Transcript SOCIAL AND COMMUNITY PERSPECTIVES

SOCIAL AND COMMUNITY
PERSPECTIVES
Understanding Lay Beliefs
18th February 2003
What are lay beliefs?
• What
people
belief
about
maintenance of health and
prevention of ill health.
• Complex and sophisticated theories
about health and causes of disease
the
the
What influences a person’s lay
beliefs?
• Idiosyncratic
– Based on patient’s observations and experiences
• Popular
– Derived from the patient’s social network
• Media
– e.g. ‘scares’ about treatments/procedures
• Alternative/complementary models
• Expert models of illness
• N.B. Lay knowledge far more compelling to
patients than biomedical knowledge.
Researching lay beliefs
• 1950–1970s sociological research influenced
by health professionals’ concerns:
– Under-utilisation of services - ‘illness iceberg’
– Over-utilisation of services
– Poor compliance
• Found:
– response to symptoms dependent upon cultural
context
– decision to seek help depend upon social factors
• Emerging concepts:
 ‘illness behaviour’ – response to symptom
 ‘health behaviour’ – maintenance of health
Researching lay beliefs
• Recent research concerned with healthrelated behaviour e.g. help-seeking
behaviour and compliance
– Why don’t people uptake health
procedures e.g. screening, immunisation?
– Why don’t people adopt health practices
e.g. eating healthier, exercising?
Researching lay beliefs
• Emerging concepts:
• Locus of control theory’
• ‘external locus of control’ = fatalistic
• ‘internal locus of control’ = believe can
influence health
• Health education change ‘externals’ to
‘internals’
Researching lay beliefs
• Health belief model
– To what extent people motivated to change health
behaviour?
– Indicators
• perceptions of susceptibility
• possible effects of illness
• costs and benefits associated with health related
behaviour
• This model = challenged
Researching lay beliefs
• Most recent research  focus on social
action rather than behaviour
• What is health?
• How do people make sense of disease?
• Often uses qualitative research
methods
Defining health
• Calnan (1987) - conceptualise health in
different ways:
– Negative –– absence of disease
– Positive - WHO
– Functional – ability to participate in normal
social roles
– Experiential – takes into account sense of
self
Defining health
• People themselves define health in
different ways:
• Herzlich (1973)
– ‘health in a vacuum’ - absence of disease
– ‘reserve of health’ – biological capacity to
resist/cope with illness which changes over
time
– ‘equilibrium’ – normal health – rarely
attained
Lay beliefs vary according to:
Social class
– w/c may have more fatalistic view compared to
m/c
– material circumstances in which people live
– Lack of a positive conception of health may
explain low uptake of health promotion/preventive
medicine
• However…..simplistic…..
– Calnan (1987) no clear distinction - w/c and m/c
women likely to define health in negative terms.
– When talk about health in more abstract terms m/c
women = more elaborate descriptions.
Lay beliefs vary according to:
Gender
– Response to illness related to gender
– Women may define selves as ’ill’ less often than
men
– More difficult for women to take time off
responsible for child-care etc ?
– Women more likely to offer expansive answers
when defining health than men
Age
– Young men: health = physical strength and fitness
– Young women = energy, vitality, ability to cope.
– Middle aged = mental well-being and contentment
Lay beliefs vary according to:
Ethnicity
– South Asian people  ‘functional’ terms
– Afro-Caribbean 
• health = energy and physical strength
• illness been as a result of ‘bad luck’
– IMPORTANT TO NOTE:
• Groups in most disadvantaged position in
society more likely to hold fatalistic views
(Donovan,1986)
• Overlaps between social
class/gender/ethnicity
Lay beliefs about illness causation
Endogenous
– emphasise inborn dispositions
– e.g heredity, genetic defects as causes of
ill-health
Exogenous
– emphasise external agents
– e.g. stress, pollution, germs
• N.B. Links with medical explanations
Helman– ‘Feed a cold, starve a fever’
• Colds and chills
– penetration of the environment through the skin
– avoid getting wet
– Colds = due to due to dropping your guard -own
responsibility
• Fevers,
– caused by “germs, bugs, or viruses”
– enter the body through orifices  natural
weaknesses in body’s defences.
– Patient not responsible for fevers
Complex nature of lay beliefs
• People still define another as ‘healthy’ even if
have serious disease – capacity to get better
• Ideas about causation of disease different to
ideas about maintenance of health
• Calnan (1987) - although have ‘healthy’
lifestyle does not follow that behaving in such
ways will prevent onset of disease
• Blaxter (1983) - w/c women causes of
disease mainly outside their control
e.g. infection, hereditary factors and
environmental factors
Complex nature of lay beliefs
• Beliefs influenced by social and medical
ideologies
– Dependency regarded as negative
– Calnan (1987) - w/c women rejected claim that
poverty caused ill health.
– Blaxter (1993)
• Women see health as individual responsibility, not just
about ‘healthy’ lifestyle but bound up with own
biographies.
– ‘ Ill’ = negative connotations
• Compared current experience to past and realised
situation much better now
Complex nature of lay beliefs
• Beliefs about disease causation and vulnerability
influenced by biomedicine
– Cornwell (1984) - people wanted to distance selves from
disease causation – ‘not to blame’
– Although may incorporate medical ideas, do not accept
passively – if not ‘plausible’  rejected
• Concepts of health vary between groups, over
time and in different social circumstances.
