needs of children, adolescents, families, schools, and communities. Such material development efforts, including that of the IRCS, help community volunteers, facilitators, and teachers to identify strategies that need to be developed to cope with an event of mass destruction. In addition, Suar (2004) recommends group meetings, and collective physical and spiritual activities in post-disaster that could reduce the cue- and/or data-driven trauma. Further, psychosocial support as a long-term proposition should be addressed by government organizations in the case of individual needs and by non-governmental organizations in terms of community level work (see Lakshminarayana, 2003; Murthy 2002). Finally, efficacious health interventions ought to have both multidimensional as well as multilayered perspectives (see Sharma, 2002; 2004a for related arguments).

OVERVIEW AND ANALYSIS

Given the multidimensionality of health, its study has been pursued with diverse emphasis. Further, a wide range of samples and health-related variables have been considered for explaining health-related outcomes. Together with diverse methods, such practices often create problems in the comparison and integration of findings. Nonetheless, the preceding review has shown that social-structural, psychosocial, and behavioural factors are significant contributors to the status of health and illness. It has been demonstrated that levels of health and illness are jointly determined by social structures of inequality, differences in health-related behaviours, and psychosocial factors including stressful life events, chronic stressors, and deficiency in psychosocial resources. It is also evident that psychosocial and behavioural factors have both direct and mediating effects on health- and illness-related outcomes. As such health inequalities can be understood to be resulting from an accumulating cascade of stressful life experiences from childhood to adulthood that directly, or through lifestyles, leave their imprint upon people and communities. Studies also emphasize that psychosocial experiences of the people and their lifestyles are patterned by social-structural variables and processes. The importance of social-structural factors in people's lives, therefore, is too strong a theme to be ignored. Within the above-mentioned three broad domains, researchers, however, laid greater emphasis on causation and recovery from illness than on illness prevention and health promotion initiatives. A significant development has been the study of the meaning of health from the perspectives of people from varied socio-economic and cultural backgrounds. Researchers have also addressed the cultural beliefs and explanations shared by people from diverse groups about their health and illness, which in turn are presumed to have a significant bearing on their health behaviour. The investigations depict discernible positive shifts such as (i) the samples studied now encompass the poor, the rural, the tribals, women, and other disadvantaged sections of society as well as the sick; (ii) greater attention is being paid to the psychosocial and coping aspects of medical illness and care; (iii) a larger concern is being evinced in the social-structural and behavioural factors; (iv) the study of macro-level issues like coping with events of mass destruction has received attention; and (v) the use of qualitative methodologies is increasing.

Notwithstanding such positive developments, research in the area of health psychology, mostly, continues to be reductionistic in theory, clinical in focus, and individual-centred in approach, with far less attention paid to its contexts. Because of a one-sided clinical focus, the use of markers of negative affectivity and a predominant study of health-damaging behaviours, some scholars suggest that health psychology in its current form may be renamed as ‘illness psychology’. Like psychology in general, health psychology also continues to look upon behaviour as regulated at an individual level, neglecting the regulatory importance of variables situated at supraindividual (social, environmental) levels (Marks, 1996). Despite some promising attempts at indigenization, a limitation of current research has been the continued lack of attention to the economic, cultural, and socio-political conditions/contexts that contribute to health and illness. Not only do lives make sense in a context, different socio-cultural and economic contexts have to be a part of explanation. There is little work explicitly focusing on maintaining and promoting health (i.e., on the sub-discipline of behavioural health). In this context, the importance of family for promoting health behaviours remains unexplored.

