David Mechanic

The concept of illness behavior.

ONE OF the principal tasks of the medical sciences is to understand and determine the conditions under which particular symptoms or disease entities arise either in individuals or among groups of individuals. Public health physicians have the further problem of effecting the arrival of “ill” persons at medical settings so that treatment can be effectively administered. Whether we concern ourselves with the necessary conditions for building adequate etiological theories or those for bringing treatment to persons most in need of such help, it is necessary that we understand the influence of a variety of norms, values, fears, and expected rewards and punishments on how a symptomatic person behaves. Such considerations lead us to propose a concept of illness behaviour. By this term we refer to the ways in which given symptoms may be differentially perceived, evaluated, and acted (or not acted) upon by different kinds of persons. Whether by reason of earlier experiences with illness, differential training in respect to symptoms, or whatever, some persons will make light of symptoms, shrug them off, and avoid seeking medical care; others will respond to the slightest twinges of pain or discomfort by quickly seeking such medical care as is available. In short, the realm of illness behaviour falls logically and chronologically between two major traditional concerns of medical science : etiology and therapy. Variables affecting illness behavior come into play prior to medical scrutiny and treatment, but after etiological processes have been initiated. In this sense, illness behavior even determines whether diagnosis and treatment will begin at all. We are here dealing with an area important for public health and medical sociology and it becomes a matter of both theoretical and practical concern to discover the sources and consequences of different illness behaviors. And if, in given populations, there are systematic differences in illness behavior, this fact has obvious implications for public health programs [5]§, estimated needs for medical care, medical economics, and our understanding of health and illness in general. That the behavioral sciences can shed some light on such questions is indicated, for example, by the researches of Koos and Saunders. Koos [7] found that upper class

Social psychologic factors affecting the presentation of bodily complaints.

PATIENTS often recognize symptoms for which they seek medical assistance, but, on the basis of a history and physical and laboratory examination, the physician cannot obtain evidence to account for...

Sex differences in psychological distress among married people

This study examines the influence of various factors, including role responsibilities and satisfaction, on depressive mood. Various competing hypotheses concerning the factors related to depression are explored using data from a study of psychological distress in a representative sample of a Midwestern community (N = 1,026). Although women reported more distress than men, the largest difference among married people was between employed married men and housewives. Employed married women experienced slightly less distress than housewives, but having minor children in the household was especially stressful for these women and counteracted the advantage of employment. The effects of children in the household on distress were strongest among working women with lower family incomes. These data support the hypothesis that the strain of working and doing the majority of the work associated with raising children increases distress among married women.

The Functions and Limitations of Trust in the Provision of Medical Care

Trust, the expectation that institutions and professionals will act in ones interests, contributes to the effectiveness of medical care. With the rapid privatization of medical care and the growth of managed care, trust may be diminished. Five important aspects of trust are examined: technical and interpersonal competence, physician agency, physician control, confidentiality, and open communication and disclosure. In each case, changing health care arrangements increase the risks of trusting and encourage regulatory interventions that substitute for some aspects of trust. With the increased size and centralization of health care plans, inevitable errors are attributed to health plans rather than to failures of individual judgment. Such generalized criticisms exacerbate distrust and encourage micromanagement of medical care processes.

Management of mental health and substance abuse services: state of the art and early results

Managed care (MC) refers to capitated practice (HMOs), utilization management (UM), and programs of case management for persons with mental illness and problems of substance abuse. These approaches differ substantially, and within each type are variations. Management of mental health and substance abuse services is increasingly prevalent, often sharply reducing costs. Savings result from reducing inpatient hospitalization and, sometimes, by substituting less expensive services for more costly ones. Most studies of managed care, however, measure costs narrowly, neglecting shifts in costs to patients, professionals, families, and the larger community. Strategies typical of HMOs and UM may result in lower-quality care for persons with serious mental illness and problems of substance abuse. Studies on this topic are reviewed, an analytic frame of reference is presented, and research needs are defined.

Sex Differences in Medical Care Utilization: An Empirical Investigation

This study examines factors related to sex differences in outpatient medical care utilization in a representative sample from a defined geographical area. Medical care use was measured using records from virtually all providers in the area. The multivariate model developed explained more than 80% of the sex difference in outpatient utilization in the year preceding the interview, but only about one-third of the difference in the year after the interview. The most important predictors of sex differences were reported number of chronic health conditions and whether or not a woman gave birth during the study period. The analyses of these data and data from other studies indicate that part of the sex differences in utilization can be attributed to real differences in health. Adjusting utilization rates for reported tendency to use physician services and belief in preventive medicine also helped explain the sex difference, but only for prior use.

The experience and reporting of common physical complaints.

Data from a sample of young adults first studied in 1961 are used to examine factors influencing reports of common physical complaints in 1977. Among the factors associated with such symptom reports are the childs illness behavior in 1961, retrospective reports of family interaction during childhood, measures of psychological state, and subjective measures of physical health status. Reported parental behavior appears to affect symptom reporting primarily through its influence on subjective psychological and physical health. It is hypothesized that reporting common physical symptoms is part of a pattern of illness behavior and response, shaped by childhood training and responsive to personal stress and the occurrence of body dysfunction.

The effect of psychological distress on physician utilization: A prospective study.

This paper examines the hypothesis that psychological distress is causally related to physician utilization among enrollees in a prepaid group practice. Measures of distress are constructed from questions included in a servey interview, while the utilization data come from medical records. Distress levels were measured prior to the period of utilization studied. The results show a positive relationship between distress and physician utilization, which persists even when a variety of sociodemographic, attitudinal, and health status variables have been controlled. The results are discussed in terms of a perspective that emphasizes social-psychological needs as triggers for physician utilization

Social selection in seeking help for psychological problems.

Social selection in seekingcarefor psychological problemsfrom psychiatric services, counselingservices, clergymen, medical services, and otherformal agencies was explored among 1,502 randomly selected university students, and their analysis was partially replicated in a prospective analysis of a subgroup of 274 students who werefollowed up two years later. Special samples were also studied of applicantsJor service from a university psychiatric unit and a counseling center. Sociocultural characteristics, attitudes, knowledge, reference group orientations, and degree of psychological problems all had independent effects on use of helping services. However, some of these variables affected generalized help-seeking behaviors while others had an effect primarily on the specific types of help consulted. While psychological distress plays a major role in seeking help, its influence is largely independent of sociocultural, attitudinal, and reference group factors.

Adolescent competence, psychological well-being, and self-assessed physical health

Longitudinal data from 1,057 adolescents in 19 public schools indicated that self-assessments of physical health were influenced by competence in several important areas of adolescent life and by psychological well-being, but not by physical symptoms. Specifically, adolescents who reported higher levels of school achievement and more participation in sports and other exercise assessed their health to be better over a one-year period, when we controlled for initial self-assessments, than those who reported lower achievement and less participation. Physical health status, as measured by common physical symptoms, was associated cross-sectionally with self-assessed health, but its longitudinal effect was mediated by initial levels of self-assessed health. Other longitudinal results showed that adolescents who were initially less depressed assessed their health more positively. The inclination among adolescents to associate competence and psychological well-being with self-assessed physical health may contribute to the expression of distress in somatic terms later in life, and may help explain this commonly observed pattern among adults.