Health and Illness in a Changing Society

Michael Bury

• Publisher: Taylor & Francis
• Year: 2013
• Print ISBN: 9780415115148
• eBook ISBN: 9781136158230
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Health and illness are intensely personal matters. It seems self evident that health is a basic necessity of the 'good life', though it is often taken for granted. Illness, on the other hand challenges our sense of security and may introduce acute anxiety into our lives. Health and Illness in a Changing Society provides a lively and critical account of the impact of social change on the experience of health and illness. It also examines the different sociological perspectives that have been used to analyse health matters. While some of the ideas developed in the last twenty years remain relevant to social research in health today, many are in need of urgent revision.

Chapter 1
From illness behaviour to health beliefs and knowledge

Introduction

This opening chapter traces the emergence of health beliefs as an important part of the medical sociology research agenda. It shows how this has reflected changes in both health policy and the wider culture surrounding health in late modern societies. It is important to recognise at the outset, however, that interest in this area among sociologists of medicine is relatively recent. Gerhardt, for example, in her wide-ranging review of the development of medical sociology discussed in the introduction to this book, deals briefly with 'lay theories' and 'patient views' of illness, but does not give prominence to wider issues of lay beliefs about health and medicine more generally (Gerhardt 1989). As will be seen, until the 1980s sociological interest in behaviour and interaction in the health service setting has tended to overshadow a broader concern with the way lay people view health. It is therefore somewhat ironic that studies of health beliefs by medical sociologists have emerged at a time when the idea of a distinct concept of lay beliefs has come in for serious and critical examination, especially by anthropologists. Although the terms 'belief' and 'lay beliefs' are now being used widely in social research on health, they are more problematic than they seem.

A useful starting point in considering these issues and in providing a guide to the chapter is provided by the anthropologist Byron J. Good in his recent book Medicine, Rationality and Experience (Good 1994). Good begins by pointing to the long tradition, and ambiguity, in the general anthropological literature on beliefs, especially where these appear to differ from what appears to be self-evidently true to the investigator. In particular, Good argues, problems for anthropologists have arisen when they have been confronted with the gap between beliefs held by peoples in traditional societies and those based on more 'reality congruent' forms of knowledge in modern science-based cultures, from which they, as investigators, have emerged.

Good also argues that, in most of the anthropological canon, the tendency to counterpose lay beliefs against scientific knowledge has meant a failure to provide a clear analysis of their relationship. As a result, anthropology has conveyed the idea that beliefs may be culturally sustained (for example, in the existence of witches) even when they are felt by the investigator to be clearly 'untrue'. Through a detailed discussion of the way in which the term 'belief and related concepts have developed, Good argues that anthropology has essentially utilised a notion of belief that 'connotes error or falsehood, though it is seldom explicitly asserted' (Good 1994: 17). As a result, the growing importance of the concept of 'belief' has, for Good, been fateful for anthropology.

The answer to this dilemma, for Good, is to focus on the contextual nature of knowledge, whether (in the medical field) that held by scientists and doctors or by 'lay' actors. In this sense, Good echoes the call by Comaroff for all ideas about illness to be treated as features of 'symbolic systems' (Comaroff 1982). Rather than scientific medicine being treated as if it were a 'mirror of nature' it should be regarded, according to these authors, as a 'rich cultural language linked to a highly specialised version of reality and system of social relations' including 'deep moral concerns' as well as technical ones (Good 1994: 5, emphasis in original). Similarly, lay practices and interpretations should be studied in order to reveal the 'diverse interpretive practices through which illness realities are constructed, authorized, and contested in personal lives and social institutions' (ibid.).

In so doing, Good is critical of researching beliefs within an 'empiricist' framework, which treats scientific facts as objectively true, and which, he argues, detracts from the central task of explicating the use of language, the fashioning of meanings in relation to experience and the development of 'representations' of ideas about disease and illness in the wider culture. One of the examples he uses in criticising 'empiricist' research is the development by psychologists of a Health Belief Model, through which it is hoped that subjective and cognitive factors can be studied in order to predict behavioural outcomes such as the use of services, and through which 'false beliefs' can be corrected, for the benefit of the public health (Good 1994: 40).

This kind of 'objectivist' approach to health beliefs, for Good, carries the danger that subjective opinions and accounts, which do not predict behaviour or 'have no grounds in disordered physiology and thus objective reality', are taken to be unreal (Good 1994: 10). Beliefs in this context are treated as irrational, and counterposed to rational scientific medical knowledge. Put simply, lay people have beliefs and doctors have knowledge. The basis of a sceptical view of this opposition, Good argues, can derive from the long tradition in anthropology of observing actually occurring cultures in which the absence of Western scientific knowledge is entirely consistent with the existence of viable forms of social life.