The majority of the studies are either non-ecological/correlational, or else employ cross-sectional/case-control designs in which psychosocial characteristics of individuals with or without a specific illness or behavioural disorder are compared. Moreover, confounding variables are not controlled or remain unaccounted. There are inherent limitations in such research. The correlations between self-reports of psychosocial factors and health behaviour/health could be inflated by methodological artifacts. Although statistically significant associations, regardless of their magnitude, often have theoretical importance, research on health issues is essentially driven by a practical concern. For instance, the overwhelming goal of reducing unhealthy behaviours and thereby improving the public health makes effect sizes (i.e., estimates of the strength of association) important. Moreover, because psychosocial variables can be influenced by the development of illness, cross-sectional designs are quite susceptible to ambiguity about the direction of causality and other threats to internal validity. Thus, anger could reflect a consequence of illness. The use of prospective designs is the answer to such methodological issues. The preoccupation of health psychologists with the strategy of relying on ‘dispositional’ variables continues. Such investigations at best can provide the psychological profile of a person. Even if the ‘profile’ is accurate, the question still remains: what next? Also, as Dalal (2001) had cautioned ‘the search for dispositional factors may result in blaming the victims for their poor health, even if in a dispositional sense’ (p. 398). The moderating role of individual and situational variables in health and well-being has not been fully explored. Researchers have paid little attention to explain the processes that underly the links of social support with health and well-being. Most of the research has dealt with the consequences of receiving support than on the consequences of providing it. Existing data is not sufficient to convince that social support interventions are effective modes of health promotion. Not only is there a lack of intervention research that is adequate from a scientific perspective, but there is also a lack of evidence on the impact of social support interventions on variables critical to public policy decisions—impacts such as reduced incidence of illness, lower medical costs, and reduced mortality (see Sharma, 1999b, 1999c).

While much has been written about the psychological sequelae of life-threatening illness such as HIV/AIDS and cancer, little is known about the specific strategies such patients enact to manage the negative emotions to minimize suffering in their lives. Yet such information could greatly inform the development of supportive interventions that would enhance the mastery of this adaptive task and others, like treatment adherence, which may be impeded by emotional distress. Also, the relationship between the patient and the health care professionals is an underemphasized social context influencing adaptation/coping. The evidence relevant to the issue of behaviour and health is also predominantly dispositional. The health behaviour of individuals is a less explored frontier of health psychology. Behavioural health involves helping currently healthy children and adults so that they remain healthy. Barring some recent attempts, coping with events of mass destruction (disaster) is yet another neglected field of health psychology. Though traumatic stress is universal in post-disaster, some researchers argue that its emotional expressions may have commonalities and differences across cultural groups (see Sharma, 2004b; Suar, 2004). The instruments for study across cultures are required to pass the acid test of ‘measurement invariance’. The absence of studies on physiological mechanisms that may connect psychological variables to the illness process, such as cardiovascular reactivity and immune competence (e.g., Panjwani et al., 1999) demands urgent attention. The preceding review also shows that the research base is not satisfactory in areas such as health communication, the role of religion and spirituality in health, and the development and empirical evaluation of culture-sensitive psychosocial interventions for medical and other problems. Given the philosophical orientation and the level of religious involvement across Indian society, research on the topic of religion/spirituality seems notable in its scarcity. Smith (2001) discussed the possibility of enhancing the efficacy of established psychosocial interventions by the addition of the religious and/or spiritual component. The issue of religion/spirituality and health is also linked with another neglected issue of cultivating positive emotions. Moreover, we still need to know more about the effective treatment of a variety of health behaviours or problems in which psychological issues are relevant. In general, research has not matured to the point at which it can provide a clear foundation for intervention. A clinical use of any intervention lacking in empirical support is potentially problematic. In the best of circumstances, empirical evidence has to guide practice even if it cannot guarantee effectiveness.

