Self-care responses to illness: A selected review

SELF-CARE RESPONSES TO ILLNESS: A SELECTED REVIEW

KATHRYN DEAN

Institute of Social Medicine. University of Copenhagen. Copenhagen. Denmark

Abstract-Self-care is the basic level of health care in all societies. Yet. little is known about the range of lay reactions to illness and the forces shaping those reactions. This paper reviews literature concerned with self-care responses to illness. Questions arising from the data are discussed and future research needs are identified.

While limited, the literature illustrates the basic role and importance of self-evaluation of symptoms and self-decisions regarding reactions to illness. However. more studies of general populations are needed lo chart the dimensions of self-care and to determine the forces which shape reactions to illness in various subgroups of society. It is particularly important at this time to design studies with uniform definitions of variables, especially definitions of self-care and self-medication.

The role and importance of self-care in the continuum of health care are subjects of widespread debate among social scientists and health professionals [l]. Interest in the self-care component of health services has been stimulated by the convergence of diverse pressures common to health services systems through- out the developed world. Depersonalized medical care, rising costs of high technology, curative care, growth of lay knowledge. recognition of the limits of medical care and documentation of the impact of the individual’s health behavior on patterns of morbidity are all factors stimulating new thinking regarding the importance of individuals and families to the effective and efficient functioning of health services systems.

Self-care and the issues associated with it have been the subject of major national and international con- ferences. The National Center for Health Services Research (NCHSR) organized the first national level meeting in the United States on this topic in 1976. One of the conclusions arising from this conference was that the American people are not receiving sufficient information “to attain a level of health consistent with the Nation’s cultural and technological capacity” [Z]. The premise underlying the first international symposium on the role of the individual in primary health care held at the Institute of Social Medicine, University of Copenhagen, in 1975 was that:

. a viable preventive and therapeutic partnership between individuals. patients and families and the

* The first international conference on Mutual Aid and Self-Help in Contemporary Society was held in Dubrovnik, “ugoslavia, 1979. While papers and discussions concerned with individual self-care behavior comprised an important part of the conference. the major focus was mutual aid programs. Information on this conference can be obtained from Alfred Katz. DSW. School of Public Health. Univer- sity of California at Los Angeles.

t This conception of self-care lends itself to a tendency to polarize self-care and professional care. Self-care as conceived by this author includes the range of individual health behavior: health maintenance’life-style. utilization of preventive health services, symptom evaluation. self- treatment and interaction with the professional sector.

professional health care worker is not only desirable, but may be essential to achieve improved access, enhanced quality of care, better accountability and lower costs [3].

Before therapeutic partnerships which fully utilize the potential health resources of individuals can be developed, it is essential to obtain information and insight regarding existing self-care behavioral practices. The conferees of the NCHSR sponsored meeting were charged with assessing the research needs related to self-care. One of their conclusions was that baseline studies of the current extent of self-care practice are important at this time. They urged caution in com- mitting resources to self-care demonstration programs before survey studies of national populations can produce findings which can support sound models for program and project development.

The purpose of this article is to review the literature on self-care in order to summarize the information available on the subject and suggest possible areas of fruitful research. Self-care behavior in response to ill-

ness is the focus of the review. Health maintenance behavior is not considered. Finally. the discussion will be limited to individual and family responses to illness. The growing body of literature available on self- help groups is not discussed [4].*

SELF-TREATMENT IN HISTORICAL PERSPECTIVE

The self-treatment component of self-care. that is decisions by lay persons to diagnose and treat perceived symptoms themselves rather than to seek professional treatment services, is frequently referred to as the self-care ‘movement’. In this context. self-care (treatment) is viewed as a reaction by the general public to the disfunctional effects of contemporary health service systems, a new and growing phenomenon rather than a universal attribute of all societies which only in recent times has been subject to widespread recognition and organizational efforts_.+

Self-care in its various forms. preventive, curative and rehabilitative. is neither contemporary nor reac- tionary. It is the basic health behavior in all societies

673

674 KATHRYN DEAN

past and present. Discussing the history of seif-care in America, Cassedy observes

I wherever people have been able to obtain their own medicines, or have read books about hygiene, or have had relatives, neighbours, or travellers to suggest remedies, they have been ready in large numbers to rely on such sources and on their own judgements rather than resort to physicians even with serious ailments [S].

In fact, no amount of resources poured into the professional sector of any health care system could substitute for the self-treatment by individuals and fami- Lies of many of their health problems, without placing an unbearable strain on that system Cl]. Indeed, for centuries an extensive amount of the printed information available regarding self-care has been provided by the medical doctor.

In England in the seventeenth century popular for- mularies on self-medication were produced by well known scientists [6]. The first comprehensive medical self-help guide in English was William Buchan’s Dom- estic Medicine, published in Edinburgh in 1769. The earlier books were self-treatment orientated [7]. They outlined treatment regimes for various conditions based on contemporary medical knowledge and practices. Conceived for the purpose of improving lay health practices, the earlier works were intended for people who could not obtain the services of a physician, or they were developed from the viewpoint that it was better for physicians to practise in families whose members knew something about medicine. This is in contrast to the later classics written for the lay public, such as Morris Fishbein’s Modern Home Medical Adviser first published in 1935, which empha- sized hygiene, basic understanding of the human body and the importance of finding a competent doctor for medical treatment.

In addition to the medical guides a parallel produc- tion of competing books on domestic medicine attacked the medical profession. These books put forth the ~gument that people were better off practis- ing self-treatment than subjecting themselves to the curative and often brutal treatment of doctors. Among the more important and successful competi- tors were the medical sectarians who challenged “the heroic therapy of the regulars’ seemingly endless rounds of bleedings, biisterings and purgings” [S]. Sectarian medical guides served as “primary care physicians” for millions of people during the nine- teenth century. While the various medical sects relied on different forms of treatment, they had in common similar critical attitudes toward the thera~utic weak- nesses of established medicine and an acceptance of self-treatment as a substitute for professional health care.

