Social and cultural interpretations of risk
While the cognitive psychological approach has been very influential, it has also been criticized for concentrating too much on individual perceptions and interpretations of risk. Some psychologists, anthropologists and sociologists have argued that, since individuals are not free agents, risks can best be understood as a social construct within particular historical and cultural contexts and within groups and institutions, not only at the individual level (8). These disciplines start from the belief that risks should not be treated independently and separately from the complex social, cultural, economic and political circumstances in which people experience them(30,31). Different groups of people appear to identify different risks, as well as different attributes, depending on the form of social organization and the wider political culture to which they belong(32)
Although it is widely accepted that the political and economic situation at a macrolevel is a strong determinant for many risk factors, microlevel studies can examine how such factors are perceived and interpreted rationally within a given local context. Microlevel studies can also be very useful in explaining certain apparent behaviours that do not appear to be rational to the "external" public health observer. For instance, although lay people may be well aware of risk factors for coronary heart disease, they also have their own "good" and rational reasons for not following expert advice on prevention (33). Thus the context in which people find themselves also largely determines the constraints they face in trying to avoid risks and the length of time over which risk can be discounted. It is an irony, however, that people living in wealthy and safer societies, with their high living standards and longer life expectancy, appear to be even more highly concerned about risks to health than people living in poorer and less safe communities. This is particularly the case with highly uncertain and highly dreaded risks.
From the cultural perspective, therefore, the type and kind of risks, as well as a person's ability to cope with them, will vary according to the individual's wider context. For instance, risk perceptions and their importance can vary between developing and developed countries, as well as with such variables as sex, age, household income, faith and cultural groups, urban and rural areas, and geographical location and climate (for example, see Box 3.4).
Box 3.4 Perceptions of risk in Burkina Faso
Social scientists frequently argue that risks can not be considered "real" outside their sociocultural context. However, research on health risk perceptions and behaviours has often focused only on a particular disease, such as HIV/AIDS, tuberculosis or malaria, and has only rarely looked across several domains and development sectors. For example, as well as risks from diseases, inhabitants in rural Burkina Faso live constantly with risks from drought, food insecurity, endemic poverty, and lack educational facilities and health services.
A study in 40 villages examined risk perceptions in relation to health, health care, economics, agriculture and climate. Subsistence agriculture and pastoralism were the main economic activities of the mixed ethnic population. Using qualitative research methods and focus group discussions, 12 important risks were identified; their perceived severity and people's vulnerability, i.e. the chance of their happening during the coming year, were assessed.
As one focus group participant said: "We have two main sources of risk: hunger and illness. In the dry season, November--February, we face soumaya (malaria) which is due to the wind and cold. Cough is due to the Harmattan winds and dust. In the hot season, March--April, we face headache due to the heat. In the rainy season, May--October, we face diarrhoea and stomach-ache due to hunger."
HIV infection was ranked as the most severe risk but it was placed twelfth in terms of personal vulnerability. In terms of perceived severity, the next four risks were a lack of rain, becoming mentally ill, being struck by lightening, and a lack of funds to buy medicines. Malaria was ranked lowest for severity but first for the chances of it happening during the next year. After malaria, the next four perceptions of vulnerability were a lack of funds for medicines, snake-bite, becoming ill from tobacco smoking, and a lack of rain.
The study found an elaborate knowledge of risks in a number of domains for which the local people felt themselves to be personally at risk. Given the complexity of living conditions in the African Sahel, health risks cannot be seen in isolation from other domains such as climate, the economy and society. These all form part of a larger local discourse on the problems, difficulties, dangers and risks related to life in general.