0277-9536189 S3.00+0.00 Copyright c 1989 Pergamon Press plc

Sm. Sci. Med. Vol. 29, No. 2. pp. 117-123, 1989 Printed in Great Britain. All rights reserved

INTRODUCTION

CONCEPTUAL, THEORETICAL AND METHODOLOGICAL ISSUES IN SELF-CARE RESEARCH

KATHRYN DEAN Institute of Social Medicine, University of Copenhagen, Panum Institute, Blegdamsvej 3,

DK-2200 Copenhagen, Denmark

The research articles in this special issue of Social Science & Medicine range from exploratory descrip- tive studies to population surveys using complicated multivariate statistical techniques to evaluation stud- ies of self-care interventions with and without random allocation of subjects. The manuscripts sub- mitted in response to a call for papers dealing with the subject of self-care were almost exclusively reports of empirical investigations. Few of the manuscripts focused on subjects of theory and concepts or ad- dressed methodological issues in self-care research. Given the fundamental importance of theoretical development, conceptual clarification and sound methodology two papers were solicited one from Ilona Kickbusch, addressing theoretical aspects of self-care in the context of health promotion, and the second from Svend Kreiner, a statistician who has specialized in methods for analysing population data, addressing methodological problems in the statistical analysis of complex health and social data. Some conceptual and theoretical issues which have method- ological aspects are also addressed in the introduc- tion.

It came as a surprise, in view of the widespread debate engendered by the subject a number of years ago, that so few of the papers focused on theory and concepts of self-care. An explanation may lie in the observations of De Ftiese et al. that self-care, while alive and well both within and outside formal health care services, as a subject in sociomedical research is being absorbed into the language of wellness and health promotion which are less threatening to health service professionals. If this is so, are there reasons to maintain self-care/self-help terminology? Are there conceptual and theoretical issues specific to the sub- ject of self-care, and distinct from those concerned with wellness or health promotion, which are impor- tant and relevant to consider? It is argued below that there are important reasons to maintain the termin- ology and to develop theory and related concepts dealing with self-care as a major determinant of human health and function.

A brief look at self-care as a subject of interest in the health field will help in the consideration of these questions. What is self-care? What do we know about it? What do we not know? How do we find out what we need to know? Although none of the manuscripts in this issue provide an overview of conceptual issues and empirical information, taken together they illus- trate that a general consensus on a definition of

self-care has begun to emerge. These articles and the research literature they cite also provide a fairly good representative overview of what is known about self-care as it has been operationalized in research investigations thus far.

WHAT IS SELF-CARE?

After an initial period with some discussion regard- ing whether or not the subject of self-care should be defined as a narrow or broad behavioural concept, a consensus emerged that self-care represents the range of behaviour undertaken by individuals to promote or restore their health. In earlier discussions of definitional issues some argued for narrow definitions of self-care as lay behavioural responses to illness in contrast to professional care. A narrow concept focused on illness ignores the extensive evidence of the role of personal behaviour in health protection. Polarizing the subject as opposite to or contrasted with professional care also fails to recognize, even with regard to illness, the range and importance of self-care. Medical contacts do not occur without symptom evaluations and decisions made by lay persons, decisions that generally are preceded and followed by self-treatments. With regard to chronic illness, self-care which often constitutes the bulk of the care of a given condition, usually takes place in conjunction with professional care.

Both the range of the manuscripts and the definitions of self-care in most of them reflect the consensus that has evolved regarding a broad concept of self-care. De Freise et al. define self-care as actions taken by lay persons in their own health interest without formal medical supervision, while Shuval and her colleagues include behaviour performed un- der the directives of health care professionals. The intervention studies serve to remind us that even when professionals prescribe or teach behaviour, performance still depends on the acceptance, motiva- tion and capacity of the lay individual. Van Agthoven and Plomp in their conceptualization of self-care add the dimension of responsibility for one’s own deci- sions and care along with a corresponding right of say in that care. Self-care as a goal is introduced in their concept. The consensus which has emerged in these definitions of self-care is on a broad concept incorpo- rating notions of autonomy and influence. In these concepts the meaning of behaviour shifts from that in the traditional concepts of health behaviour and

117

118 Introduction

illness behaviour where people seek care or utilize screening or curative professional services to some- thing they do themselves. Self-care is active, it is participation rather than passive receiving of care or directives given by professionals.

