Consultation and illness behaviour in response to symptoms: A comparison of models from different disciplinary frameworks and suggestions for future research directions
Introduction
In 1962 Mechanic (1962) coined the term ‘illness behaviour’ to encompass, “the varying ways individuals respond to bodily indications, how they monitor internal states, define and interpret symptoms, make attributions, take remedial actions and utilise various sources of formal and informal care” (Mechanic, 1995, p1208). Since then, social scientific interest in illness behaviour has continued unabated; social scientists argue that a detailed understanding of the social and cognitive processes involved in responding to symptoms is essential for effective self-management and better health service use.
Most social scientific research has focused on explaining, or attempting to predict, formal help-seeking or use of preventative health services (see e.g. Calnan, Wainwright, O'Neill, Winterbottom, & Watkins, 2007; Rogers, Hassell, & Nicolaas, 1999; Uehara, 2001). Dingwall (2001) characterised existing models of help-seeking as ‘individualistic’ or ‘collectivist’. Individualistic models, such as the Health Belief Model (Rosenstock, 1974), focus on explaining behaviour with reference to personal characteristics or rational cognitive processes. Collectivist models, such as that described in Zola's classic study ‘From person to patient’ (Zola, 1973), focus on explaining behaviour in relation to factors such as access to services or interactions with others. One influential model, the Behavioural Model (Andersen, 1995), combines aspects of individualistic and collectivist perspectives in recognising the importance of psycho-social influences (such as attitudes and beliefs) and of enabling resources (such as access to care). A common criticism of all models of healthcare use is that they focus on explaining a singular decision to seek professional help whereas the decision is better represented as a process, a series of smaller decisions or actions that are taken and reflected on over time. In addition, the use of survey data to assess the Health Belief and Behavioural Models means that characteristics such as gender or ethnicity are used as proxies to measure social structural factors. Such proxy measures inadequately represent the social context of people's lives and belief systems (Biddle et al., 2007; Pescosolido, 1996) or more preformative understandings of gender and ethnicity.
More dynamic models recognise help-seeking as part of a broader, socially embedded, ‘illness career’, comprising the complex processes, multiple ‘small’ decisions and ‘recipes’ of action (Robinson, 1971) that take place as symptoms are experienced, evaluated and managed. In these understandings, as Biddle et al. (2007) point out, “Illness behaviour is not a simple decision about professional help-seeking but a multi-faceted, protracted career composed of a plurality of strategies […invoked] during the process of coping with symptoms” (p984). ‘Illness career’ approaches focus on the process as well as the outcome of decisions, addressing such questions as ‘how do people come to feel ill and what do they do about it?’ rather than ‘who uses formal services?’ (Biddle et al., 2007; Calnan et al., 2007; Dingwall, 2001; Rogers et al., 1999). In sociology these models are best represented by the Illness Action Model (Dingwall, 2001), the Network Episode Model (Pescosolido, 1991, 1992) and the multilevel network episode model (Pescosolido, 1996), and in psychology by the Common Sense Model of the Self-Regulation of Health and Illness (Leventhal, Leventhal, & Contrada, 1998), hereafter called the Common Sense Model.
These models characterize response to symptoms as an iterative process. The Common Sense Model has been particularly influential although all have informed subsequent research to some degree (see e.g. Locker (1981), Calnan et al. (2007) and Biddle et al. (2007) for research that references the Illness Action Model; Hagger and Orbell (2003) for a review of the application of the Common Sense Model, and Wearden and Peters (2008) for an overview of interventions designed on the Common Sense Model; and Pescosolido and Boyer (1999) and Pescosolido, Garder & Lubell (1998) for applications of the Network Episode Model in mental health services).
However, researchers who apply these models have largely operated in disciplinary silos, with little cross-referencing, and little recognition of the existence of alternative formulations of the same problem. Surprisingly, to our knowledge, there has only been one previous attempt to integrate sociological and psychological understandings of responses to symptoms (Dracup et al., 1995), but this model only focussed on individual responses, and has not been widely applied in subsequent research. In short, neither sociologists nor psychologists have recognised, acknowledged or built on relevant research in other disciplines, resulting in wasted intellectual and empirical effort, an absence of accumulation across disciplines and an unhelpful entrenchment of the disciplinary divide between psychology and sociology.
In this paper we attempt to bridge this divide to describe and critically compare the Illness Action Model, the Common Sense Model and the Network Episode Model as part of an iterative process to develop an integrated interdisciplinary framework to understand, and influence, response to symptoms. First, we describe each of the three models in detail, drawing out key differences and similarities between them. We go on to describe how an integrated framework for understanding response to symptoms can focus at the same time on interpretation, action and evaluation influenced by knowledge, by embodied experience of symptoms and by resources one has available. With reference to some other literatures, we suggest that this process, in turn, needs to be understood in the context of social networks, culturally influenced expectations of illness and services, and social structure. We suggest that changes in knowledge, or symptoms, or resources can precipitate a re-evaluation of the most appropriate responses to underlying bodily states. Finally, we identify a challenging agenda to further develop an integrated symptom-response framework that has the potential to inform more effective policies.
Section snippets
The Illness Action Model
The intellectual origins of the ‘Illness Action Model’ (Dingwall, 2001) lay in the sociology of deviance. Dingwall argued that illness can be seen as a failure of everyday life, that “being ordinary was something we had to work at. We had to know what it would take to ‘be ordinary’ and we had to be able to command the skills and resources, including our own bodies, to do this.” (Dingwall, 2001; ppix).
In developing the model, Dingwall placed importance on interactions between human actors and
The development of an integrated symptom-response framework
As we have seen, there are many similarities but some differences between the models. Given the similarities and evidence complementarities we suggest bringing them together in an integrated symptom-response framework that will better enable an accumulation of knowledge across disciplines. An integrated symptoms-response framework would include the iterative processes of recognising, interpreting and responding to illness at an individual level (emphasised in the Illness Action and Common Sense
Challenges for developing and applying an integrated framework
In this paper we have compared three, dynamic, models of response to symptoms; two from sociology (the Illness Action and Network Episode Model) and one from psychology (the Common Sense Model). We have shown that despite origins in completely different intellectual disciplines, and positions within disciplines, they have some remarkable similarities. In particular that: the purpose of illness behaviour is to (re)achieve normality in physical or social functioning; interaction with others is
Acknowledgements
Kate Hunt is funded by the Medical Research Council (Gender and Health Programme MC_A540_5KT50).
Consideration of the methodological approaches to test the integrated framework benefitted from discussions with many colleagues, including, in relation to cultural understandings of the concept of ‘candidacy’ Sara Macdonald.
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