1. SOCIAL AND COMMUNITY PERSPECTIVES
Understanding Lay Beliefs
  18th February 2003

2. 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

3. 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.

4. 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

5. 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?

6. 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’

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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)

19. Making sense of cancer Stress Physical environment
Personal differences
Fatalism
Personal Behaviour

20. 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)

21. Physical environment e.g. chemicals
Gill blamed : “sprays on the fields and things like that”.

22. 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).

23. 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)

24. 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)

25. 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)

26. Lay beliefs and medical consultations
Before consulting a doctor people often consult family and friends
 Lay referral system (Freidson, 1970)

27. 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

28. 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

29. 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

30. 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”

31. Delayers Used medical and non-medical treatments: Attempted to treat
Lay consultation
Use of personal/contextual information – being working ‘too hard’, something eaten

32. 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.

33. 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

34. 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

35. 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

36. 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