the measurement of beliefs about physical symptoms in english general practice patients

Pergamon 0277-9536(95)00263-4

Soc. S¢i. Med. Vol. 42, No. 11, pp. 1561-1567, 1996 Copyright © 1996 Elsevier Science Ltd

Printed in Great Britain. All rights reserved 0277-9536/96 $15.00 + 0.00

THE MEASUREMENT OF BELIEFS ABOUT PHYSICAL SYMPTOMS IN ENGLISH GENERAL PRACTICE PATIENTS

PETER SALMON, ~ MARIA WOLOSHYNOWYCH 2 and ROLAND VALORI 3

tDepartment of Clinical Psychology, University of Liverpool, Whelan Building, PO Box 147, Liverpool L69 3BX, England, 2Department of Psychology, University College London, Gower Street, London WC1E 6BT, England and 3Department of Gastroenterology, Gloucester Royal Hospital, Great Western

Road, Gloucester GL1 3NN, England

Abstract--A way of measuring patients' beliefs about the origin of their symptoms would allow the investigation of important questions concerning the consultation process and its outcome. The purpose of this study was to develop an instrument that could measure the beliefs about symptoms of patients attending their general practitioner and to demonstrate its utility by comparing beliefs about three types of symptom (respiratory, musculoskeletal and gastrointestinal). Interviews of 150 patients generated items for the belief questionnaire which was then completed by a second sample of 406 general practice patients. Principal components analysis of the responses identified eight readily interpretable belief dimensions: stress; lifestyle; wearing out; environment; internal-structural; internal-functional; weak constitution; concern. Scales were constructed to measure each dimension and the symptom groups were compared. Gastrointestinal symptoms were the most likely to be attributed to internal malfunction and to lifestyle or weak constitution. Musculoskeletal symptoms were more likely to be attributed to structural problems caused by the body wearing out and respiratory symptoms, in contrast, to the influence of the environment. Contrary to prediction, attribution to stress was made equally for the different types of symptom.We have devised a questionnaire, valid specifically for general practice patients, which permits the quantification of beliefs in this setting. The questionnaire could be used in future to track how beliefs respond to medical intervention and how, in turn, beliefs influence illness behaviour. Copyright © 1996 Elsevier Science Ltd

Key words--beliefs, physical symptoms, primary care

INTRODUCTION

Physical symptoms such as back or abdominal pain and respiratory complaints, are common in the general population and only a minority of sufferers consult their general practitioner. Which patients consult, and what they seek when they do, depends on factors in addition to the nature and severity of symptoms [1-3]. One such factor is what patients believe about their symptoms.

The influence of beliefs has been studied from different theoretical stances [4]. The health belief model maintains that behaviour, such as compliance, can be predicted by the perceived severity of disease, perceived susceptibility to it and the perceived costs and benefits of the behaviour. Consistent with this, compliance has been shown to be related more to patients' perceptions of severity or risk than to their doctors' judgements of the same variables [5]. Arguably, although the model provides a way of predicting compliance, it is limited as an explanation. For this, we need to know the beliefs that underly perceptions of severity, vulnerability or treatment effects.

Another approach has been to measure the extent to which individuals hold certain general beliefs about health and illness and to find out whether these can predict their illness behaviour. Of particular

interest has been the belief in the ability to carry out behaviours which will influence one's health (self- efficacy [6] and health locus of control [7]). Belief that symptoms indicate physical disease has also been related to persistent health care behaviour [8] and, more recently, to poorer recovery [9].

These approaches share an important limitation as descriptions of lay, or common-sense understanding. The belief dimensions have been defined a priori or for theoretical reasons and, therefore, do not necessarily correspond to the ways in which patients normally organize their beliefs. Descriptions of 'naive' or 'common-sense' beliefs about particular illnesses, such as hypertension, have shown the importance of beliefs that are distinct from theoretically derived dimensions [10-14]. For example, believing that a disease, such as hypertension, can be cured medically is associated with poor continued compliance [10]. However, this and the previous approaches share a further limitation which is a focus on medically-defined illnesses rather than symptoms as experienced by the individual [15]. This is a crucial limitation if research is to study beliefs before a diagnostic label is accepted. Since merely receiving a diagnosis can change beliefs about symptoms [16], the relevance of this work to undiagnosed symptoms may be limited.

