Illness and Sick-Role Behavior (Encyclopedia of Public Health)
Generally, health-related behaviors of healthy people and those who try to maintain their health are considered as behaviors related to primary prevention of disease. Such behaviors are intended to reduce susceptibility to disease, as well as to reduce the effects of chronic diseases when they occur in the individual. Secondary prevention of disease is more closely related to the control of a disease that an individual has or that is incipient in the individual. This type of prevention is most closely tied to illness behavior. Tertiary prevention is generally seen as directed towards reducing the impact and progression of symptomatic disease in the individual. This type of prevention is highly related to the concept of sick-role behavior. In general, illness and sick-role behaviors are viewed as characteristics of individuals and as concepts derived from sociological and sociopsychological theories.
The concept of illness behavior was largely defined and adopted during the second half of the twentieth century. Broadly speaking, it is any behavior undertaken by an individual who feels ill to relieve that experience or to better define the meaning of the illness experience. There are many different types of illness behavior that have been studied. Some individuals who experience physical or mental symptoms turn to the medical care system for help; others may turn to self-help strategies; while others may decide to dismiss the symptoms. In everyday life, illness behavior may be a mixture of behavioral decisions. For example, an individual faced with recurring symptoms of joint pain may turn to complementary or alternative medicine for relief. However, sudden, sharp, debilitating symptoms may lead one directly to a hospital emergency room. In any event, illness behavior is usually mediated by strong subjective interpretations of the meaning of symptoms. As with any type of human behavior, many social and psychological factors intervene and determine the type of illness behavior expressed in the individual.
Considerable research exists showing the importance of age and gender in illness behavior. Illness behavior, as shown in the use of medical services, is far greater in women. Many studies have linked illness-behavior variation to ethnicity, education, family structure, and social networks. Illness behavior is also shown to be related to health care coverage and insurance. Most importantly, illness behavior is highly related to socioeconomic status. Classic studies done in the 1950s powerfully demonstrated that socioeconomic class influenced how symptoms were acted on, with lower-class individuals (lower in socioeconomic status) most likely to delay seeking professional health care even when presented with severe symptoms.
While much of the early work on illness behavior was seen in the context of understanding patient help-seeking behavior, the large research literature on illness behavior has gone well beyond this more narrow medicalized view. Many studies have considered the different perspectives of illness behavior held by individuals and health care practitioners. The differing worldviews of patients and practitioners are now seen as highly relevant to illness behavior. The medical practitioner and the individual experiencing symptoms go through very different appraisals of the meaning of the symptoms. Increasingly in the literature there is the recognition of the strong relationship between the physical and mental experience of symptoms and the meaning of that experience for illness behavior. David Mechanic, a pioneer in the study of illness behavior, best summarizes the current perspective on illness behavior: "Illness behaviors arise from complex causes, including biological predispositions, the nature of symptomatology, learned patterns of response, attributional predispositions, situational influences, and the organization and incentives characteristic of the health care system that affect access, responsiveness and the availability of secondary benefits" (Mechanic, 1995).
The sick role is a concept arising from the work of the important American sociologist Talcott Parsons (1902979). Parsons was a structural functionalist who argued that social practices should be seen in terms of their function in maintaining order or structure in society. Thus Parsons was concerned with understanding how the sick person related to the whole social system, and what the person's function is in that system. Ultimately, the sick role and sick-role behavior could be seen as the logical extension of illness behavior to complete integration into the medical care system. Parsons' argument is that sick-role behavior accepts the symptomatology and diagnosis of the established medical care system, and thus allows the individual to take on behaviors compliant with the expectations of the medical system. Basically, Parsons defined the "sick role" as having four chief characteristics. First, the sick person is freed or exempt from carrying out normal social roles. The more severe the illness, the more one is freed from normal social roles. Everyone in society experiences this; for example, a minor chest cold "allows" one to be excused from small obligations such as attending a social gathering. By contrast, a major heart attack "allows" considerable time away from work and social obligations. Second, people in the sick role are not directly responsible for their plight. Third, the sick person needs to try to get well. The sick role is regarded as a temporary stage of deviance that should not be prolonged if at all possible. Finally, in the sick role the sick person or patient must seek competent help and cooperate with medical care to get well. This conceptual schema implies many reciprocal relations between the sick person (the patient), and the healer (the physician). Thus the function of the physician is one of social control.
The complicated theoretical explanations of Parsons yielded a voluminous research literature in the second half of the twentieth century, and they continue to stimulate much research today. In particular, there has been much study of the norms and values that define the behaviors of both the sick and those providing treatment. These studies form the basis for present-day research on the patient-physician relationship. They inform the various strategies undertaken by behavioral scientists to intervene in this relationship to bring about positive behavioral changes in both patient and practitioner that will lead to better health outcomes.
There are many research issues attendant to understanding this complicated relationship between patient and practitioner. One paramount issue is that of the differential power of the participants in the relationship. According to this view, the superior power of the physician, in terms of technical expertise and status, will more effectively induce the patient toward a positive medical outcome. It is this superior power that helps make possible the often painful procedures to which the patient concedes.
CONCEPTS OF ILLNESS BEHAVIOR AND SICK-ROLE BEHAVIOR IN PUBLIC HEALTH
In present-day public health practice, which is based on population and community-based approaches with an emphasis on participation, the research from these concepts of behavior has helped immensely in clarifying critical approaches to public health. The concept of diversity in populations has been greatly enhanced through the articulation of the concepts of illness behavior and the sick role. Researchers now have a significant body of research showing the wide variation in these behaviors with respect to all the key demographic variables. For example, there has been excellent work showing how the presentation of symptoms to a physician is highly dependent on gender, ethnic background, and other sociocultural characteristics. Research on the sick-role concept has elucidated the issue of power and its many manifestations in doctors' offices, hospitals, and other medical settings. It would be difficult, given this literature, for a practicing health educator not to consider the role of power in patient-physician interactions.
Present-day health education has also been heavily influenced by the research on illness and sick-role behavior. These concepts have helped inform part of the scientific basis for the educational and environmental approach to health promotion planning elucidated by L. W. Green and M. W. Kreuter in their widely used PRECEDEPROCEED model. At the same time, the conceptual components of illness and sick-role behavior continue to be explored in narrative analyses of the written and spoken traditions of peoples to describe their experiences of illness and sickness.
DAVID V. MCQUEEN
(SEE ALSO: Behavior, Health-Related; Health Belief Model; PRECEDE-PROCEED Model; Psychology, Health; Self-Care Behavior; Social Determinants)
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