Life contexts and health-related selves in old age Perspectives from the United States, India and Congo/Zaire.(Statistical Data Included)

1. Introduction

Gerontological studies on the meaning of aging have found that individuals often associate aging with losses in health and psychophysical functioning. Since the aging process is commonly believed to be manifest in terms of physiological changes, i.e. changing skin texture, reductions in eyesight, muscular flexibility and strength or a heightened susceptibility to illness, such a focus on losses in health in later life seems self-evident. However, gerontological studies on the meaning of aging have mainly been carded out in a North American or Western European context. A few cross-cultural studies have found that even though physical status is a relevant criterion in defining old age in cultural communities as diverse as the !Kung in Botswana, Hong Kong Chinese, and college-educated Americans, the specific meanings attributed to biological decline differ between societies (Blok, 1996; Keith et al., 1994; Shweder, 1998; Van der Geest, 1998; Westerhof & Dittmann-Kohli, 1997). In this article we will study the meaning of health in later life in three largely different contexts: the United States, India, and Congo/Zaire. Since there have been few systematic cross-cultural studies in gerontology (Fry, 1996), such work dealing with cross-cultural differences on the meaning of health in later life will provide more knowledge about the universal and culture-specific aspects of aging.

There is a second reason why such a study is important. The association between aging and biological decline appears so self-evident from a North American or Western European perspective that this view has been incorporated in scientific gerontological theories. Even though gerontologists have argued that aging is a biological, psychological, and social process, many claim that the gerontological field is dominated by medical sciences. Images of aging as biological decline have even gained scientific status, for example, in the so-called `deficit' model of aging (see also Katzko, Steverink, Dittmann-Kohli, & Herrera, 1998). This model holds that aging primarily involves coping with or adjustment to a wide range of losses in life, especially in the domain of physical functioning. When we find that the meaning of biological decline differs between cultures, one might question whether such gerontological theories are as universal as they sometimes pretend. In other words, it might be the case that gerontology makes implicit assumptions about the aging process which in fact mirror particular cultural meanings of aging (Fry, 1990). Thus, incorporating culture into views about perceptions of biological aging can only enhance our understanding of the personal salience of age-related changes in perceptions of health and their consequences for older individuals.

In health research the biopsychosocial paradigm places the person at the center of a hierarchy of systems which includes microlevel systems (molecular, cellular, and organs) as well as macrolevel systems (social structures, like medical systems for curing diseases and family and community systems for caring for the ill). Contrada and Ashmore (1999) have called for more research on the dynamic interplay between self-systems, physical health, and social systems from this perspective. Hence, a theory is needed that relates a psychological view on self-systems to biological and social systems. In the following we first describe our psychological perspective on the self-concept which takes into account biological and social structures. We then discuss variations in diseases and in social structures with regard to caring for and curing the ill in the United States, India, and Congo. In the Method and Results sections we describe our study on health-related selves. In the Discussion we will interpret our findings in relation to the life contexts described in the Introduction and reflect on the relations between body, mind, and society.

1.1. Semiotic subjects

Traditional psychological theories have conceptualized the self mainly in terms of self-esteem or personality traits. Such conceptualizations of the self separate mind from body and individuals from social contexts. Since they often failed to emphasize that human selves are both embodied and social, they have been criticized for reproducing specific Western concepts of the person at the level of scientific theories (Kempen, 1996; Sampson, 1988). Furthermore, by a priori separating the self from the body and the social context psychologists have had difficulties in bringing them together again. An approach is needed which goes beyond the definition of the self in terms of self-esteem and personality and provides a theoretical integration of the embodied and social nature of the self.

Such an approach can be found in the notion of individuals as `semiotic subjects' who strive for meaningful interpretations of themselves in relation to their life world (Shweder & Sullivan, 1990). From this perspective, selves can be recursively directed towards their own psychological functioning, as self-contained views of the self would have it. They can also be directed to aspects of one's life context that are personally relevant to a subject. As James (1890/1983) already observed, self-concepts do not only refer to the psychological `me' but also to what is considered `mine.' One's health status might be a personally relevant aspect of life, just as well as activities, social relations, material living conditions, or society at large (Dittmann-Kohli & Westerhof, 2000). Furthermore, individuals as semiotic subjects do not only attribute meaning to themselves in their environment in a reactive way, but they also proactively anticipate future developments. Hence, self-concepts do not only refer to meanings of present states and conditions (`real selves'), but also to beliefs about how these might be in the future (`possible selves'; Cross & Markus, 1991). To capture this widened concept of self, the concept of personal meaning system was introduced (Dittmann-Kohli, 1995). In the following we will first discuss how health can become part of self-concepts and then explain our position with regard to self, culture, and life contexts.

1.2. Health-related selves

Studies have shown that health can become part of the self-concept in a number of different ways (Cross & Markus, 1991; Hooker & Kaus, 1994; Westerhof & Dittmann-Kohli, 1997; Westerhof, Kuin, & Dittmann-Kohli, 1998). Health-related real selves refer to health and illness in general and also to aspects of psychophysical functioning, such as being fit, strong, mobile, and cognitively competent. Real selves do not only refer to losses in health and psychophysical functioning, but they may also include positive cognitions such as feeling healthy or describing health as an important value. Health-related possible selves can comprise hopes for maintenance of health and psychophysical functioning, intentions for healthy behaviors as well as fears for illness. Health-related possible selves may also include references to the consequences of health declines, especially with regard to the possibilities of continuing one's activities, to issues of care (being autonomous or receiving support), and finitude of life. These studies (Cross & Markus, 1991; Hooker & Kaus, 1994; Westerhof & Dittmann-Kohli, 1997; Westerhof et al., 1998) suggest that experiences and anticipations of illness call for an adaptation of the self-concept, in which health can become a relevant and important aspect of one's self. From a psychological point of view such a transformation is needed in order to maintain well-being and self-esteem (Brandtstadter & Greve, 1994).

1.3. Self, culture, and life contexts

In cross-cultural comparisons psychologists have often treated culture as an independent variable which somehow influences the psychological make-up of an individual (Church & Lonner, 1998). In such studies culture is often defined in terms of shared values. This conceptualization of culture and self suffers from two drawbacks. First, culture and self are a priori conceptualized as two distinct entities so that it will always be difficult to bring them together. Second, values are almost always derived from similarities in individual cognitions or behaviors. When one subsequently wants to explain individual cognitions or behaviors in terms of values, one risks ending up with redundant explanations.

To avoid these problems, we do not conceptualize culture and self as distinct entities. Shared patterns in self-concepts are already cultural and cannot be explained in terms of culture. The main aim is not to characterize cultures in terms of values, but to understand how people invoke values in giving meaning to themselves and their lives (Edwards, 1995). Values are not distinct entities, but they get substantial meaning when people reflect about themselves and their life world (Westerhof, Dittmann-Kohli, & Katzko, 2000). Hence, it can be expected that similarities in meaning patterns are at least to some extent the result of similarities in objective life contexts. First, in construing health-related selves, people will take into account what is normal at a certain age or what can be expected in the near or far future (Westerhof et al., 1998). Second, social scientists have described social systems, like medical systems, in terms of monitoring and disciplining individuals (Lock, 1999). Hence, social systems may have an effect on self-concepts. In the following we will describe differences between the United States, India, and Congo in terms of biological decline and social structures for curing and caring for the ill. Understanding such differences is critical to the interpretation of health-related selves as being intertwined with life contexts.

1.4. Biological decline and social systems in the USA, Congo, and …