Читать книгу Health Psychology - Michael Murray - Страница 77

If inequalities can be reduced at all, the evidence suggests that this will only happen by adopting a thoroughly multi-layered approach. Dahlgren and Whitehead (1991) identified four different levels for tackling health inequalities:

 Strengthening individuals.

 Strengthening communities.

 Improving access to essential facilities and services.

 Encouraging macroeconomic and cultural change.

These four levels correspond to the four layers of influence in Whitehead’s ‘Onion Model’ of the determinants of health outlined in Chapter 1 (see Figure 1.5). Extra microsystem and mesosystem levels, as in Bronfenbrenner’s model, could perhaps be added to Whitehead’s list. Psychologists do not usually talk quite so simplistically about ‘strengthening’ individuals; they analyse the personal characteristics and skills associated with positive health (e.g., self-efficacy, hardiness, sense of coherence, social skills). Developing interventions aimed at individual health beliefs and behaviours is a core feature of psychological theory, research and practice.

Interventions aimed at tackling inequalities at an individual level have shown mixed results. There are four possible reasons. First, people living and working in disadvantaged circumstances have fewer resources (time, space, money) with which to manage the process of change. Second, health-threatening behaviours, such as smoking, tend to increase in difficult or stressful circumstances as they provide a means of coping. Third, there may have been a lack of sensitivity to the difficult circumstances in which people work and live that constrain the competence to change. Fourth, there has been a tendency to blame the victim. For example, cancer sufferers may be blamed for the disease if they are smokers on the grounds that they are responsible for the habit that caused it.

Overall, efforts directed at the individual level have been inconclusive and small-scale. Because most health determinants are beyond the control of the individual, psychological interventions aimed at individuals have limited impact on public health problems when considered on a wider scale. There is a need for psychologists to work beyond the individual level, with families, communities, work sites and community groups. We are not alone in thinking that structural changes at a societal level are ultimately required if the prevalent inequities are ever going to be reduced. Anything else is simply tinkering, a case of ‘fiddling while Rome burns’.