Lay Health Beliefs (LHB):

Although it may appear that medical knowledge is dominant within Western societies, there are also lay (non-medically qualified) health beliefs, which may be different to those within medicine.  There are many components to lay health beliefs including culture, gender, norms, values, beliefs, attitudes, personal and familial experiences, and socioeconomic status.   

The importance of LHBs for clinicians is in understanding how individuals construct their beliefs and interpret their symptoms, and having a dialogue where LHBs are acknowledged and, if necessary, deconstructed.  Within sociology, one of the most influential pieces of research is by Blaxter (1990), who suggested that class, age and gender are crucial in making LHBs.  Within psychology, there is a high degree of overlap with sociology, when looking at how individuals make sense of becoming ill.  A key theory within psychology is Attribution Theory (Heider 1958), where we have a tendency to see our world as predictable and controllable, and are along several continuum’s: internal vs externality; stability vs instability; controllability vs uncontrollability.

 Sick Role: Parsons (1951)The notion that illness can disrupt a society’s ability to function effectively and efficiently, was taken up by Talcott Parsons who developed the ‘sick role’ – where individuals who are ill have to retreat from their usual daily functioning and tasks, seek medical advice, and try to get better, clinicians play their part in the sick role as they have the appropriate authority to treat people who are ill and have the necessary qualifications and experience to treat illness. 

Parsons’ vision of the ‘sick role’ is that it is a temporary state, there must a distinction between the biological and social basis of illness (hangovers are not seen as being ill as they are a social construct and can be avoided), any illness is based on the norms and values of any society (think about ME, IBS, CFS) and also the morality attached to some illnesses/diseases (such as HIV AIDS)

More formally, the rights and obligations of the ‘sick role’ are:

Patients’ Obligations:The individual must want to get wellPerson who is ill has to seek medical help and comply with treatment

Patients’ Rights:They can legitimately withdraw from ‘normal obligations’, such as paid work, looking after  their familyThe individual is not culpable for being ill            Health Practitioners Obligations: To be technically competent and have the appropriate expertise To provide objective, altruistic care (the welfare of the patient is paramount)            Health Practitioners RightsHealth Practitioners are treated as experts/professionals with a degree of independence        and self-regulation (relates to universalism, whereby doctors are expected to be expert in specific areas and a body of knowledge which is universally applied) Health Practitioners are allowed access to examine a patient, physically, psychologically, emotionally, and to treat a patient as appropriate (e.g., surgery)                                                                                                                                                                        

As can be readily seen, the ‘sick role’ represents a somewhat idealised version of people who are ill.  And, crucially, not everyone who is ill consults a doctor, and those who do consult are often perceived as presenting with trivial complaints.  Such observations have led to the concept of the ‘symptom iceberg’ where one third of people who experience symptoms do nothing, one third self medicate (or seek alternative therapies), and one third consult a doctor. 

Stigma: Goffman (1968)

Stigma is based on a distinction between ‘virtual social identity’ ie stereotyped imputations we make in everyday life, and ‘actual social identity’ ie attributes that an individual possesses (Goffman 1968).  Any physical or social attribute or sign that so devalues an actor’s social identity as to disqualify him or her from ‘full social acceptance’.  Certain diseases and functional disabilities are more or less obviously stigmatized – e.g., facial disfigurement, amputation, AIDS/HIV.

}  Likelihood of stigmatization

}  Visibility, the extent to which the signs or symptoms of a condition are recognised by others

}  ‘Know-about-ness’, the extent to which others are aware of  an illness

}  Obtrusiveness, the extent to which the flow of interaction is impeded

}  Further distinction between the ‘discreditable’, attributes which are not visible and only potentially stigmatizing, and the ‘discredited’ attributes which are visible

}  Enacted stigma – discrimination against people on perceived inferiority

}  Felt stigma – feelings of shame which is associated with fear of enacted stigma

Stereotypes, following Lippman (1922), arises out of cognitive processes and social categorisation, whereby prejudices about individuals and groups are formed, where differences between the familiar and the strange are accentuated.  Stereotypes are usually oversimplifications and over generalisations of someone or something.

The purpose of stereotypes is to make the world easier to deal with, and simplifies our environment, we also share these with members of our own social groups, and use them to blame minority groups for societal problems or justify acting in an exploitative way towards them

Health Seeking Behaviour: Zola (1973)

Despite many symptoms that people experience, indicating disease processes, seeking medical help or treatment is not always the case.  Resolving, or taking action depends upon other factors, such as timing of decisions.  Many people tolerate their symptoms for some time, there had to be other ‘triggers’ (Zola identified 5) to make an individual seek help.

}  The occurrence of an interpersonal crisis (e.g., death in a family)}  Perceived interference with social or personal relations}  ‘Sanctioning’ – pressure from others to consult}  Perceived interference with vocational or physical activity}  ‘Temporalizing of symptomatology’ – the setting of a deadline, e.g., If I’m not

well by Monday.......

Critically, when clinicians do not take sufficient account of the trigger which the individual uses to seek help, then the higher the chance that the patient will stop treatment, or not adhere.

Illness Behaviour: Mechanic (1978)

The complexity surrounding decision-making around consulting medical help was taken up by Mechanic and Volkart (1960) who define ‘ illness Behaviour’ as the ways in which given symptoms may be differently perceived, evaluated, and acted (or not acted) upon by different kinds of persons

Illness behaviour refers to the way in which people define and interpret their symptoms and the actions they take in seeking help.  There are many sociodemographic characteristics involved in seeking medical help, for example, high users are generally women, children, and the elderly.  Additionally, social class, ethnic origin, marital status and family size are all implicated in why some people seek medical help and others do not.