A clearer focus on people's beliefs about experi-

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1562 Peter Salmon et al.

enced ill-health rather than medically-defined illness is seen in a long tradition of qualitative, anthropological research [17]. This has emphasized the identification of beliefs whereby people naturally interpret their ill-health. One product of this research is the description of important dimensions of belief such as 'invasion', 'degeneration' or 'imbalance'. However, the value of these results is limited by the absence of a method for quantifying the identified beliefs. Generalization about lay beliefs and comparison between them would be facilitated by a method of assessment which combines the advan- tages of qualitative and quantitative approaches. That is, such assessments, while being quantitative, should be sensitive to the belief dimensions along which people normally explain their symptoms. Available questionnaires do not yet meet this need. Although Turk et al. [18] have reported an instrument for measuring beliefs, its content was based, not on patients' own reports of beliefs, but on theoretical models. Moreover, it was validated on the basis of ratings, mainly from healthy subjects, of specific illnesses.

Therefore, the purpose of this study was to develop a symptom belief questionnaire specifically for the range of physical symptoms presented at the first point of contact with health care: general practitioners. To achieve content validity, its content was based on interviews with a large sample of patients; i.e. its items reflected the kinds of belief that patients actually have, described in words that they use. Its structure was then assessed quantitatively in a sample of 406 similar patients. To test the utility of this questionnaire, we went on to determine whether it could detect differences in beliefs about three different types of symptom: gastrointestinal, respiratory and musculoskeletal. Different beliefs are likely to be associated with these commonly presented complaints. Everyday language suggests that gastrointestinal symptoms are popularly linked to stress ('nervous stomach', 'butterflies', 'shit scared'), and that respiratory symptoms are attributed to penetration by cold, dampness and germs ('catching a chill' or a 'bug') whereas musculoskeletal symptoms are related to internal damage caused by injury and degeneration ('strains', 'worn joints'). Patients presenting these symptoms were identified and their beliefs compared. Those with other types of symptom provided an unselected group for comparison.

METHODS

Construction o f the questionnaire

Interviews. One hundred patients complaining of physical symptoms were chosen at random from those attending 2 general practices in inner city areas of G--eater London and interviewed. Each patient w a s a s k e d to describe briefly the symptoms which

had led to their visit and then to explain what they thought caused their symptoms. As exploratory interviews, they were unstructured [19], except for the two initial questions, asking 'What symptoms have brought you here today?' and 'What do you think has caused your symptoms?'. Patients were prompted, as necessary, to talk about the following areas: whether the symptoms were normal or not; whether they were worrying; contributory factors; their causation, mechanism and time-course; and the ability of their general practitioner (GP) or a specialist to treat them. Similar interviews were carried out with a total of 50 patients selected sequentially from those attending three outpatient clinics in a central London teaching hospital (gastroenterology, respiratory medicine and rheuma- tology). In case the medical settings of these interviews had restricted the range of responses, additional interviews were carried out with a sample of 34 people not currently under treatment, drawn from a central London university undergraduate common-room. They were interviewed about their most recent symptoms for which they had not consulted their GP. Each interview was conducted in a private room, and lasted from 10-20 min.

Item selection. Every comment which reflected a patient's understanding of the symptoms was noted (e.g. 'allergy', 'worn joints', 'caused by stress'), but medical labels (e.g. 'asthma', 'arthritis', 'ulcer') were ignored. The interviews of subjects not under treatment yielded only one item which had failed to emerge from interviews of patients: 'weak constitution'. Ambiguous, synonymous and idiosyncratic items were discarded, but the item pool was not further reduced at this stage. Two further items were added on the basis of existing anthropological and sociological literature, including published results of previous similar interviews, where no relevant item had emerged from our interviews ('someone trying to harm me', 'a payment for something I have done'. The remaining items were formed into a list and given to 20 general practice patients and 10 further undergraduates, selected as above. Ambiguous items were clarified on the basis of their comments. The final questionnaire contained 71 items, summarized in Table 1. Each was given a 3-point scale. Fifty-seven items concerning causation were answered in response to the question 'whether it probably has or probably has not helped to cause your symptoms' (responses: 'probably has', 'don't know', 'probably has not'). Seven further items asked whether different ways of 'helping to deal with' the symptoms would help or not (responses: 'probably would help', 'don't know', probably would not help'). Additional items asked: whether the symptoms were thought to be serious; whether they were caused by a longstanding factor; whether most people experienced them; whether they would get worse; whether the patient believed that s/he knew the cause; whether the patient had thought about the

Measurement of befiefs about physical symptoms 1563

Table 1. Results of principal components analysis of responses to beliefs questionnaire. Loadings reaching 0.40 are shown

Internal Internal Weak Item Stress Wearing out Environment structural functional Concern Life-style constitution