A third major source of information which has tra- ditionally influenced self-care behavior is promotional material developed for non-prescription drugs. With the invention of the printing press the potential for instantaneous expansion of markets for proprietary

* Only those findings relevent to the discussion of self- care behavior in response to illness from the seiected studies will be included here.

t There were exceptions to this perspective, for example see the reference to Stimson [42. p. 191,

medicines was rapidly exploited. English patent medicine appeared on the American market in the early eighteenth century. The patent medicine makers joined the medical sectarians in offering their products as an alternative to the services of the regu- lar doctors. Painless, pleasant-tasting products were promoted to an anxious public as effective aiterna- tives to powerful emetics, mercury and the lancet. With profit as the underlying motive. the proprietary industry, capitalizing on the atmosphere of caveat emptor utilized newspaper and other forms of adver- tising to promote remedies for more and more ailments [9].

In turn, it was toward the extravagant claims of the proprietary drug industry as well as the proliferation of poorly trained doctors that the early reform efforts of organized medicine and health legislation were directed [lO]. Finally, contemporary critics now fault the medical profession for unnecessary surgery. iatro- genitally caused illness, limited access to medical services and rampant inflation in the medical care system [ 111,

Self-care is apparently not only the basic health behavior, but also a factor in the complex evolution of medical treatment. The various issues of access to professional care, the side effects of caustic medicines and dangerous treatment procedures. and concern regarding cost, benefit and profit are today the same or related to the major issues surrounding self-care developments in the 17th and 18th centuries. The polar positions generally taken on the problems associated with professional care and the perceived dangers involved in self-care inhibit the objective study of the broad range of lay response to illness. There are, however, some empirical data available.

SELF-TREATMENT IN PRACTICE’

Research interest in self-care behavior is not a new development. In the past such behavior has been investigated under varying contexts of illness and preventive health behavior. The earlier studies were predominantly focused on the utilization of physician and hospital services [12], delay in seeking care [13], and patient compliance with medical regimes [14]. Stemming from a professional orientation, such investigations viewed individuals as responders and com- pliers. The implicit, sometimes explicit, assumption of these studies was that patients were only recipients of professional care, It was a professional approach cen- tered in a medical dominance of the health care deliv- ery system [lS]. The individual as an active partici- pant in the health care process was ignored. Decision making by the patient, if discussed at all. was considered in terms of complying with medical direc- tives.?

Reflecting a professional bias. these studies approached self-care as behavior to be avoided or changed. As a result they could not provide an objective description of self-care. nor an assessment or evaluation of self-treatment practices which might serve as a base for strengthening the quality of self- care practices and improving patient~physician interaction and communication. At the most negative extreme. lay involvement in health care has been deni- grated as misinformed and dangerous [3].

Self-care responses to illness 675

Recently there has been a shift in research focus Professional contacts (predominantly visits to phys- from a predominant concern with the utilization of icians) were made on only 6.8”/, of the adult com- professional services toward the study of self-medica- plaint days and on 7.47, of child complaint days, tion. the role of the family in health maintenance and while self-decisions (medications and home remedies) the self-care of individuals as the first level of care. were the illness responses on 93.6Td of the adult com- The literature on self-care is nevertheless extremely plaint days and on 92.6% of the child complaint days. limited both in amount and in scope of content. Most (Taking a prescribed medication as instructed was investigations have continued to focus on patient considered a self-decision.) The sex of the family populations. However, there have been a few empiri- member was related to both the morbidity and the cal investigations of the behavioral response to illness illness behavior reported. Women experienced more in lay populations. Several of the earlier studies of this symptoms, used more medicine, and consulted pro- type were conducted in the United States using health fessionals more often than men. Findings related to diary techniques for the collection of family health other social and demographic variables were not information. reported in this article.

Albert et al. [16]. for example, studied the illness behavior of 78 families using an urban medical emergency clinic in Boston. Massachusetts, U.S.A. (see Table 1). The 78 families were selected from a sample of 500 users of the emergency clinic included in a longitudinal study of the health care of low income families. Family reactions to illness were classified into 4 response patterns:

(1) no response (2) emotional support (3) maternal (home) help given. and (4) medical help sought.

Medically non-attended symptoms were found to exceed medically attended ones by a ratio of seven to one. ‘Maternal (home) help’* was the most frequent response to symptoms in the majority of symptom categories. If the decision to do nothing and emotional support are added to maternal (home) help, the role of professional treatment of illness was minor in relation to self and family health care behavior in this sample. In addition to morbidity and illness behavior data. the family health calender also was used to collect information on stressful events. Family stress was positively related to both the morbidity reported and the seeking of medical treatment for symptoms. At the same time. the number of children in a family was positively related to stress. morbidity, and treatment response. Other demographic variables were not discussed.

These findings may overstate the amount of self- treatment in relation to professional consultation due to the utilization of complaint days rather than illness episodes as the unit of analysis. However, this effect is tempered by the ‘priority rule’ in the coding procedure. On any day when multiple behavioral responses to a condition were reported, a physician consultation would override the other responses in the coding procedure. The total effect would thus seem to be a slight underestimate of self-treatment in relation to the unit complaint day, but also an underestimate of professional consultation in relation to illness episode, which is a more appropriate unit of analysis for consultation behavior. Nevertheless, the primary role as well as predominant amount of self- treatment and family treatment of illness in this population were evident.

A study of illness behavior in an urban community in the United States was conducted by Roghmann and Haggerty [I71 using a random sample of families living in Rochester. New York. Both health diaries and household interviews were utilized in order to compare the two methods of data collection. The unit of analysis used in the investigation was days of illness. The 2547 persons in the study experienced 11.625 ‘complaint days’. Data were analyzed separ- ately for children and adults. Between 15 and l7”, of the symptoms were not perceived as sufficiently serious or bothersome to require special action. About 85”,, of the conditions were reported to need some kind of daily attention. while 80”, received care.

The illness behavior of individuals has been the focus of a number of studies conducted in Great Britain. In a comparative study of the illness behavior patterns of 1503 people continuously registered in a suburban British practice during the first 10 years of the National Health Service, Kessel and Shepherd [ 183 found that the amount of serious illness experienced by people who regularly visit the doctor is not greater than that of people who seldom visit the doctor. There were no differences in the social class, employment status, marital-status, or size of households of the ‘non-attenders’, persons who had not visited the doctor for over 2 years, as compared to the ‘recent attenders’, those who had visited the doctor within the past year. There were, however, fewer children in the households of the non-attenders. The lat- ter group contained a greater number of older people, as well as more males than the recent attenders.