Is self-care behaviour the same as health promo- tion or wellness? It can be a form of health promo- tion, and might contribute to wellness, which is a goal of both self-care and of health promotion, but they are not the same. Health promotion is a broader concept. Self-care is personal behaviour that can influence health, but many other things also influence health, the physical and social environment, eco- nomic conditions, heredity, health services. Promot- ing the health of populations involves the actions of participants at different levels of society. Both the concepts of self-care and health promotion are mud- dled by not distinguishing between them. It is perhaps even more problematic to individualize the concept of health promotion than to bury the concept of self- care behaviour in the broader concept.

What about the problem that the term self-care appears to bother some professionals. Would it be better to just stay with the old terminology of health and illness behaviour. I think not. There are more important reasons for terminology recognizing the central role individuals play in their own care. While self-care behaviour is certainly not new, but rather the oldest and most widespread of all forms of behaviour that affect the health of individuals, the use of the term in the health field is new. It is a response to developments and attitudes regarding the role of individuals that occurred over the past hundred years or so. During the era dominated by the germ theory of disease, individual behaviour and social environ- ments were not considered important in health and health care. Health was considered preserved or restored by professional care either preventing specific diseases with immunization or treating dis- eases with chemical agentsiremoval of diseased parts of the body. The limitations of this model of health via disease are increasingly recognized. Health cannot be reduced to experts attenuating an unlimited array of potential disease agents. The crucial role of the strength and vitality of the ‘host’ is again gaining recognition. It is thus important to maintain focus on self-care behaviour as a factor among many that are essential to health protection.

The rapid changes in the organization, content and delivery of formal health services also suggest another reason for maintaining the term self-care and devel- oping associated theory and concepts. The major health problems of modern societies are long term chronic conditions which depend on effective self-care for maintenance of function and residual health. The input needed from the health system for these condi- tions involves effective listening. encouragement and guidance to help people to help themselves. Health care in the sense of the term care is needed rather than the administration of treatments to passive patients. During the historical period of shift from acute to chronic diseases, with the corresponding increase in the need for human caring, health service systems have been transformed into bureaucratized, technical systems of ever increasing specialization. People are less heard and more alienated. They are patients

subjected to tests and treatments with machines which are often overwhelming and dangerous. It is precisely knowledgeable people acting in their own health interests that are necessary if these systems are to achieve a balance between the caring needs and technological potential of modem societies.

In the consideration of these concerns regarding the meaning of self-care in modern societies. a key research question is the extent to which our knowl- edge about self-care contributes to understanding the processes that maintain health and provides a useful knowledge base for health promotion.

WHAT DO WE KNOW ABOUT SELF-CARE?

Paradoxically, it must be concluded that what is known about self-care is at one and the same time a great deal and very little. A major part of the problem when assessing what is known about the subject arises from the fact that most of the information on self- care must be extracted from investigations conducted for other purposes by a broad range of disciplines using different methods.

It is known from behavioural epidemiology that personal behavioural practices influence health, func- tion and longevity. This body of research, however, provides little useful information about how be- havioural influences interact with other factors that affect health or about the processes that shape be- haviour. Findings reported in this issue suggest pat- terns in behavioural practices that affect health, e.g. heavy consumers of tobacco are also often heavy consumers of alcohol (Calnan and Dean in this issue); men in contrast to women more often display pat- terns of health damaging behaviour (Dean). It ap- pears that social network variables are important in the initiation of smoking and that socio-economic status is related to patterns of tobacco and alcohol consumption. It also appears that health maintenance and illness related self-care may be unrelated (Haug and Dean in this issue). Very little is known about behaviour consciously undertaken to promote or protect health. Gender may influence a tendency toward more conscious health protection among females (Dean) as well as the greater risk taking behaviour of males.

From numerous anthropological, sociological and health services research investigations. it is known that the bulk of all care in illness is self-care [l]. While little researched, the data which is available suggests that illness related self-care is in most cases appropri- ate and effective [2]. It is generally ‘softer’ and low-tech compared to professional care, often involv- ing social approaches or responses to promoting health or treating illness. Therefore, it may be safer than professional approaches to the same problem. The evaluation studies reported in this publication provide evidence that self-care interventions can be effective in improving the knowledge and the health related decision making of mothers caring for small children (Rasmussen), reducing the frequency and duration of chronic headaches (Winkler et al.), and reducing pain and depression among persons with arthritic conditions (Lorig and Holman). Given the growing evidence on the physiological consequences

Introduction 119

of stress reactions and depression, the potential of self-care for prevention of disease and reduction of existing symptomatology may be considerable.