The importance of this debate for this opening chapter is that it helps to lay bare a series of tensions to be found in research on health and illness. Opposition between illness and disease, lay beliefs and professional knowledge, subjectivity and objectivity - in short, opposition between the worlds of patients and doctors - has been a major theme in medical sociology. Good argues that each mode of thought and practice should be regarded, relativistically, in its own social context. In this way the form and content of each can receive proper attention. Though this relativism may, in turn, avoid awkward questions of how we evaluate one form of culture against another (Gellner 1992), Good's approach does, at least, point to the real difficulties of maintaining a strict separation between the ideas, beliefs and practices of 'lay people' and the scientifically based knowledge of professional health care workers and 'experts'. In following such a line of argument, however, it is equally important not to fall into the trap of treating all lay ideas as if they are true and expert ideas as inherently suspect. A route out of this dilemma is to pay attention to the social consequences of beliefs (whether lay or professional) within a value framework that has a continuing commitment to the relief of pain and suffering. As will be seen in chapter 6, Good's 'soft relativism' in exploring the lay/professional divide is tempered in this way and by a strong adherence to empirical evidence on the nature of such consequences.

In any event, institutional changes in late modern societies are themselves undermining the maintenance of strict dividing lines and boundaries between lay and professional modes of thought. Not only have critiques of an empiricist science and of depictions of 'irrational' lay ideas emerged to challenge such oppositions, but the social conditions which have sustained these distinctions, and the intellectual positions related to them, have also altered in a number of significant ways.

Again, as argued in the introduction to this book, disease, illness, health and medicine all occur today in a social context of considerable complexity. The development of health promotion, the related but separate processes of the massive information explosion on health and medicine, the decline in the central position of medical authority as the unquestioned source of knowledge and the growth of pluralistic forms of health care, including 'alternative' forms of medicine, all point to the relative decline in the pre-eminence of 'objectivist' science criticised by Good.

The study of health beliefs has therefore turned, in recent years, from a focus on the gulf between lay and scientific modes of thought to one where each is considered in a context of rapid social change. This shifting scene is characterised by considerable overlap and erosion of boundaries. Today, people's lay knowledge of health and illness is likely to be studied as much as their lay beliefs. However, before developing this argument in more detail, there is first a need to sketch in the influential legacy of the 1970s, in which a clear lay/professional divide was propounded. From there it will be possible to look at the emergence of social research on health beliefs (influenced by the kind of anthropological insights discussed above) and then the further exploration of ideas about lay knowledge.

The Lay/Professional Divide in Medical Sociology

The origins of the sociological, as opposed to the anthropological, study of health beliefs can be seen in the examination of the issues of medical dominance, illness behaviour and lay referral processes in the use of medical services. During the 1960s and 1970s a critical analysis of the power of medicine was developed, reacting to the rapid growth in importance of medical thought and practice following the Second World War. This was especially related to the massive increase in medical activity in the US and its expansion in the rest of the 'developed world'. Although, as Strong (1979a) has argued, the critical sociologists were, of course, engaged in seeking greater social influence for themselves in setting out their case, the argument ran that doctors and a ('mechanistic' or 'objectivist') biomedical model were exercising undue influence over the organisation of health care and over the lay public in general. Attention to illness behaviour and lay referral processes also aimed to act as a counterweight to the widespread medical view that patients exhibited irrational tendencies in responding to symptoms, and in deciding whether to use services or not. Doctors routinely complained that patients both delayed seeking help and presented with trivial complaints, especially to GPs' surgeries. These paradoxical injunctions can still be heard emanating from the medical profession today.

The most cogent sociological critique of professional power, at this time, was that of Eliot Freidson (1970a, 1970b). In his influential book, Profession of Medicine, Freidson put forward the idea that the world of medicine and doctoring, based on a technical/scientific model of disease, stood in sharp contrast to that of lay persons and patients and their concerns with illness. As a result, Freidson argued, the increasing organisation and extension of modern medicine posed a threat to the civil liberties of modern populations. This was partly because medicine's professional autonomy frustrated proper regulation by the state, and partly because its monopoly over determining what was, and what was not, illness effectively excluded patients' concerns from medical practice. From the dominant medical perspective, patients' perceptions and beliefs were either ignored or rejected out of hand (Freidson 1970a).