Contrary to the frequent assumption that self-medication is an alternative to orthodox medical care, Kessel and Shepherd found that there was a considerable amount of self-medication among both recent attenders and non-attenders. Only persons who had not consulted the doctor for 10 years or more did not self-medicate. Nor did non-attenders take a more limited view of the doctor’s role. They were, however, more critical of his services. Although there was no difference in objective morbidity experience, the non- attenders tended to view themselves as healthy more often than the recent attenders. The authors concluded that those who seldom consulted the doctor “were actuated not from fear, ignorance, inattention to or denial of symptoms. but by sensible attitudes toward their health”. The findings of this study, however, must be considered in light of the fact that the

* The labeling of health care services provided in the farnil) unit as maternal help states explicitly a social expec- tation that the wife. mother is the provider of family health care. The extent to which adult males and children provide health services in families is a subject which needs to be investigated.

Tab

le

I. B

ehav

rora

l re

spo

nse

lo

ill

nes

s

So

urc

e P

op

ula

tio

n

Sam

ple

D

ata

colle

ctio

n

Tim

e sp

an

Maj

or

fin

din

gs

Alp

ert.

K

osa

an

d

Hag

ger

ty

Ro

gh

man

n

and

ti

agg

erly

Kes

sel

and

S

hep

her

d

An

der

son

. B

uck

. D

anah

er

and

Fry

Lo

w-i

nco

me

78 f

amili

es:

Fam

ily

hea

lth

P

rosp

ecti

ve:

Fam

ily

care

. ei

ther

‘m

ater

nal

’ ca

re o

r em

oti

on

al

sup

po

rt

was

th

e re

spo

nse

to

u

sers

of

an u

rban

I5

6 ad

ult

s ca

len

dar

4-

wee

k p

erio

d

ove

r 70

”,,

of

the

sym

pto

ms

rep

ort

ed.

Med

ical

h

elp

w

as s

ou

gh

t fo

r o

nly

12

”,,

emer

gen

cy

clin

ic

254

child

ren

o

f th

e sy

mp

tom

s.

Str

ess

was

p

osi

tive

ly

rela

ted

IO

b

oth

th

e m

orb

idit

y in

Bo

sto

n.

MA

. re

po

rted

an

d

the

use

o

f se

rvic

es.

Th

e n

um

ber

o

f ch

ildre

n

in

a fa

mily

w

as

U.S

.A.

po

siti

vely

re

late

d

to s

tres

s. m

orb

idit

y an

d

trea

tmen

t re

spo

nse

Fam

ilies

w

ith

S

yste

mat

ic

ran

- ch

ildre

n

aged

I7

d

om

se

lect

ion

o

f o

r yo

un

ger

in

51

2 fa

mili

es:

Ro

ches

ter,

N

ew

I08

I ad

ult

s.

Yo

rk,

U.S

.A.

1466

ch

ildre

n

Per

son

s re

gis

tere

d

in

the

sub

urb

an

Lo

nd

on

p

ract

ice

of

a B

riti

sh

pri

mar

y ca

re

ph

ysic

ian

Per

son

s re

gls

tere

d

in t

he

gen

eral

p

ract

ices

o

f IO

ph

ysic

ian

s In

th

e g

reat

er

Lo

nd

on

ar

ea

Elli

ot-

Bln

nh

P

erso

ns

reg

iste

red

w

ith

a N

ort

ham

pto

n.

En

gla

nd

. g

ener

al

pra

ctit

ion

er

167

per

son

s d

ivid

ed

into

m

atch

ed

sam

ple

s ac

cord

ing

to

ag

e,

sex

and

le

ng

th

of

tim

e si

nce

la

st

med

ical

co

nsu

l-

tatl

on

60

age

and

se

x m

atch

ed

pai

rs

reg

iste

red

in

th

e sa

me

pra

cllc

e.

wh

o

had

si

mila

r sy

mp

lom

s fo

r w

hic

h

on

e h

ad

con

sult

ed

a p

hys

icia

n

and

th

e o

ther

h

ad

no

t

IO00

p

atie

nts

. ev

ery

5th

p

atie

nt

con

sult

ing

fo

r il

n

ew

sym

pto

m

Fam

ily

hea

lth

ca

len

dar

P

rosp

ecliv

e:

4-w

eek

per

iod

Pat

ien

t re

cord

s an

d

ind

ivid

ual

in

terv

iew

s

Ret

rosp

ecti

ve:

pat

ien

t re

cord

s.

IO-y

ear

per

iod

; in

terv

iew

s,

4-w

eek

per

iod

Ove

r 90

”,,

of

the

acti

on

s ta

ken

in

re

spo

nse

to

sy

mp

tom

s w

ere

bas

ed

on

se

lf-d

ecis

ion

. T

akin

g

med

icat

ion

s w

as

the

mo

st

freq

uen

t sy

mp

tom

re

spo

nse

. W

om

en

rep

ort

ed

mo

re

sym

pto

ms,

u

sed

m

ore

m

edic

ine

and

co

nsu

lted

pro

fess

ion

als

mo

re

oft

en

than

m

en

did

Per

son

s w

ho

h

ad

no

t co

nsu

lted

a

ph

ysic

ian

fo

r o

ver

two

ye

ars

rep

ort

ed

mo

rbid

ity

com

par

able

to

th

ose

w

ho

h

ad

con

sult

ed

rece

ntl

y.

Sel

f-m

edic

atio

n

did

n

ot

sub

stit

ute

fo

r p

rofe

ssio

nal

co

nsu

ltat

ion

, b

ut

was

co

nsi

der

able

in

bo

th

gro

up

s.