Other than the literature on utilization of medical services and use of medicines, little study has been directed toward various components of self-care. Large bodies of research literature document the influence of variables in the social situation (cultural values, socio-economic status, education, occupation, family and other social network influences) on deci- sions to seek medical care [3]. Much has been learned about mechanisms of lay referral and attribution of illness in investigations of medical care seeking. In earlier work a great deal of attention was given to cultural influences, and the major importance of lay networks for care and care seeking was recognized.

ON THEORETICAL ISSUES WITH METHODOLOGICAL ASPECTS

In more recent years since the widespread use of standardized computer packages has been adopted, much less attention has been given to theoretically modelling social and cultural influences. It is at this point that theoretical and methodological issues need to be addressed in the next stage of research on the ways in which people act to protect and restore their health. In spite of the considerable advances in the range and quality of options for multivariate analysis of complex population data, a characteristic of the research findings available at this time is fragmenta- tion. Most behavioural investigations of social scien- tists start from some theoretical framework or at least point to a psychological or sociological perspective behind the variables they analyse, but a discussion of the findings in the context of their implications for the theory (for modifications in the theory, discarding the theory or integration of theories) is often lacking.

For example, numerous investigations referring to one or another theoretical construct have studied the influence of health beliefs on behaviour, especially use of professional services, and confirmed an effect controlling for socio-demographic and other vari- ables, but accounting for quite small amounts of the ‘variance’. My interpretation of this literature is that generalized health beliefs, at least as they have been measured thus far, have quite limited influence on both health maintenance behaviour and on decisions to seek professional advice [4]. Beliefs or attitudes encompassing a sense of personal responsibility for and ability to protect health may affect behavioural change in the face of health threat. Findings based on the locus of control construct reported in this publi- cation lend support to this interpretation of the literature. Measures of locus of control, examined in several of the investigations were generally not related to tobacco or alcohol consumption, routine physical exercise, self medication/home remedies or decisions to obtain professional care (Calnan; Segall and Goldstein; Dean). However, an internal locus of control orientation was associated with self-selection into a self-care intervention programme (Winkler et al.) and what appears to be illness related avoidance behaviour (Dean).

It appears that attitudes or beliefs specific to medical care, low faith in or skeptisism regarding

medical treatment may be related to a tendency toward self-treatment in contrast to seeking medical services for symptoms (Haug; Segall and Goldstein), although this tendency was not found in the Danish data (Dean). Perceived seriousness of symptoms and perceived health status which suggest experienced discomfort rather than beliefs. were more important for self-care responses to illness in the studies re- ported here.

This is consistent with what emerged in the inves- tigations focused on professional care seeking. When variables representing the illness experience were introduced into multiple regression analyses of uti- lization behaviour it was found that they produced the major ‘independent’ influence [S, 61. Health beliefs and other psychosocial and social variables exerted little or no influence in most such analyses. There followed a period when findings from large scale population surveys suggested that variables such as perceived seriousness of symptoms, perceived health status and days in bed were the major determinants of use of medical services. Even though these studies still accounted for very small amounts of the varia- tion in utilization behaviour, as assessed in multiple regression procedures, it was concluded that the above mentioned variables, once considered impor- tant, were either quite minor influences or had repre- sented spurious relationships.

During periods of focus on one or another class of variables, age and sex differences in the data are often simply taken for granted or ascribed to age and sex differences in health status. The cultural and social meanings of the variables are generally not discussed in the reports of population research. Findings from qualitative (soft) research are not given serious atten- tion. Neither do qualitative researchers often collab- orate with survey researchers to operationalize and test their findings in population studies.

When particular variables are studied in cross-sec- tional data without thinking through the limits of the statistical procedures and without expanding and revising the theory, a body of knowledge regarding behaviour cannot readily develop. What does it mean when variables representing the way illness is experi- enced produce large beta weights in multiple regres- sion procedures? Is it justifiable to place variables like perceived seriousness of symptoms and bed days as causal factors parallel to other influences in stat- istical procedures that produce relative weights of ‘independent’ influence on a behavioural or health variable. Both theoretical and methodological considerations suggest that it is not. Neither symptom perceptions nor bed days are simple attributes of individuals. Rather, they themselves may more readily assume the role of outcome variables. Indeed, remaining in bed is itself a form of self-care response to illness. Both of these variables are shaped by multiple psychosocial and social factors. What then happens when they are placed in procedures as ‘independent’ factors when they are not independent of other variables in the model. They collect the variation of factors influencing them and thus hide their influence. This potential to hide rather than explicate the nature of influences is one of the limitations of some regression procedures.