Personal, domestic or financial problems 0.75

Moods/emotions 0.74 Stress 0.73 Overwork 0.69 'Nerves' 0.65 Being rundown 0.60 Working/living conditions 0.59 Job/housework 0.58 Personality 0.54 Demanding family/friends 0.50 Part of body wearing out 0.69 Tissues hard or soft 0.63 Body tissues less firm/supple 0.63 Part of body slowing down 0.63 Part of body not working

as well as used to 0.62 Worn joints 0.60 Weather or changes in

temperature 0.72 The time of year 0.69 Something I caught from

someone else 0.69 Dampness or a chill 0.63 Illness which others can

catch from me 0.54 Germ or infection 0.49 Pollution 0.48 *Tests or X-rays 0.63 *An operation 0.63 Something out of place 0.58 *Seeing a specialist 0.57 Damage to part of my body 0.57 Part of my body is strained 0.48 An accident 0.47 Pressure building up somewhere

in my body 0.46 Something seriously wrong

with me 0.45 A growth 0.61 Weak blood 0.55 Sluggish bowels 0.53 Poor digestion or weak

stomach 0.52 Heart trouble 0.51 Pills or medicine 0.49 I have no idea of the reasons

for my symptoms 0.59 I have not thought about my

symptoms 0.54 Cause probably has not been

going on for long 0.47 The food that I eat 0.65 *Changing my diet or

lifestyle 0.65 Something I ate 0.57 Warning from my body to

change the way I treat it 0.50 Being over or under weight 0.47 Not looking after myself

properly 0.45 Part of my body is inflamed 0.47 A 'weak spot' in my body 0.46 Weak consititution or low

resistance < 0 . 4 6

0.87 0.81 0.77 0.79 0.73 0.47 0.74 0.54

*Items which would 'help deal' with symptoms. Removed items: Someone trying to harm me; symptoms will get worse unless I deal with them now; a previous illness; an allergy; impurities

or additives in food or water; my body lacking a substance it needs (e.g. vitamins); smoking and/or alcohol; my perinds/menstrnal cycle; weak bones; poor circulation; a payment for something I have done; something that runs in the family; most people get these symptoms; not getting enough sleep; not getting enough exercise; problem I was born with; a blockage somewhere in my body; weak kidneys; *having GP explain what is wrong; *talking about my symptoms; *medicine, pills or injections.


cause; and whether others could catch the illness from the patient.

Subjects Patients were recruited from three practices in

Greater London: two from poor inner city areas and one from a prosperous suburb. In each practice, consecutive patients over 16 years attending to see a GP for current symptoms were approached after reporting to the receptionist.

Procedure

Patients were asked to help with a study into 'what patients think are the causes of their symptoms' by answering the questionnaire about the main symptoms that they intended to present to the GP. Consenting patients were asked to complete the questionnaire before consultation. A frontsheet to the questionnaire sought demographic information. Ad- ditional questionnaires are not reported here. Patients were assured of confidentiality and asked not to write their name on the questionnaires.

For each patient, the GP allocated their main presenting symptoms to one of the following: gastrointestinal (including infections); respiratory (including colds and 'flu); musculoskeletal (including back pain); or 'other'.

Statistical analysis

Responses to one item, 'someone trying to harm me', were highly skewed and were therefore removed from the analysis. To refine the item pool, successive principal components analyses (using the correlation matrix in order to standardise scores) were carried out. Items loading at <0.30 were removed after the first analysis, those loading at <0.35 were removed after the second. From the final analysis, items loading at 0.45 or above were used to construct component-based scales. The number of components to retain for Varimax rotation after each analysis was decided with the help of a scree test. The internal consistency of each scale was estimated by standardized Cronbach ~ reliability coefficients.

Symptom groups were compared on each of the beliefs by analysis of variance. Significant effects were analysed by post-hoc t-tests, using the error term from the analysis of variance.

RESULTS

The sample

Of 515 eligible patients approached, 406 (79%) completed questionnaires of whom 136 (34%) were male and 259 (66%) were female (11 did not record their sex). The mean age was 42 (range 16-91); 19 (5%) were in professional or managerial jobs, 29 (7%) in clerical, 14 (3%) in technical jobs and 75 (18%) in manual work; 252 (62%) were not employed (including students and those that had retired).

0.5'

O

-0.5

-1

1

0.5

0

-0.5

-1

1

0.5

0

-0.5

Internal Weak Functional*** Lifestyle* ConsUtutioe*"

Environment" Concern* Stress

Weadng Internal -1 Out'** Structural'**

Fig. 1. Explanatory beliefs of groups of patients reporting different symptoms. For each belief, mean standardized scores are shown for each symptom group. Errors bars show

SEM. *P < 0.05; **P < 0.01; ***P < 0.001.