Mal

es

and

o

lder

p

erso

ns

con

sult

ed

ph

ysic

ian

s le

ss o

ften

. N

o

soci

al

clas

s.

emp

loym

ent

stat

us

or

size

o

f h

ou

seh

old

d

iffe

ren

ces

wer

e fo

un

d

bet

wee

n

the

two

g

rou

ps

ind

ivid

ual

in

ter-

R

etro

spec

tive

: vi

ews

2-w

eek

per

iod

Th

ose

w

ho

vi

site

d

the

do

cto

r re

po

rted

m

ore

se

rio

us

per

son

al

pro

ble

ms.

per

ceiv

ed

them

selv

es

as l

ess

hea

lth

y,

had

le

ss o

ften

at

tem

pte

d

self

-tre

atm

ent

and

re

po

rted

fe

wer

o

bst

acle

s IO

vis

itin

g

the

do

cto

r.

Th

ere

was

no

sta

tist

ical

ly

sig

nif

ican

t d

iffe

ren

ce

in

the

nu

mb

er

of

sym

pto

ms

rep

ort

ed

by

mem

ber

s o

f th

e tw

o

gro

up

s.

A

pan

el

of

gen

eral

p

ract

itio

ner

s w

ho

ev

alu

ated

th

e se

lf-c

are

pra

ctic

es

con

clu

ded

th

at

app

roxi

mat

ely

two

-th

ird

s o

f th

ose

w

ho

h

ad

trea

led

thei

r sy

mp

tom

s u

sed

eff

ecti

ve

trea

tmen

ts.

lnd

lvid

ual

in

terv

iew

s R

etro

spec

tive

: D

efin

ed

as “

trea

tmen

t o

f th

e p

atie

nts

o

wn

ch

oo

sin

g

wit

ho

ut

refe

ren

ce

lo

Ad

vice

o

bta

ined

o

ther

p

eop

le

or

sou

rces

”.

self

-tre

atm

ent

was

pra

ctis

ed

by

52”,

, o

f th

e p

atie

nts

.

[or

and

tr

eat-

A

dd

itio

nal

ly,

the

1000

p

atie

nts

h

ad

sou

gh

t ad

vice

fr

om

17

64

lay

sou

rces

m

ent

of

the

prc

- re

gar

din

g

trea

tmen

t o

f th

e p

rese

nti

ng

sy

mp

tom

s p

rio

r to

co

nsu

ltat

ion

. O

f .s

cnri

ny

sym

pio

m

rela

tive

s co

nsu

lted

. w

ives

w

ere

per

ceiv

ed

as

giv

ing

th

e m

ost

so

un

d

advi

ce.

prio

r lo

co

nsu

l-

Mal

e re

lati

ves

usu

ally

ad

vise

d

ph

ysic

ian

co

nsu

ltat

ion

la

tio

n

Pcdc

rsen

Pe

rson

s C

onse

culiv

e rc

gist

ercd

in

the

sc

lecl

ion

of 5

00

subu

rban

pa

tient

s co

nsuh

- C

open

hage

n in

g fo

r th

e fi

rst

prac

tice

of a

tim

e fo

r th

e D

anis

h pr

imar

y pr

esen

ting

care

phy

sici

an

sym

ptom

s

Indi

vidu

al

inte

r-

view

s R

etro

spec

tive:

T

he

pred

omin

ant

form

of

tr

eatm

ent

prio

r to

co

nsul

tatio

n w

as

self

- Se

lf-t

reat

men

t of

m

edic

atio

n.

Thi

rty-

nine

pe

r ce

nt o

f th

e pa

tient

s ha

d tr

eate

d sy

mpt

oms

with

th

e pr

esen

ting

pres

crib

ed

med

icin

es

and

25”,

, with

non

-pre

scri

bed

med

icin

es

prio

r to

vi

sit-

sy

mpt

oms

prio

r in

g th

e do

ctor

. T

he s

elf-

trea

tmen

t pr

actis

ed

was

con

side

red

rele

vant

in

77”

,, to

con

sulta

tion

and

part

ially

re

leva

nt

in 1

2””

of t

he c

ases

. A

dditi

onal

ly,

bene

fit

or r

elie

f w

as

obta

ined

62

”,,

of t

he

time.

The

se

lf-t

reat

men

t w

as j

udge

d as

dam

agin

g in

on

ly o

ne c

ase

Gan

nik

and

Jesp

erse

n In

habi

tant

s ol

’ Ntu

stve

d,

Den

mar

k,

betw

een

20 a

nd

54 y

ears

of

age

Ran

dom

se

lec-

Po

stal

qu

estio

n-

Cur

rent

an

d pa

st

Tw

enty

-sev

en

per

cent

of

th

ose

repo

rtin

g ba

ck

prob

lem

s ha

d ne

ver

con-

tio

n fr

om t

he

nair

e;

inte

rvie

ws

hist

ory

of h

ack

sulte

d a

prof

essi

onal

pr

ovid

er

of s

ervi

ces

for

thei

r sy

mpt

oms.

Se

vent

y-ei

ght

Dan

ish

Nat

iona

l an

d cl

inic

al

sym

ptom

s pe

r ce

nt h

ad t

reat

ed

them

selv

es.

Gen

eral

ly.

the

self

-tre

atm

ent

beha

vior

w

as

Popu

latio

n ex

amin

atio

ns

of

foun

d to

par

alle

l th

at

obta

ined

fr

om

phys

icia

ns.

alth

ough

it

was

usu

ally

a

Reg

iste

r :

hOof

the

less

in

tens

e fo

rm

of t

he

trea

tmen

t (D

ata

colle

cted

in

th

e in

terv

iew

s an

d N

= 5

17

pers

ons

who

cl

inic

al e

xam

inat

ions

ar

e in

the

sta

ge o

f pr

elim

inar

y an

alys

is)

retu

rned

th

e qu

estio

nnai

res

Dea

n A

dult

citiz

ens

of

Den

mar

k.

18-7

X

year

s of

age

A.