FUTURE DIRECTIONS: CHALLENGES

Marks (1996) argued for a new agenda in which ‘health psychology should accept its interdisciplinary nature, venture more often out of the clinical arena, drop white-coated scientism, and relocate in richer cultural, socio-political and community contexts of society’ (p. 19). In order to fulfil its potential, health psychology must become more interdisciplinary in nature, examine variables at different levels of analysis (individual, family, work site, and community) and study health promotion and maintenance in addition to illness. In the pursuit of its goals, health psychology cannot ignore (i) individual lifestyles, (ii) gender differences, (iii) social and community factors, (iv) living and working conditions, (v) general socioeconomic, cultural, and environmental conditions, and (vi) interactions among these factors when attempting to understand health and illness. There is now a growing realization that health psychology can greatly benefit by examining (and utilizing) health systems of tribal and traditional societies. Such a premise has exciting interdisciplinary research possibilities along with social anthropology and medical sociology. Dalal (2001) also pointed out that social customs and rituals associated with health and illness and indigenous practices provide many worthwhile research possibilities. Large-scale projects are needed on the meaning of health, traditional, health beliefs and practices, thereby not only linking cultural context to health issues, but also taking into consideration social, economic, and political contexts. With respect to suggestions for future research, Sharma (1999b) and Verma and Kaur (2000) highlight certain issues like the use of multiple (positive as well as negative) markers of physical and mental health, gender-related concerns, ethics, and a simultaneous evaluation of dispositional and situational variables, coping strategies vis-à-vis health and well-being. Health psychologists are also required to address the issues of psychosocial and psychosomatic dimensions of women-specific life-cycle challenges (e.g., childbirth, infertility, premenstrual disorders, menopause, obesity and ageing) and their possible life-threatening chronic conditions (e.g., breast cancer, cervical cancer, and cardiovascular health). For instance, infertility is considered one of the most acute/chronic stressful situations for a women. It is not just a loss of function of an organ system, it is also a loss of relationship, prestige, self-esteem, security, and something of symbolic value. As such, infertility and its consequences of well-being for women can be investigated from a stress perspective. Gender norms and values lead to gender differences and inequalities. Women constitute a more vulnerable group as they take most of the burden of bearing and rearing of child and household management. The problems related to child-birth, abortion, STDs, and gynaecological health take a heavy toll on women's health. Further, Vindhya (1999) suggested a social constructionist approach to meaningfully understand and reconstruct female mental health problems.

Moreover, the capacity to experience positive emotions remains largely an untapped human strength. We need to identify intervention strategies for building personal strengths, resilience, and well-being to the extent that they cultivate positive emotions. One possible way to cultivate positive emotions and well-being is through religion and spirituality. After discussing the multidimensional nature of religion and spirituality, S. Sharma (2004c) argues that religious or spiritually oriented interventions like meditation, prayer, and service have a complementary relationship among themselves, and together these interventions cultivate positive emotions (e.g., joy, contentment) that have undoing effects on negative emotions (anxiety, depression, anger). The paucity of research on religion/spirituality and health is striking, and thus necessitates a comprehensive research effort to determine their relative efficacy on various health and other outcome variables for persons with different religious- or spiritual backgrounds as well as for those who do not consider themselves religious or spiritual (see also Smith, 2001).

Trying to clarify why a religious or spiritual factor, among other factors, may influence health and well-being presents another genuine challenge. Until such time when the constructs of religion and spirituality can be reliably operationalized, it will be difficult to move the examination of the link between religion or spirituality and health from the vulnerable current state of anecdotal collections and apparent associations to a more meaningful examination of causality and prediction. Moreover, Richards and Bergin (1997) have identified ethical concerns and dangers regarding the use of religious/spiritual interventions, including the danger of usurping religious authority or engaging in questionable ‘priestcraft’, trivializing the sacred, and imposing the therapist's religious or spiritual values on clients. Evidence is also needed to determine when, how, and for whom religious or spiritual interventions could be included in treatment regimes with beneficial effects. One of the most important and significant dimensions of human experience and emotional life is happiness. The question why some people are happier than others is the central goal of a comprehensive positive psychology. Lyubomirsky (2001) observed that chronically happy and unhappy people differ systematically in the particular cognitive and motivational strategies they use. She also discussed promising research directions for positive/health psychology in pursuit of the sources of happiness as well as the prescriptions for enhancing well-being. This research area requires further exploration in the Indian socio-cultural and economic contexts. Research is needed to determine the role of chronic socio-cultural/psychological stressors (e.g., poverty, chronically unequal or insecure neighbourhoods) in interaction with psychological risk factors in the frequent triggering of physiological stress reactions and behaviour patterns that are thought to contribute to illnesses. A biopsychosocial perspective on such illnesses can provide a valuable model of understanding the interaction among socio-economic, medical (e.g., viruses, bacteria), psychosocial and behavioural or lifestyle factors in causing such illnesses. Such developments need to collaborate with other disciplinary perspectives such as behavioural medicine and behavioural health. Multidisciplinary perspectives and the corresponding emphasis on beliefs, behaviours, and environmental factors aim at developing alternative paradigms to understand the cause, care, and cure of illness and promoting health. Health psychologists can find ways to help currently healthy citizens to prevent illness and maintain health through health behaviours/health lifestyles, that is, by a variety of self-initiated individual and shared activities (e.g., regular exercises/yoga; proper sleep and rest habits, refraining from smoking or abusing drugs, alcohol; reducing their salt- and dietary cholesterol intake).