120 Introduction

These considerations are illustrated in the research on health beliefs. After over 20 years of study by numerous researchers we understand very little about the influence of beliefs regarding health on behaviour. The position of beliefs in processes of influence is not understood. Their role in the face of other variables that may enlarge or reduce their importance in different circumstances is little studied. As Calnan points out in his discussion of the general lack of influence of the locus of control construct on the behaviours he studied, ethnographic research shows that lay beliefs about health and its control are complex. This is not really surprising since the preser- vation or breakdown of health are the result of many complex forces. He suggests that we need measures more sensitive to lay beliefs, and that a more fruitful area of investigation may be beliefs about the be- haviour rather than generalized beliefs about health.

Findings of other articles in this issue lend support to Calnan’s interpretation. In the Danish data we found that the internal locus of control variable was unrelated to behavioural practices with the exception of male avoidance behaviour in what appears to be responses to existing conditions. On the other hand, ‘knowledge’ (beliefs) that specific behaviours could prevent cancer or cardiovascular disease was related to reporting behaviour undertaken specifically for health reasons. Similarly, Segall and Goldstein found that measures of locus of control were not significantly related to decisions about appropriate self-care or to self-medication in contrast to beliefs regarding the health influence of specific behaviours. Consequently, they also found that skepticism re- garding medical care rather than generalized health beliefs was related to a tendency toward self-treat- ment without medical contact. Haug et al. found that generalized beliefs were not significantly related to decisions to consult doctors for symptoms considered serious in contrast to low faith in medical care. Finally, Bentzen et al. found no effect of generalized beliefs on illness related self-care as they analysed it. Similar to the other studies, attitudes toward doctors (in addition to age, sex and chronic conditions) affected decisions to seek medical care for symptoms during the study period. while age, sex and chronic conditions were the only significant variables related to doing nothing about illness and self-treatment in their analyses.

Does the quite limited evidence regarding general- ized health beliefs mean that they do not influence health behaviour? There is a tendency to consider negative or small effects as unimportant, and there- fore to either not report them or to find elaborate explanations for their possible meaning. Negative or weak findings, however, are a very important part of scientific enquiry and only lose their importance if they are ignored so that they cannot contribute to developing a body of behavioural theory and knowl- edge. The closing selections of many research reports in discussing the small amount of ‘variance explained’ point out that important causes of the behaviour have not yet been found. Still the same or similar variables tend to be studied in the same manner without questioning the approach or methods.

Perhaps it is the search for causes (usually concep- tualized in academic constructs), that needs reconsid-

eration. While the technical approaches and variables under study are somewhat different in behavioural epidemiology and social science studies of behaviour, similar problems in the bodies of research are being discussed.

The theoretical and methodological issues appear to be the same. Procedures that examine relative influence or relative risk imply simple causal relation- ships based on magnitude rather than interacting processes of influence. This is illustrated in the search for the causal effects on behaviour of health beliefs or the identification of some other factor that is the important influence. This search for the cause or major cause is often bound by particular academic disciplines or research traditions. Another example is the separate traditions of behavioural and social epidemiology which have resulted in an excessive focus on discrete behaviours in population interven- tions.

In discussing the epidemiology of coronary heart disease a few weeks ago in the Lancer, McCormick and Skrabanek [7] pointed out that the list of “risk factors” for CHD, now around 250 in number, includes “not having siestas, snoring, having English as a mother tongue, and not eating macherel”. The array of factors for which one can find a ‘relative risk’ is obviously very broad. At the same time, the evidence regarding one risk factor (smoking) about which there is most agreement has developed holes. McCormick and Skrabanek point out that in the Framingham study, smoking was not a risk factor for CHD for women. Likewise they note mortality trends from heart disease in 26 countries over the last 30 years conflict with any notion of a direct causal link between CHD and risk factors. The most striking feature of the trends is the decline in the mortality of women, yet during the same period men smoked less while women smoked the same or more. More than one researcher, they note, has identified ‘a slight decline in risk’ of CHD in light smokers compared to non-smokers.