Ran

dom

se

lect

ion

from

th

e D

anis

h N

atio

nal

Popu

latio

n R

egis

ter:

N

=

1462

B

. Sub

-sam

ple

of

proj

ect

A

natio

nal

sam

ple:

N

= 4

50

Post

al

ques

tion-

R

etro

spec

tive:

A

t le

ast

one

med

icat

ion

was

tak

en i

or 3

3”,,

of t

he 3

100

cond

ition

s re

port

ed.

nair

e 6-

mon

th

peri

od

Prof

essi

onal

pr

ovid

ers

of s

ervi

ces

wer

e co

nsul

ted

for

26”,

,. w

hile

one

or

mor

e x 5

non-

med

icat

ion

and

non-

cons

ulta

tion

resp

onse

s w

ere

repo

rted

fo

r 76

”” o

f ::

the

cond

ition

s.

Age

. se

x an

d oc

cupa

tiona

l di

ffer

ence

s w

ere

syst

emat

ical

ly

8 re

late

d to

th

e be

havi

oral

re

actio

ns.

The

da

ta

sugg

est

that

it

was

co

mbi

- na

tions

of

lif

e si

tuat

ion

vari

able

s su

ch

as

soci

al

netw

orks

or

si

tuat

iona

l {

cons

trai

nts

at t

he w

ork

plac

e w

hich

w

ere

the

unde

rlyi

ng

fact

ors

shap

ing

the

Indi

vidu

al

inte

r R

etro

spec

tive:

se

lf-c

are

beha

vior

(A

naly

sis

of p

roje

ct

B d

ata

is a

bout

to

beg

in)

P

view

s (i

-mon

th

peri

od

6 _.

t w

D

Bel

gian

Pri

mar

y H

ealth

C

are

Proj

ect

Flem

ish

popu

la-

tion

of B

elgi

um,

over

14

yea

rs

of a

ge

Rep

rese

ntat

ive

sam

ple

of

popu

latio

n:

N =

17

45

Indi

vidu

al

inte

r-

view

s R

etro

spec

tive:

3%

wee

k pe

riod

M

edic

atio

ns

wer

e us

ed f

or 7

0:;

of t

he r

epor

ted

com

plai

nts.

A

tot

al

of 5

2,00

0 da

ily d

oses

w

ere

repo

rted

. L

ay p

erso

ns

wer

e co

nsul

ted

rega

rdin

g sy

mpt

om

resp

onse

s fo

r SS

S,; o

f th

e re

port

ed

com

plai

nts.

A

med

ical

co

ntac

t w

as s

ug-

gest

ed

by t

he f

irst

lay

adv

isor

co

nsul

ted

for

36”,

of

the

com

plai

nts

678 KATHRYN DEAN

study was limited to one rather homogeneous, middle-class population.

A substitute effect was found in a British study utilizing a matched-pair research design. Attenders randomly selected from 10 general practices in the greater London area by Anderson er al. [19] were matched with non-attenders from the same practices who had experienced similar ailments. The patients who consulted the doctor had attempted less self- treatment than those who did not consult. The study did confirm one finding of Kessel and Shepherd. that persons who consult the doctor infrequently perceive themselves as healthier than persons who consult frequently. even though there is no difference in morbidity. Additionally, the members of the matched pairs who consulted a physician reported a signifi- cantly higher amount of stress than did the non-users of professional services.

In a British study of 1000 patients attending a general practice in Northhampton. Elfiot-Binns [20] defined self-treatment as a source rather than a form of ‘lay medicine’. That is. it was taken to mean “treatment of the patient’s own choosing without reference to other people or impersonal sources’.. As such the 52”, figure for the patients who self-treated is an underestimate. since it does not include the home remedies or self-medication recommended by other sources.

The loo0 patients had sought advice from 1764 lay sources in addition to the 521 self-decisions regarding treatment of the presenting symptoms prior to consultation. Male relatives usually suggested going to the doctor. Of the relatives consulted. wives were perceived as having given the most sound advice. Of professionals contacted, pharmacists were rated highest for the soundness of their advice. The home medical guides used by the patients to obtain information regarding the treatment of symptoms tended to be out-of-date. The mean age of these books was calcu- lated to be 27.5 years.

Pedersen [21], in a study of self-care prior to medical consultation in his Danish general practice. found that over SO”, of the patients had undertaken some form of self-treatment before deciding to consult him. A slightly larger proportion of men than women reported that they had treated their symptoms before contacting the doctor. No systematic age differences were found among those who self-treated prior to consultatjon and those who did not. A medicine was used for the self-treatment in 64”” of the cases. Forty per cent of the patients used a combination of medicine and some type of non-medication procedure to treat their symptoms.

This study. like Kessel and Shepherd’s, was limited to one middle-class urban practice. in this case without consideration of non-attenders. An observation which further clouds the question of whether self- treatment is used as a supplement or substitute for

* Papers covering the basic findings of this investigation, self-medication in Denmark and female health behavior. are in preparation.

+ The most frequently consulted non-medical providers were physical therapists. social workers. and chiropractors. An investigation of the use of non-medical providers of care in Denmark has been completed by Launso and Jen- sen [24].

professional care was that those attenders who seif- treated tended to contact the doctor earlier. indicating to some extent at least a degree of supplementation. Such a conclusion, however. would be unwarranted due to the absence of a comparison group of non- attenders.

A major strength of Pedersen’s study is that it allowed for the simultaneous medical evaluation of the relevance and effectiveness of self-treatment by the general practitioner familiar with the persons studied. Using his professional judgement as a standard Pedersen concluded that the self-treatment was relevant in 909, of the cases. The treatment was considered to have been beneficial or at least helpful in alleviation of symptoms in 62”; of the cases, with indifferent effects found in 32”” of the self-treatment epidodes. In only one case was the self-treatment considered injurious. Self-treatment also was judged effective in the matched pairs study conducted by Ander- son et al. which is cited above. In that study a panel of general practitioners who evaluated the self-treatment reported by the respondents concluded that two-thirds of the persons who treated themselves used fully or partially effective remedies.

Gannik and Jespersen [22] conducted a condition specific investigation of back problems among resi- dents of a Danish community. The investigators’ intention was to study a wide-spread health problem which to a large extent is affected by social conditions and to evaluate the services provided for that problem. Only findings related to self-treatment and setf- decisions regarding consultation are reported here.