– Implications - listening to what someone says on one
occasion does not mean can predict future actions
– “….people hold a multiplicity of accounts about health and
illness, and this is hardly surprising given the multifaceted
nature of people'’ lives and lifestyles." (Nettleton,1995,49)
Making sense of cancer
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•
•
•
•
Stress
Physical environment
Personal differences
Fatalism
Personal Behaviour
Stress
• That’s what made me ill, the stress of living with him
made me ill (Edna).
• It all ran into one, this business with this cancer. My
mother had a stroke, she couldn’t move, then she
died. Then my son’s wife left him with two boys, and
then I had this problem. So really, I’ve had a very
stressful few years, so whether that’s got anything to
do with the cause of cancer I don’t know... You’ve not
got to blame anybody, there’s nobody to blame really.
But you’d like to work out why, why did it happen,
what did I do wrong, or something like that. I just put
it down to stress and leave it at that. (Liz)
Physical environment e.g.
chemicals
• Gill blamed : “sprays on the fields and
things like that”.
Self-evident personal
differences
• ‘Hereditary’
• My mother had died of cancer and her
mother had died of cancer, and I always
in the background thought, oh it’ll get
me one day. My mum was only 50, and
I always had this feeling that I would,
you know, get cancer before 50, or at
50, or something. I never sort of felt why
me, or that, probably because I always
expected it I think (Anna).
Fatalism
• Bad luck, personal destiny
Just my number isn’t it? Just in my book
of life. It says, “Right you’re going to get
cancer.” That’s it there’s nothing you
can do about it. Nothing anyone can do
about it. When your number’s up, it’s up
isn’t it? (Sarah)
Personal behaviour
• Smoking
I said to my husband “Do you think the cancer
I’ve got is caused by the cigarettes?” and he
says, he did when he first heard I’d got
cancer, but when he knew that the cancer
was on my ovaries he thought different about
it. He says when he knew that my liver and
kidneys and my lungs were alright he felt
different then. He didn’t think for one minute
that it could be the cigarettes that give me
cancer. (Roz)
Making sense of cancer
• Extent to which these ideas informed by
elements of biomedical understanding
• However, ‘lay epidemiology’ recognises that
not everyone who fits these criteria gets
cancer and some who don’t do – must be an
element of luck.
• “Health promoters, keen to present
unequivocal, simplified and straightforward
messages, fail to address these anomalies
and so underestimate the sophistication of lay
thinking.” (Nettleton,1995,45)
Lay beliefs and medical
consultations
• Before consulting a doctor people often
consult family and friends
 Lay referral system (Freidson, 1970)
Lay beliefs and medical
consultations
Zola (1973) 5 ‘triggers’ to seeking medical help
• the occurrence of an interpersonal crisis
• perceived interference with social or personal
relations
• ‘sanctioning’
• perceived interference with vocational or
physical activity
• a kind of ‘temporalizing of symptomatology
Lay beliefs and medical
consultations
• Patients do not accept medical model
•
•
•
•
uncritically
Patients re-interpret within a lay framework
Conflict between lay and medical ideas can
give rise to serious dissatisfaction
Lay ideas determine compliance
Lay ideas important influence on the
experience of health and illness
Ruston A Clayton J Calnan M (1998)
“Patients’ action during their cardiac
event”
BMJ 316: 1060-5
• Interviewed patients admitted to hospital with
cardiac event
• Why do some people delay seeking help?
• 3 groups:
• non-delayers
• delayers
• extended delayers
Non-delayers
• reinterpreted symptoms by using:
– previous experience
– medical knowledge (from media)
– intuition
“I knew it was my heart….. you know
your own body and I was pretty sure that
was what it was”
Delayers
• Used medical and non-medical
treatments:
– Attempted to treat
– Lay consultation
– Use of personal/contextual
information – being working ‘too
hard’, something eaten
Extended delayers
• Tried treatment/movement/ lay and
medical consultation.
– More interventions used  greater delay
– Influence of contact with medical
profession
– discounted patients’ risks and attributed
symptoms to other causes.
Why did people delay?
Perception of heart attack before the event:
– Typical victim – obese, smoking, drinking, fatty
foods
– Typical heart attack – sudden  death
– Portrayal in media
• Own heart attacks not like this – still able to
do things
• Belief that cardiac event = sudden, dramatic
 death
• Their experience = evolving
Concluded
• Most important factor = recognising symptoms as
cardiac in origin.
• Those who sought help within 4 hours more likely:
• to see themselves at potential risk,
• know more symptoms
• Less likely to treat symptoms with drugs
• Impact of lay beliefs on consulting after cardiac
events
– General information campaigns - recommend that people
experiencing chest pain for more than 15 minutes seek help.
– People wait much longer
–  15 minute rule may be too simplistic
– ‘Stereotypical’ heart attack victim and attack needs to be
dispelled
Summary
Understanding lay beliefs is important for
medical practitioners because:
• Determine health-related behaviour and are
relevant to understanding patients’
experiences of illness
• Help us to understand the patient-practitioner
relationships
– Affect whether patient seeks medical help at all
– Strong influence on compliance
– Affect what patient tells you
Summary
• Influence patient’s expectations of the
consultation, and subsequent
satisfaction
• Provide an insight into lay concepts
which may be regarded as ‘incorrect’ by
professionals
• Important in health education and
promotion