Similar findings have been found with regard to another important risk factor-alcohol. We would not conclude from a relative risk in the opposite direction that these substances are not potentially dangerous for health. One wonders why concepts and procedures measuring relative risk are not more actively scrutinized and why there is not more con- cern directed toward finding theories. strategies and techniques that help to study levels of influence and multiple influence. Of course much excellent work does just that, but the various research literatures on health related behaviour have become immense with often inconsistent and contradictory results. Looking back to the sixties one is reminded that a great deal was written about levels of influence in aetiological chains [8] and adequate theories of aetiology of disease (the same applies to behaviour) which required specification of important independent vari- ables with linkages through intervening processes and explication of conditions under which patterns hold PI.

It would appear that the persistent and growing gender differences in health and longevity offer fertile ground for exploration of both the processes that shape behaviour and the interacting influences that

Introductign 121

promote health. It would seem important to pay much more attention to gender differences in health and social data and to question inconsistencies that emerge in analyses.

An even more potentially fruitful area of explo- ration in studies directed toward understanding mul- tiple causation and levels of inguence among variables in behavioural research may be age. Often given little attention, age differences may reflect a wide array of cohort effects that go undetected in research where age is viewed as a simple measure rather than representative of numerous interactions among social, psychosocial and functional variables. The important work of Matilda White Riley [lo] on the sociology of age as an analytic framework for understanding processes of influence provides an approach and many suggestions for promising re- search. Discussing the results of her theoretical and methodological work on the interplay of per- sonal ageing and changing social structures, she concludes:

. . . macrolevel changes in society and microlevel changes in individuals are only the polar extremes. To examine how they influence each other we have to probe more deeply into the complex intervening structures and mechanisms that underlie the abstract principle I have outlined [l 11.

Several of the papers in this special issue find age and gender differences that suggest directions for re- search. Many useful theories and models are avail- able for testing and replication in the study of behaviour and health [12]. Research approaches for study of the situational context in which be- haviour takes place, using process models and flexible statistical methods, can help to elaborate levels of influence and meaningfully integrate behavioural theories.

NEED FOR BROAD RESEARCH AND METHODOLOGICAL

DISCUSSION

This special issue reflects the state of the art of self-care research. Contributions range across the field from studies concerned with behavioural prac- tices that have been considered important for health through illness related self-care, to intervention stud- ies and investigations of self-care education, self-help groups, and professional attitudes toward self-care. While the scope of the research is broad, survey studies dealing with self-care behaviour on represen- tative samples of populations and clinical trials of self-care interventions are rare. Methodologically rig- orous longitudinal studies are virtually non-existent.

The studies also reflect something more than the state of the art of research in a subject area that only in recent years has started to receive a focus appropri- ate to its relative importance for the health field. The descriptive papers illustrate the value which descrip- tive research can have for providing information on the scope of an area or on incongruities between professionals and clients which affect the effectiveness or efficiency of health care. Of course, descriptive data can be misused when important information is

wasted or causal influence is incorrectly imputed from findings.

On the other hand, inappropriate use of sophisti- cated statistical techniques, also can be misleading and waste information. Some of the strongest criti- sism from reviewers of manuscripts for this issue has been directed toward what was considered inappro- priate or incorrect use of sophisticated statistical procedures. Disagreement most often revolved around the appropriateness of using analytic tech- niques based on the ‘parametric’ statistical model, a complex technical issue. Because appropriate and sound data analyses are major aspects of the scientific worth and usefulness of social science research, methodological issues, like theoretical and conceptual issues, are essential to consider in the development of the field of self-care research. Therefore, it seems relevant to take this opportunity for open discussion on these subjects. I have asked the statistician, with whom I have been working on technical aspects of methodological and theoretical issues in the study of levels of influence among variables affecting be- haviour and health, to address some of the statistical issues in his paper on methodological problems faced in the analysis of complex health data. He has received an overview of comments from reviewers and was asked to take up major points as briefly as possible. Some of the issues have also been addressed in the communication from Kate Lorig and her colleagues.

Hopefully these discussions of theoretical, concep- tual and methodological issues will continue in other contexts.

The papers which follow in addition to providing valuable information offer many suggestions for potentially fruitful directions for research.