Based on data collected from self-administered postal questionnaires. returned by 517 persons randomly selected from the Danish population register, 63”” had one or more episodes of back-pain, Seventy-eight per cent of those who reported back-pain had engaged in self-treatment. The most frequently reported treatment procedure was the use of a heating pad. followed by self-medication, some form of exer- cise and obtaining massage. Twenty-seven per cent had never consulted a professional regarding their symptoms. Of those who had consulted, 63”” at one time or another had contacted a general practitioner. Physicial therapists and chiropractors were the next most frequently consulted providers of services. Twenty-six per cent of the respondents with back symptoms had consulted one or the other of these two types of therapists. Generally, self-treatment behavior was found to parallel that obtained from physicians except that the professional treatment was usually a more intense form of the therapy. e.g. stronger medications.

A multiphase investigation of self-care behavior m a national population is being conducted in Denmark by Dean [23]. The first phase of the project utilized a self-administered postal questionnaire to collect data on behavioral responses to six common illness conditions from a random sample of Danish citizens over 17 years of age.* The six conditions were: ‘cold’, skin rash. lumbar pain. symptoms of influenza, depression. and chest pain. A total of 3100 conditions was reported by 1297 respondents. Eleven per cent (165 respondents)reported none of the conditions. At least one medication was taken for 33”, of the reported conditions. while professional providers of caret were


consulted for 26”,, of the conditions. One or more home remedies, non-medication and non-consultation responses, were reported for 76”” of the illness episodes. No action was taken for 139, of the problems. Fifty-one per cent of those reporting symptoms used at least one medication. while 43:, consulted professional care givers for one or more of the conditions during the &month period.

Results from the first phase of the project demon- strate the basic importance of the individual in primary care. For only one of the conditions, chest pain, was consultation of physicians the behavioral response most frequently reported by the respondents. Furthermore, in those cases in which self-evaluation of symptoms resulted in a medical contact, self-treatment of the condition often preceded the consultation.

The findings suggest that it was the interaction of basic life situational variables which exerted the strongest influence on the self-care practices of the individuals responding to common illnesses. Age, sex, and occupational differences were systematically related to the behavioral reactions reported by the respondents for the study conditions.

Of the three, age exerted the most systematic effect on behavior. It appeared, however, that the social networks of older people and the social resources available to them may have been important underlying factors shaping their illness behavior. Similarly, it was not simply the sex of the respondents which accounted for the differences in behavior. The types of situations in which males and females functioned were important factors in their responses to illness.

In the second phase of this project, interviews have been conducted with a subsample of the national sample in order to collect data on the behavioral response to all illness conditions reported by the respondents. Additionally. data on patterns of social interaction. perceived stress and modes of stress reduction as well as responses to questions concerned with attitudes toward health, disease and medical care were obtained in the interviews. In the analysis of the interview data special attention will be given to the importance of social networks and other types of situational constraints on the tendencies to choose alternative type responses to illness.

Data on self-care responses to illness and on lay referral were collected in a comprehensive study of primary health care in Flemish Belgium [25]. One or more medications were used to treat 709; of the complaints reported in this investigation. A physician or dentist was consulted for 37”. of the complaints. while for 58”” of the complaints one or more lay persons were consulted regarding a course of action. Medical consultation was suggested by the first lay advisor for 36”,, of the conditions. while for 29:” of the problems, the first lay person contacted provided reassuring comfort to the respondent while advising no treatment.

The data were analyzed according to the number and form of phases of illness behavior. For 12”” of the complaints. no action was taken. As soon as two or

* Litman [ZS] has also provided an indepth discussion of the family as the basic unit in health and medical care, along with an extensive review and discussion of the relevant literature.

more behavioral forms were seen, lay referral was the most frequent response in the first phase after the onset of symptoms. At the same time. the behavior following lay referral was most often medical consultation. The findings suggest that lay referral is an important factor to consider in relation to patterns of utilization of medical services.

ROLE OF THE FAMILY IN SELF-CARE

Several of the above studies indicate the important role of the family, especially the wife/mother in health care behavior. However, Litman [26] has found evidence that knowledge about health and disease as well as knowledge about health care practices may be quite limited. Moreover, due to her central familial role, the wife/mother tends to be especially vulnerable to illness. In a sample of three-generation-families prolonged incapacitation of the wife was consistently regarded in all three generations to be a major disrup- tive influence on the functioning of the family. At the same time, the wife was the family member who most often consulted a physician. In examining the potential for family care Litman found a considerable lack of knowledge and ability to perform home care techniques such as taking temperature either orally or rectally, giving an enema, taking a pulse or stopping bleeding. This situation was found frequently in all three generations, but especially in the senior generation families. Both the need to prepare families for effective home care and the need for more extensive family health education were suggested* (Table 2).

Pratt [27] has studied the structure of the contemporary urban American family in relation to health and health behavior. The investigation was based on the hypothesis that differences in family structure and functioning in various socio-economic groups might be an underlying factor in findings of poorer health and health practices among persons in lower social class groups.

The family characteristics found to have the strongest relationship to good health were high levels of interaction, support and encouragement among family members accompanied by correspondingly low levels of obstructive conflict. Generally, the characteristics of family functioning found to influence health were also the important factors associated with effective health practices and effective use of professional medical services (e.g. taking advantage of preventive medical services). Those aspects of family functioning that facilitated coping behavior were relatively more important to the effective use of services, however, while supportive interaction which enabled family members to develop and use theit capacities were the crucial factors related to health.

The relationship between family structure and the use of professional services was not affected by social class differences. However, the type of family identified as exhibiting the most effective health behavior was found to be rare. Finally, it was concluded that effective family interaction with the health care system is inhibited by structural characteristics of the system. Disadvantages faced by families in their interactions with professional medicine included working arrange- ments organized for the convenience of professionals rather than the needs of patients. authoritarian func-

680 KATHRYN DEAN

z i

tioning and bureaucratic rigidity. At the same time. lay persons were restrained from developing the knowledge, skills and confidence needed for effective self-care.