Further, coping with events of mass destruction has been a neglected field for heath psychologists. As such, it provides exciting research challenges and possibilities. Further research could deal with material development, fostering individual and community resilience, the use of the ethnographic approach, development of psychological first aid (PFA), and identifying interventions to deal with traumatic stress such as psychosocial care. Suar (2004) calls for a careful process documentation of successful post-disaster managements. Such an analysis can inform how resilience can be enhanced and vulnerability reduced for rebound and transformation of survivors (individuals, families, and communities).

Given the research emphasis on health promotion and the importance of disease prevention (e.g., AIDS), it is surprising how little is known about the predictors of adolescent health. This may be due to the perception that adolescents are healthy in general and it is premature to study their health problems (see also Broota & Misra, 1997). Yet, lifestyle behaviours that contribute to health (e.g., regular exercise, good eating habits, adequate sleep, and abstaining from smoking tobacco) originate long before disease outcomes are evident. Future research needs to study the development of healthy habits or lifetyles as well as prevention or reduction of unhealthy behaviours. Both the impact of ongoing lifestyles or behaviours on health, as well as the influence of health and illness states on psychological factors need to be explored. Also, psychological linkages in areas such as psychoneuroimmunology, pain, cardiovascular disorders, cancer, and HIV/AIDS are required to be more clearly defined.

The relative importance and determinants of various health behaviours or lifestyles are likely to vary across a life span and as functions of social-structural variables like gender, SES, ethnicity, and psychosocial factors. Understanding such influences on health behaviour, the process of change in health behaviour, and determining the effectiveness of related interventions represent an essential part of the agenda for future research. Eventually, a systematic and cumulative body of evidence describing various factors that affect health behaviour could guide the development, evaluation, and practical implementation of risk reducing preventive interventions. Health psychologists also need to address the macro level issues of community health. The study of community attitudes, beliefs, and practices remains important in the light of policy changes in the direction of community health care. In this respect, it is now clear that any community-based or nation-wide health promotion programme would bear only marginal results unless it is backed by appropriate communication strategies that is, it provides health information in easy, understandable form to motivate the development of an attitude of healthy living. Consequently, health communication becomes an important issue for research. The challenge lies in the development of programmes communicating information keeping in view factors like audience segmentation (based on demographics), the use of celebrities in transfer of illness prevention messages, and balancing educational messages with the entertainment presentation elements (edutainment).

The health scenario in India presents a challenge before health psychologists. There has been a rapid expansion of health care infrastructure and medical colleges. This has brought down the infant mortality rate to 85/1000 and enhanced the life expectancy from 32 years in 1947 to 61 years in 2001. After adopting WHOs call for ‘Health for All by 2000’, India has been engaged in large-scale expansion of primary health centres (PHCs). Special attention was paid to maternal and child-care, family welfare, and hygiene education (see Mukhopadhyaya, 1993). In 2001, the Government of India declared a new health policy with the main goal of achieving an acceptable standard of good health of the general population. In particular, the policy made provision to strengthen information, decentralize health care delivery through Panchayati Raj, set up national accounting services and regulate private practice. Unfortunately, adequate mechanisms have not been worked out to translate these laudable goals into practice. The health sector was opened up to private enterprises with the hope that through the monitoring and regulation of the services provided by them, the resource crunch in this sector would be reduced.

Given the increasing focus on quality and the social–cultural sensitivity of research endeavours, we conclude that the future of health psychology in India appears more promising and exciting than its past and present.

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