In short, Freidson argued, there existed an inherent conflict of perspectives between doctors and patients (Freidson 1970a: 323). In contrast to Parsons' (1951) earlier claim that there was a high degree of reciprocity between doctors and patients, Freidson argued that conflict was built into modern medicine. This, in turn, was based on fundamental differences between the biological and social realms in understanding illness. Freidson stated:

While illness as a biophysical state exists independently of human knowledge and evaluation, illness as a social state is created and shaped by human knowledge and evaluation.

(1970a: 223, emphasis in original)

The main point of this argument was to underline Freidson's contention that illness as a form of social deviance is 'imputed and not merely "there"' (p. 222). Labelling theory, which was developed in the 1960s to provide a critical account of deviance in modern society, could thus be extended to take into account all forms of illness, and not just mental illness, to which it had been applied by writers such as Scheff (1966), This extension, Freidson and his followers hoped, would bring a critical edge to bear on the study of medical practice as a whole. The processes involved in the 'imputation' of illness by doctors, and their institutionalised expression in the modern clinic, where doctors exercised considerable power relative to lay people, led Freidson to argue that:

while the patient can be involved in mutual participation by virtue of his [sic] similarity to the therapist, he is never wholly cooperative. Given the viewpoints of the two worlds, lay and professional, in interaction, they can never be wholly synonymous. And they are always, if only latently, in conflict.

(Freidson 1970a: 321)

While the main focus of Freidson's work was more concerned with the analysis of medical work and developing a critique of professional autonomy than it was with lay conceptions of illness, this approach opened the way to a greater recognition of the place of the patient and of lay views. An important space opened up in which a more relativistic analysis could be developed in which patients' views could be examined in their own right. Note here, however, that at this time when the lay/professional divide was discussed it was mostly patients' views of illness rather than their beliefs about health that were under consideration. Problems associated with the treatment of illness rather than the promotion of health dominated the policy and research agendas, and most sociologists at this time were concerned with observing doctors and patients in the context of the hospital or clinic, rather than the broader canvas of everyday life in the community. As argued above, the shift towards a more explicit concern with health beliefs in medical sociology coincided with a growing crisis in modern medical practice and health care systems, and a change towards health promotion policies.

Observational studies dominated the emerging medical sociology research agendas in the UK in the 1970s and were concerned with examining medical dominance and 'lay experiences' of patients within the medical encounter. Bloor (1976), for example, studied the 'decision rules' involved in the imputation of the diagnosis of tonsillectomy in patients in ENT clinics, and showed the way in which lay views were effectively ignored or circumvented by the routines employed by doctors. Similarly, Strong studied the 'ceremonial order of the clinic' and the 'bureaucratic format' through which decisions in hospital paediatric services exercised 'powerful control over the shape and content of medical consultations' (Strong 1979b: 212). Though following Freidson's views on the power of the medical profession and the lay/professional divide, Strong attempted to finesse this approach by stressing the complexities of medical encounters, and the use of ceremony and 'medical gentility', as part of maintaining control over the patient. Strong's work was influenced as much by Goffman's 'micro sociology' of interactional rules as by Freidson's rendition of labelling theory. The hospital had become a convenient focus for sociologists' concern with examining the ways in which 'negotiated order' could be constructed in modern societies (Strauss et al. 1963).

The other related concern in sociological research during this period was with debates about access to and utilisation of health care. Here, sociologists also sought to challenge the dominant medical perception of the 'proper' or 'appropriate' use of services by asking what led people to seek help in the first place. The medical approach seemed to rest on the assumption that people should be educated just enough to recognise symptoms correctly and actively seek help at the right time, and then become passive again once in the doctor's surgery, ready to comply with 'doctors' orders' (Bloor and Horobin 1975; Stimson 1974). By contrast, sociologists were keen to situate such help-seeking action in the contexts and social circumstances of people's lives. Again, it was hoped that such work would show that lay people's actual perceptions and actions contained a greater degree of rationality than doctors were prepared to admit, and that ideas of 'educating' patients about appropriate conduct, and bringing them in line with professional dictates, were largely misplaced.

David Mechanic's earlier work had identified a series of factors that might explain lay people's illness behaviour. These included lay perceptions concerning the seriousness of symptoms, competing needs such as work or home life and the availability and perceived benefits of services (Mechanic 1968, 1978)....

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of illustrations
• Acknowledgements
• Introduction: Health, illness and sociology
• 1 From illness behaviour to health beliefs and knowledge
• 2 Inequalities in health
• 3 Doctors, patients and interaction in health care
• 4 Chronic illness and disability
• 5 Death and dying
• 6 The body, health and risk
• References
• Index