SELF-MEDICATION

The most extensive data available on self-treatment has been collected in studies of medication behavior. Pratt [6] in reviewing data on family medication behavior concluded that two-thirds of all persons exper- iencing illness practise self-care exclusively with regard to that illness. Knapp and Knapp [29] using a longitudinal panel design studied for a period of 30 weeks* the medication behavior of 278 families in a midwestern United States urban community. The sample was selected from a subject pool of randomly selected Columbus, Ohio households. Criteria for in- clusion in the pool were: the presence of a telephone in the home, at least one child under 21 years of age living at home and a sufficient level of literacy to be able to complete the health diaries.

The data provided information on the behavioral response to over 3300 instances of illness or injury. In over 90”,; of the illness episodes at least one medication was used. Prescription medicines were used 31”” of the time and non-prescription products were used for over 704, of the conditions. In 110, of the cases both prescribed and non-prescribed medicines were used. Additionally. in this sample selected to exclude most of the elderly population, 70”” of the households contained one or more persons who regularly used drugs. The surprisingly high rate of use of medication led the authors to conclude that it was perhaps the use of medicine itself that helped the respondents define incidents for recording in the diaries. While this factor probably accounts for a portion of these high rates.t there is evidence that the consumption of medicines in the United States is relatively high (Table 3).

A cross-national investigation of medication behavior found a greater consumption of medicines in the United States than in either Great Britain or Yugosla- via. White er al. [30] reported that 48”,, of the respondents in the United States sample had used a medication in the 2 days prior to the interview compared to 38”” of the British respondents and 19”” of the Yugo- slavian sample. The rates were higher in the United States for both prescription and non-prescription drugs. The figures suggested, however. that physicians in the United States may prescribe relatively more medications for their patients. Twenty-seven per cent of the United States sample reported using a prescribed medicine compared to 19”, of the British respondents. The difference was smaller for the use of non-prescribed medicines. with 18”,, reported for the United States respondents and 15”, for the British. The Yugoslavian rates were lower for both prescribed and non-prescribed medicines. with 12”” and 6”,, reported respectively.

* 234 families remamed in the study for 37 weeks. t If the study was introduced as a study of the use of

medications.. there may have been a suggestion effect actually increasing the use of medicines in response to illness.

Tab

le

3. S

elf-

med

icat

ion

Sour

ce

Popu

lalio

n Sa

mpl

e D

ata

colle

ctio

n T

ime

span

M

ajor

fi

ndin

gs

Kna

pp

and

Inha

bita

nts

with

27

X h

ouse

hold

s H

ouse

hold

in

ter-

Pr

ospe

ctiv

e:

At

leas

t on

e m

edic

atio

n w

as

used

in

ov

er

90”,

, of

th

e ca

ses.

Pr

escr

iptio

n K

napp

at

le

ast

one

child

se

lect

ed

ran-

vi

ews

and

fam

ily

30

wee

k pe

riod

dr

ugs

wer

e us

ed

in

3l”,

, an

d dr

ugs

obta

ined

w

ithou

t pr

escr

iptio

n in

ov

er

unde

r 21

of

dom

ly

from

he

alth

di

ary

70”,

, of

the

ca

ses.

O

ver

60”,

, of

th

e ill

ness

es

wer

e tr

eate

d w

ith

non-

pres

crip

- C

olum

bus,

O

H.

thos

e ho

useh

olds

tio

n dr

ugs

only

. L

arge

so

cial

cl

ass

diff

eren

ces

wer

e fo

und

in

the

stoc

king

of

U

.S.A

. co

ntai

ning

te

le-

med

icat

ions

. E

ven

thou

gh

mos

t of

the

el

derl

y po

pula

tion

was

ex

clud

ed

from

ph

ones

th

e sa

mpl

e.

over

70

”,,

of t

he

hous

ehol

ds

cont

aine

d on

e or

m

ore

pers

ons

who

re

gula

rly

used

m

edic

atio

n _

Whi

te,

Inha

bita

nts

of

Prob

abili

ty

Indi

vidu

al

inte

r-

Ret

rosp

ectiv

e:

App

roxi

mat

ely

one-

four

th

of t

he

resp

onde

nts

in e

ach

area

ha

d no

t co

nsul

ted

And

jelk

ovic

, (I

) C

hest

er,

sam

ples

: vi

ews

with

pr

oxy

Mor

bidi

ty.

pro-

a

phys

icia

n fo

r on

e ye

ar.

In

all

thre

e ar

eas

roug

hly

80”,

, of

th

ose

who

Pe

arso

n.

Mab

ry

Uni

ted

Kin

g-

(I)

890

inte

rvie

wer

s fe

ssio

nal

cons

ul-

repo

rted

th

at

they

ha

d ex

peri

ence

d ‘g

reat

di

scom

fort

’ du

ring

th

e pr

evio

us

2 an

d Sa

gen

dom

:

(2)

II98

fo

r ch

ildre

n ta

tion,

2-

wee

k w

eeks

fr

om

one

or

mor

e of

12

ac

ute

and

chro

nic

cond

ition

s ha

d no

t (2

) Sm

eder

eva.

(3

) II

I8

peri

od;

use

of

cons

ulte

d a

phys

icia

n.

In

cont

rast

to

m

ost

stud

ies,

th

e us

e of

pr

escr

iptio

n Y

ugos

lavi

a;

and

med

icat

ions

, m

edic

atio

ns

was

re

port

ed

mor

e of

ten

than

th

e us

e of

m

edic

ines

ob

tain

ed

5

(3)

Chi

ttend

en,

2-da

y pe

riod

w

ithou

t pr

escr

iptio

n D

U

nite

d St

ates

2 z

Bus

h an

d R

abin

In

habi

tant

s of

A

rea

prob

abili

ty

Hou

seho

ld

inte

r-

Ret

rosp

ectiv

e:

Thi

rty

per

cent

of

pe

rson

s re

port

ing

sym

ptom

s us

ed

non-

pres

crib

ed

B

Bal

timor

e.

MD

, sa

mpl

e of

hou

se-

view

s 2-

day

peri

od

mor

bidi

ty

rela

ted

med

icin

e.

Mor

e ad

ults

, w

omen

an

d w

hite

s us

ed

non-

:

U.S

.A.

hold

s:

pres

crib

ed

med

icin

es

in

all

econ

omic

cl

asse

s.