In the first paper, Kickbusch takes up theoretical issues in the study of self-care. Her extensive experience affords special insight into the importance of understanding the social context of self-care for effective health promotion programme develop- ment.

Calnan reports on a study of relationships among the three dimensions of the health locus of control variable, employment status and three behavioural practices: tobacco and alcohol consumption and level of physical exercise in a large sample of adults living in two health districts in southern England. In dis- cussing the weak relationships found in this data Calnan points to potentially fruitful areas for further study, especially to the need to understand more about how health beliefs differ according to social situation variables. He suggests the value of develop- ing quantitative measures based on ethnographic research.

The next paper examines findings from my investi- gation of health maintenance and illness related components of self-care behaviour in a community sample of persons over 45 years of age in Denmark. The major goal of this paper is a first attempt at placing the study of self-care in a lifestyle framework focusing especially on gender as a universally impor- tant force in socialization and social situations. The findings of this study underscore the need to focus on patterns of behaviour and interactions among different types of influences.

122 Introduction

Segall and Goldstein report on a study of projected self-care behavioural responses to illness and use of non-prescription medication/home remedies in a sample of adult residents of Winnipeg, Canada. In addition to findings regarding health, social situa- tional and attitudinal influences on behaviour, this paper provides interesting information on population beliefs about what protects health, including the disturbing finding that only one third of the residents felt use of seat belts was an important health mainte- nance factor.

Teperi and Rimpell also look at both health related practices and symptom responses. Their major focus is to examine the prevalence in girls in Finland of menstrual pain, use of medication and school absenteeism due to the pain in the context of physiological, perceived health and behavioural vari- ables. Their findings that pain was associated with gynaecological age (length of time since onset of menstruation) and indicators of poor self-related health rather than social situational variables raise a number of questions. For example, are social situational variables related to low physical activity, not feeling active in the morning etc., that were associated with pain and absenteeism? What factors, social and cultural, as well as physiological, are involved in the passage of time after onset of men- struation that may influence experienced pain. As the authors point out, we need to shift studies of this sort from focus on chemical meditators to lifestyle approaches.

Haug, Wykle and Namazi report on a study of self-care responses to illness among persons over 45 years of age in three geographical areas in the mid- west of the United States. As mentioned above, low faith in medical care rather than generalized health beliefs was related to a tendency to self-treat without seeking professional advice for symptoms perceived to be serious. For symptoms perceived as non-seri- ous, only measures of health were independently related to the tendency toward self-treatment. Educa- tion and race examined as controls were related to self-treatment of both serious and non-serious symp- toms. Here again questions for future research include the study of how psychological distress and social situational variables affect both the attitudinal and health variables. Indeed, the authors illustrate the importance of psychological distress for illness and the influence of gender, age and education on the measure. Finally, as they point out, it is the person’s perception of symptom seriousness, rather than professional assessment of threat that triggers action. Much more needs to be known about this subject.

Bentzen, Christiansen and Pedersen have used an economic framework in their approach to the subject of self-care. Conceptualizing a model based on episodes of illness in which self-care is studied as a continuum of care from doing nothing to seeking medical care, they study behaviour in a rich data set based on interviews and health diaries completed in a panel study of the adult Danish population, A model based on illness episodes and the continuum of care is a conceptual advancement in the study of individual behaviour in illness. Here again, very useful information could be derived from

understanding how the psychosocial and social vari- ables inter-relate in this data.

De Friese and his colleagues report on a survey study of the scope, organizational structure and content of self-care education programmes in the United States. This paper documents the extent of the recognition in the United States of the role and importance of self-care behaviour in population health care.

Ramussen reports on a random allocation study of the difference in knowledge and decision making of Swedish mothers caring for small children after re- ceiving educational materials by mail, in contrast to those who participated in an educational teaching session in addition to receiving the written material.

Winkler and his colleagues report on the results of a clinical trial of the effectiveness of a self-care programme of stress management for control of chronic headaches in an Austrian community. Not only did this experiment demonstrate self-treatment gains that were maintained and even increased over a 12 month period, the physicians who referred patients to the project reported improvement in the patients ability to cope and control symptoms. Furthermore, the physicians saw the self-care format as potentially useful for other problems, and 48% said participation in the project had led them to use self-care concepts/techniques with other patients.

The effectiveness of a self-care programme, with and without reinforcement, among patients coping with arthritis is the subject of an intervention study conducted in the United States by Lorig and Holman. They report beneficial effects of the project which were demonstrated over a 20-month period regardless of reinforcement.