Why people do, or do not seek medical help does not rest solely on the presence of illness or disease, but also how the individual and others around them respond to symptoms.  Mechanic (1978) suggested 10 variables, although not exhaustive, and many are inter-related, they have a high degree of resonance for understanding illness behaviour

}  Visibility, recognisability, perceptual salience of signs and symptoms}  The extent to which the symptoms are perceived as serious}  The extent to which symptoms disrupt family, work and other social activities}  The frequency of the appearance of the signs and symptoms, their persistence,

or their frequency or recurrence}  The tolerance threshold of those who are exposed to and evaluate the signs and

symptoms}  Available information, knowledge and cultural assumptions and understandings

fo the evaluator}  Basic needs that lead to denial}  Needs competing with illness responses}  Competing possible interpretations that can be assigned to the symptoms once

they are recognised}  Availability of treatment resources, physical proximity, and psychological and

monetary cost of taking action (not only physical distance and costs of time,

money and effort but also such costs as stigma, social distance and feelings of humiliation) 

Illness Belief Model (Illness Cognitions, Illness perceptions Model, Self Regulation of Illness Cognition and Behaviour): Leventhal et al (1980; 1984; 1997;2003)This work within psychology looks at illness beliefs which are stored in long-tem memory and are schemas or representations.  These representations are models of an illness – an illness representation, and contain information on: the potential course of an illness; the symptoms associated with it; and what to do when experiencing an illness.  These ideas have been formulated into the SRM – self-regulation of illness cognition and behaviour.  Central to this model is the idea that individuals want to maintain equilibrium, and illness represents an unstable state.  So, we are motivated to work to reinstate equilibrium.  The model is a cognitive-affect model, where cognitions include: identity (illness label which match the symptoms); timelines (how long the illness will last, acute, chronic, cyclic); cause (beliefs about what may have caused the illness); control/cure (how much can the symptoms be controlled by medication, or behaviour); and consequences (expectations about the effects of an illness), and the affect (emotional impact of an illness upon an individual): fear; distress; anxiety; and negative mood.   

  

Biographical Disruption: Bury (1991: 2001)

Biographical Disruption occurs when a life story that is expected to unfold in a relatively predictable fashion, and predicated on being healthy, is disturbed by an illness.  Bury suggested that there are 3 dimensions (Bury 1991)

1.‘ Coping’ – cognitive processes to sustain self-worth and come to terms with different situation and body

2.‘ Strategy’ – management of illness: mobilise resources, make demands, and remain independent

3.‘ Styles of Adjustment’ – disclosure, disguise, withdrawal, ‘ normalization’,

integration

Illness narratives developed out of Biographical Disruption, where it was recognised that Narratives, which are form of story-telling, are part of reinstating the gaps between the healthy and ill self.  The suffering and disturbance caused by illness can be re-shaped, made into meaningful and crucially, individuals gain control of their lives, outwith their biological suffering!  People put together their stories/narratives formed by psychological needs, individual motivations, presentation of self, how illness has impacted upon their lives, and how they present themselves to others.  So, it is important for clinicians to elicit patients’ narratives as they may uncover all kinds of psychological needs, health beliefs, and adherence issues.  

So, Bury (2001) suggested 3 forms of Illness Narratives

1.      ‘Contingent Narratives’ – describe the events surrounding the onset of an illness, such as a traumatic life event, and the early course of an illness/disorder, such as the medical diagnosis.

2.       ‘Moral Narratives’ –  refer to social apologia, defence of a situation, and self presentation to ensure that the narrator is competent, active and social.

3.      ‘Core Narratives’ – describe the course of an illness with different types of expression including: epic, heroic, tragic, comic, didactic

Health Belief Model (HBM) The (HBM) has developed within psychology, and tries to explain and predict health related behaviors.  The HBM rests on the notion that individual’s attitudes and beliefs are core components of predicting their behavior. The original conception of the HBM was the 1950s by social psychologists Hochbaum, Rosenstock and Kegels. The model was developed in response to the failure of a free tuberculosis (TB) health screening program.  The HBM has been adapted to explore a variety of long- and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS.

The HBM is based on the understanding that a person will take a health-related action (e.g., stop smoking) if that person:

1. Feels that a negative health condition (i.e., getting lung cancer) can be avoided.

2. Has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition (i.e., access a smoking cessation programme to stop smoking and lessen the chances of developing cancer).

3. Believes that he/she can successfully take a recommended health action (i.e., he/she can use nicotine replacement patches easily and with confidence).

The HBM was spelled out in terms of four constructs representing the perceived threat and net benefits:

1.       Perceived susceptibility2.        Perceived severity3.       Perceived benefits4.       Perceived barriers

 These constructs were proposed as accounting for people's "readiness to act." An added concept, cues to action, would activate that readiness and stimulate overt behaviour.

Additionally, the concept of self-efficacy, (the ability to successfully perform an action) has been added to the HBM.

Stress Myers (1998)

The process by which we perceive and respond to threatening events

 

Inequalities in Health

The gaps in mortality and morbidity between social classes has been apparent since the conception of social class and associated epidemiological work.  The message that re-appears over and over again, is that the higher the social class the greater the chance that you will live longer and suffer with less disease.