• Gastrointestinal

[] Respiratory

[] Musculoekeletal

• Other

Principal components analysis of the questionnaire

Items discarded because of low loadings are shown in Table 1. The final analysis of the remaining items yielded eight components, accounting for 46.2% of the variance, which described interpretable and discrete types of belief (Table 1; see discussion). All but 2 of the component-based scales had satisfactory internal consistency (Table 1). The exceptions, Concern and Weak Constitution, should therefore be interpreted and used with caution.

Comparisons between patients reporting different symptoms

Of the 406 patients, 343 (84%) were allocated by the GPs to symptom groups: gastrointestinal (N=33) , respiratory (N=61) , musculoskeletal (N = 62), 'other' (N = 185). The remaining patients were unallocated, mainly because the GPs forgot to record the code number which identified the relevant patient's questionnaire.

Mean standardized scores on each belief dimension are shown in Fig. 1 for each group (concern is scored such that increasing scores signify concern rather than lack of concern). Gastrointestinal patients were distinguished from all other groups by higher scores on two beliefs: Internal-functional [F(3,339) = 5.67; P < 0.001; minimum t ffi 2.80; P < 0.01] and Life- style [F(3,339) ffi 3.44; P < 0.05; minimum t ffi 2.93; P<0.01] . On neither of these beliefs did the remaining groups differ amongst themselves. A

Measurement of befie~

similar pattern was seen with Weak constitution [F(3,343) = 3.87; P < 0.01], although only the comparisons of gastrointestinal with 'other' and respiratory groups reached significance (ts = 3.07, 3.12, respectively; Ps < 0.01).

Two beliefs distinguished musculoskeletal patients from all the other groups and, to a lesser extent, characterized gastrointestinal patients also. For Wearing-out [F(3,339)= 17.60; P<0.001] , scores were higher in patients presenting musculoskeletal symptoms than in any other group (minimum t = 3.25, P < 0.01) and higher in gastrointestinal patients than in 'others' (t = 1.97; P < 0.05) or in respiratory patients (t = 3.25; P < 0.01). Similarly, Internal-structural belief [F(3,339) = 16.96; P < 0.001] was greater in musculoskeletal patients than in any other group (minimum t--3.16; P < 0.01) and higher also in gastrointestinal patients than respiratory ones (t = 3.16; P < 0.01).

Respiratory patients were distinguished by higher scores on Environment [F(1,343) = 39.46; P < 0.001] than in any other group (minimum t = 5.78; P < 0.001). The remaining belief dimension, Con- cern, showed the same pattern [F(3,334)= 3.54; P = 0.02; minimum t = 1.98, P < 0.05]: respiratory patients were less concerned than any other group. The groups did not differ in their belief in Stress [F(3,339 = 2.20; P > 0.05].

DISCUSSION

Our interviews allowed the construction of an inventory of beliefs about symptoms which was brief and which proved acceptable and understandable in ordinary primary care settings. Of the eight dimensions of belief that were identified by the principal components analysis of the responses, four distinguish aspects of perceived aetiology. The dimension labelled 'Stress' shows a broad view of the nature of psychological demands and their subjective effects. It included subjective feelings of being 'run down', but also specific categories of objective stressor arising in working or domestic life. Central to this dimension is, therefore, the attribution of symptoms to other people. In 'Environment', patients display a belief that symptoms result from penetration from a wide range of physical agents. Although objectively these are quite disparate, including weather, dampness, infection and pollution, the patients evidently see them as linked. The 'Lifestyle' dimension describes the belief that patients' conscious behaviour is responsible for symptoms and that, presumably, they could deal with them without medical intervention. 'Weak constitution' attributes symptoms primarily to a localized weakness in the body.

Other dimensions describe mechanisms that medi- ate symptoms rather than the root causes. 'Wearing out' is the belief in a process of gradual deterioration in the body. The items that load on 'Internal-struc-

about physical symptoms 1565

tural' signify a belief that the cause of the symptoms is serious and hidden, but nevertheless identifiable and rectifiable. This is the only dimension that expresses the belief that the symptoms are amenable to 'modern medicine': i.e. tests, specialists or operations. The third mechanistic dimension, 'Inter- nal-functional', also describes a belief in a hidden mechanism, but one that results from disordered function rather than structure and which, although amenable to medication, is not so amenable to the other tools of conventional medicine. The final dimension, 'Concern', was neither aetiological nor mechanistic: it refers to knowledge or concern about the symptoms.