The reported benefits of self-help groups in Ham- burg, F.R.G. is the subject of the next paper. Dis- cussing the types of benefits reported, Trojan makes the important point that just as the transition from healthy to sick is fluid with no fixed borders so is the transition through coping with illness to re-estab- lished function. The importance of knowledge, self- esteem and action emerge in this data. The methodological problems and weakness of evalua- tions based on self-selection are taken up.

Shuval, Javetz and Shye take up the subject of professional attitudes about self-care in their study of physicians’ opinions regarding the effects of self-care on health and the health care system in Israel. The results reported in this paper offer insight into the difficulty/discomfort some physicians have with the concept of self-care. While there was widespread approval among the physicians, as well as perceived benefits from the self-care behaviours studied, there was quite limited approval of lay initiatives and patient independence. The authors note these differences as simultaneous acceptance of positive effects of specific self-care behaviours along with an attitude complex in which there is widespread physi- cian rejection of independence and autonomy in patient behaviour and attitudes. These findings have important implications for doctor-patient interaction and communication.

In an investigation conducted in the Netherlands, van Agthoven and Plomp studied the congruency

lntroductian 123

between home nurses and clients on the self-care potential of patients and the nursing care provided by the home nurses. These findings illustrate the need that may be present in treatment situations to recon- cile discrepancies in the outlook and interpretations of lay and professional persons.

Finally, Svend Kreiner, responding to a specific request, addresses issues in the statistical analysis of complex health and social data.

REFERENCES

Mechanic D. Handbook of Health, Health Care and the Professions. Chau. 25-27. The Free Press. New York. 198j; Tucket 6. Introduction to Medical Sociology; pp. 161-174. Tavistock, London, 1976; Dean K. Self care responses to illness: a selected overview. Sot. Sci. Med. ISA, 673, 1981. Dean K. Lay care in illness. Sot. Sci. Med. 22, 275, 1982. It is not possible to refer to the extensive research literature on these subjects. Some representative source works in addition to the Mechanic and Tucket volumes in Ref. [l] include: Jaco E. Patienrs, Physicians and Illness. The Free Press, New York, 1972; Saunders L. Culture Differences and Medical Care. Russell Saee. New Yorky1954; Stoeckle J., Zola I. and Davidson 2: On going to see the doctor: the contribution of the patient to the decision to seek medical aid: a selective review. J. chron. Dis. 16, 957, 1963; McKinlay J. Some approaches and problems in the study of the use of services-an overview. J. Hlth sot. Behav. 13,115, 1972; Litman T. The family as a basic unit in health and

4.

5.

6.

7.

8.

9.

10.

II.

12.

medical care: a social behavioural overview. Sot. Sci. Med. 8, 495, 1974. Dean K. The influence of health beliefs on lifestyle: what do we know? Eur. Monogr. Hhh Educ. Res. 6, 127. 1984. Wohnsky F. Assessing the effects of predisposing. enabling- and illness-morbidity chara&eristics on health services utilization. J. Hlth sot. Behac. 19. 384. 1978. Mechanic D. Correlates of physician utilization: why do major multivariate studies of physician utilization find trivial psychosocial and organizational effects? J. Hlrh sot. Behac. 29, 387. 1979. McCormick J. and Skrabanek P. Coronary heart disease is not preventable by population interventions. The Lancer 8615, 839, 1988. Graham S. Cancer culture and social structure. In Pafients, Physicians and Illness (Edited by Jaco E. ). The Free Press, New York, 1972. Reeder L. Social epidemiology: an appraisal. In Patients, Physicians and Illness (Edited by Jaco E.). The Free Press, New York, 1972. Riley M. Health behavior of older people: toward a new paradigm In Health, Behavior and Aging (Edited by Patron D., Solomon F. and Rodin J.). National Academic Press, Washington, D.C., 1981; Riley M. Age strata in social systems. In Handbook on Aging and Social Sciences (Edited by Binstock R. and Shanas E.). Van Nostrand Reinhold, New York, 1985. Riley M. On the significance of age in sociology. Am. Social. Rm. 52, 1, 1987. Becker M. and Maiman J. Models of health related behavior. In Handbook of Health, Health Care and the Professions (Edited by Mechanic D.). The Free Press, New York, 1983.