social and community perspectives understanding lay beliefs 18 th february 2003

SOCIAL AND COMMUNITY PERSPECTIVES

Understanding Lay Beliefs

 18th February 2003

What are lay beliefs?

• What people belief about the maintenance of health and the prevention of ill health.

• Complex and sophisticated theories about health and causes of disease

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 health-related 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

• 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