In South Africa, English is only the sixth most common language spoken within households. But it’s dominant outside the home, including health and medical contexts.
Communicating information relating to health in South Africa requires careful consideration of the cultural context in which this information is to be received. Clinicians must think about this to enhance their relationship with patients and the patient experience.
The COVID-19 pandemic showed the need to communicate concepts of health in ways that the public understands.
It matters, too, when talking about mental health – a field often entwined with people’s cultures and histories, and where outward symptoms might not show. South Africa has come a long way in understanding the struggle of language within psychiatric or mental healthcare. But some concepts are still only vaguely understood by the general public. This is not just true for poor mental health – like anxiety and depression – it is also true for good mental health.
Flourishing is one way to think about good mental health. Flourishing as a concept involves what it means to live a good life or a life worth living. Flourishing is an old concept. But in recent years, interest has grown in how flourishing relates to health. Most of the published research, however, is overshadowed by western ideals and concepts, mainly pointing towards internal mechanisms such as personal traits for flourishing.
We set out to understand what flourishing means by way of a deep dive into studying real people and cultures in South Africa. Flourishing is related to people’s lived experiences, which differ from place to place.
Recognising how people conceive flourishing in relation to, or in spite of, a diagnosed medical condition can help clinicians grasp why and how patient perceptions of health may not always align with medical terms. Such local understanding can transform how clinicians frame clinical decisions and weigh the impact communal resources and relationships may have on how patients are cared for, or feel cared for within clinical spaces.
Ukuphumelela in Soweto
As we started our second year of a study of stress and chronic illness, we realised that people wanted to talk about how they conceptualised good health as much as they wanted to explain what caused them to become sick.
We interviewed 30 people in Soweto who had expressed interest in discussing what it means to live a good life, a flourishing life. They were a balance of men and women. Most were middle class and middle aged (around 45-50 years old), and relatively healthy.
Soweto is an urban area of more than five million people. It is heterogeneous in terms of housing, language, occupations, and living standards. Speaking IsiZulu, the most commonly spoken language within South African households, we found that flourishing was largely a social concept and has personal attributes. The people we spoke to used the IsiZulu word ukuphumelela (roughly translated as “becoming victorious”) when speaking about doing well despite obstacles.
Many people used their personal journey to describe how they flourished (or not), and how they defined ukuphumelela. We found ukuphumelela involved three elements: material or structural factors (like money or financial security); internal or personal character (like discipline); and social dynamics (like reciprocity and caring for others).
One young man explained:
I can say it’s a person who’s not from a good background … Managed to finish school after all those worst case scenarios so now he’s made it … He’s just started a family, got married and we’ve all witnessed that. He now drives fancy cars. He looks after his siblings and he has renovated his home so that it shows he’s made it in life.
A woman in her early thirties explained ukuphumelela in terms of the term ubuntu, generally understood as meaning “a person is a person because of other people”. She said it was important to her to help others, despite her own limited means. It underscores the idea that the self extends beyond an individual to include their community.
These findings show that the ideas people use to describe good mental health are not universal.
Our findings showed that people in Soweto defined flourishing by both individual and collective elements. Individual elements include things like determination, faith in God, and overcoming challenges. Often these individual characteristics were bolstered by structural elements like having an opportunity to pursue a good education and have enough money to cover basic needs.
Also connected were collective elements, such as having strong mentors and caring for others. Flourishing is not just about what an individual becomes in their pursuit of a good life but also the impact they have on the people around them. In this way, many people described flourishing not as an end point or goal, but a journey.
Good life and health
Recognising how people think about themselves in relation to others, and what it means to live a good, meaningful, and flourishing life, is crucial for understanding health.
Speaking the language of good health is also an important element of understanding, designing programmes for, and elevating the health of people and populations.
This research emphasises the social and relational aspects of health that could make the clinic a poor solution for fostering good public health. Investing in churches as places to gather, or mentorship programmes through schools and community centres, may facilitate improved health and well being in meaningful ways.
Without understanding ukuphumelela – what fuels or impedes someone to flourish – health promotion will struggle to serve the people who need it most.
Lindile Cele, Research associate, SAMRC Developmental Pathways for Health Research Unit, University of the Witwatersrand; Edna N Bosire, Postdoctoral Research Scientist, Georgetown University (USA) & Kamuzu University of Health sciences (Malawi); Researcher, DPHRU, University of the Witwatersrand (South Africa) & Brain and Mind Institute, Aga Khan University, East Africa., University of the Witwatersrand, and Emily Mendenhall, Professor, Georgetown University