Despite our conservative criterion for deciding the number to retain, the 8 components explained nearly half the variance in the 50 questions. The remaining variance includes, in addition to error, relatively specific beliefs represented by individual items that did not load on any of the components. Some of these items, such as 'smoking and/or alcohol 'or 'an allergy', obviously represent important beliefs. They were eliminated from the final questionnaire, not necessarily because they are unimportant, but because they do not help to measure the more general beliefs which our technique identifies.

There have been previous psychological studies of lay beliefs [4], but it is hard to compare our results to the belief dimensions that have arisen from that work because that literature has focused on specific, medically defined illnesses rather than experienced symptoms. There is, however, clearly no support for the claim that psychological and physical causation represent opposite poles of a bipolar factor, as in Bishop's [13] results. Patients are more sophisticated: whether symptoms have a physical basis (internal- structural or internal-functional) is independent of whether psychological factors (stress) are also involved. By contrast, there is clear convergence with the results of anthropological studies of people's beliefs about symptoms and ill health [17]. Our results confirm, quantitatively, key belief dimensions which have emerged from that qualitative work; in particular, vulnerability (weak constitution), degeneration (wearing out), invasion (environment), mechan- ical malfunction (internal-structural) and stress. There is clear overlap also between the accounts of 'imbalance' and our own internal-functional dimension, with its emphasis on falling short of a desirable set point: e.g. weak blood or sluggish bowels. Responsibility for ill-bealth has emerged as a particularly Western belief [17, 20] and is clearly reflected in our lifestyle dimension.

Our results advance on previous research, not just by identifying important belief dimensions, but by providing a method to quantify these beliefs. This allowed us to test whether the scales formed to measure the identified belief dimensions were able to distinguish between patients presenting different types of symptom which, according to everyday


language, are construed very differently. Several dimensions were linked in a predictable way to specific symptoms. For instance, a belief in environmental causes (including temperature, dampness and germs) characterizes respiratory symptoms, which were also the least likely to cause concern. Also as might be expected, gastrointestinal symptoms were linked to Internal-functional mechanisms, as well as aetiologies such as Lifestyle and Weak Constitution. Similarly, degeneration (Wearing out) and mechan- ical malfunction (Internal-structural) are linked to musculoskeletal symptoms. By contrast, one key prediction was refuted: gastrointestinal symptoms were not preferentially attributed to stress. Although language links stress with respiratory and musculoskeletal symptoms less commonly than with gastrointestinal symptoms, our results show that patients' underlying beliefs are more in tune with evidence that psychological stress has more general effects, including reduction in resistance to upper respiratory tract infections [21] and exacerbation of musculoskeletal symptoms such as backache [22].

It is clear that patients' own beliefs about their symptoms and, in particular, the degree to which they and their doctors are in agreement, influence their decision to consult and their subsequent compliance [23-26]. It is also clear that GPs and patients do have different explanatory models of the patients' symptoms and that perception of the patients' models is often inaccurate [27]. Use of the questionnaire in clinical practice could therefore help to alert the GP to a patient's model although it should not be a substitute for sensitive interviewing. More impor- tantly, the questionnaire offers a quantitative way of researching the influence of beliefs on consultation. However, beliefs are not static and even less is known about how patients' beliefs change as a result of consultation with their doctors. In current views of the somatization process, physical treatment for subjective symptoms such as pain or fatigue is assumed to reinforce a belief in the organic basis of the symptoms [28], but this prediction has not been systematically tested. A clear hypothesis can be framed in terms of our results. Consider patients with, for instance, gastrointestinal symptoms who attend with a belief or suspicion that their symptoms result from lifestyle disturbing the function of their body in a way that is not as amenable to medical intervention as if a structural problem were present. To receive a referral for investigation might counter this set of beliefs and encourage, instead, the belief in a serious internal-structural problem which requires expert medical or surgical intervention. Our questionnaire would allow the systematic testing of this type of hypothesis.

Acknowledgements--We are indebted to the general practioners and staff at the following practices for enabling us to carry out this study: Betfinal Green Health Centre, London E2; Clapton Health Centre, London E5; Purley

Health Centre, Purley, Surrey. We thank Dr S. Nazeer, Dr L. Brad and Ms N. Breitschmid for their help with collecting data. We are grateful to the Astra Research Foundation for financial assistance and to Dr R. Littlewood for his advice in designing the study. Preparation of the manuscript was assisted by a grant from the Middlesex Hospital Special Trustees.

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