Use

di

d no

t in

crea

se

with

Q

1239

fa

mili

es

incr

easi

ng

seve

rity

of

mor

bidi

ty.

Non

-pre

scri

bed

med

icin

e us

ers

who

w

ere

ill

F

3481

in

divi

dual

s w

ere

less

lik

ely

to

use

pres

crib

ed

med

icin

es

or

to

have

vi

site

d a

phys

icia

n =;

5

than

no

n-us

ers

sugg

estin

g a

subs

titut

ion

effe

ct.

B

Gag

non,

Sa

lber

A

sm

all

farm

54

7 ho

useh

olds

H

ouse

hold

in

ter-

R

etro

spec

tive:

E

lder

ly

whi

te

fem

ales

w

ere

cons

iste

ntly

hi

gher

us

ers

of m

edic

atio

ns.

Sex.

ag

e,

and

Gre

en

rura

l ar

ea

of t

he

with

in

com

es

view

s 4

l-w

eek

peri

ods

educ

atio

n,

and

inco

me

wer

e al

l re

late

d to

th

e us

e of

pr

escr

iptio

n m

edic

ines

. so

uthe

rn

Uni

ted

belo

w

S16.

000

How

ever

, w

ithin

ea

ch

cate

gory

of

ag

e,

sex,

ed

ucat

ion,

in

com

e an

d fa

mily

St

ates

si

ze,

whi

te

pers

ons

used

m

ore

pres

crip

tion

drug

s th

an

blac

k pe

rson

s.

Fort

y-

one

per

cent

of

the

bl

ack

pers

ons

com

pare

d to

68”

” of

the

w

hite

pe

rson

s ha

d vi

site

d a

phys

icia

n.

The

pr

opor

tions

of

pe

rson

s us

ing

non-

pres

crip

tion

drug

s w

ere

sim

ilar

in

the

two

raci

al

grou

ps

Jeff

erys

, B

roth

erst

on

and

Car

twri

ght

Inha

bita

nts

of a

R

ando

m

sele

c-

Hou

seho

ld

inte

r-

Ret

rosp

ectiv

e:

Tw

enty

-fiv

e pe

r ce

nt

of

thos

e in

terv

iew

ed

had

take

n pr

escr

ibed

m

edic

ines

.

post

-war

L

on-

tion

of d

wel

lings

: vi

ews

4-w

eek

peri

od

whi

le

66””

ha

d ta

ken

self

-pre

scri

bed

med

icin

es.

Mor

e w

omen

th

an

men

re

-

don

N

= 24

55

port

ed

usin

g m

edic

ines

at

al

l ag

es

over

IO

yea

rs.

Am

ong

adul

ts

no

sign

ific

ant

publ

ic

hous

ing

I399

ad

ults

ed

ucat

ion

and

soci

al

clas

s di

ffer

ence

s w

ere

foun

d in

the

us

e of

sel

f-pr

escr

ibed

esta

te,

pred

omi-

10

56

child

ren

med

icin

es.

Self

-med

icat

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Bush and Rabin [31] examined the use of non- prescription medicines in Baltimore, Maryland, USA. In the two days prior to interview. 30”. of the respondents had used a non-prescribed morbidity related medication. (Drugs sold without prescription which had been suggested by a physician were coded as prescribed medicines.) The use of these medicines was more frequent among females and white persons in all income groups. While the use of non-prescribed medications decreased with age. more women used the medications in five of the six age groups. Most of the sex related difference was due to the more extensive use of analgesics among women.

Evidence of a substitution of self-prescribed medications for physician consultation was found in this investigation. Persons who used non-prescribed medicines for symptoms had less often used prescribed medications or visited a physician. At the same time, fewer of the persons who had consulted a physician had used non-prescription medicines. Finally, non- prescription and prescription medicines were seldom used for the same purpose.

Gagnon er al. [32] used a panel design to study racial differences in illness behavior in a rural population. A significant racial difference was found in the use of medications over a 4-week period. It appeared, however, that it was differences in the use of professional services that was responsible for this finding. Fifty-six per cent of the whites compared to 31”;, of the blacks repotted using prescribed medicine. At the same time, 684, of the whites compared to 419, of the blacks consulted a physician. Elderly white females were consistently higher users of prescription drugs. While there were mote elderly whites than blacks in the population, within every category of age, sex, education, income, perceived health status and family size. whites used more prescription drugs than blacks. In the case of non-prescription medications, the rates repotted were essentially the same, 729; for whites and 709, for blacks. Rabin and Bush [33] also found non-whites less likely to use medications in Baltimore. Consistent with the findings of Gagnon et al., the major difference was in the use of prescription medicines.

The high level of reliance on self-medication seen in these studies was also found by Roghmann and Hag- gerty. In their prospective study. discussed above, taking medications was found to be the most frequent daily response to symptoms. Nearly all of the complaints or symptoms reported were followed by the taking of some kind of medication. At the same time, over 90”, of the actions taken in response to symptoms were based on self-decision [17]. Although Alpett found that ‘maternal (home) help’ was the overwhelming response to the symptoms experienced in the low income urban users of a medical emergency clinic, he reported a much smaller reliance on proprietary medicine than other studies have found. One reason may be that he defined non-proprietary medicine as that listed in the Physicians Desk Reference

and categorized it as ‘medically advertised medicine in contrast to ‘proprietary medicine’ [ 163.

A number of investigations into the use of medication have been conducted in Great Britain. A study of the population of a post-war housing estate by Jef- fetys er al. [34] found that while one-fourth of the

sample members had used prescribed medicine during a 4-week period between two interviews, the ptopor- tion of individuals who had used non-prescription medication was much greater, about two-thirds. Self- medication was not an alternative to the consultation of physicians. For given numbers of illnesses, those persons who took two or mote self-prescribed medicines had higher consultation rates than did persons who took none or only one.

Medicating preschool children with non-prescrmed medications was positively related to both education and social class. Among adults, however, no significant education and social class differences were found in those who took self-prescribed medications and those who did not. The use of medicines was greater among females than among males at all ages from ten years, with the sex differences greatest between the ages of 25 and 45 years.

Wadsworth, Butterfield and Blaney [35] found in the study of a working class area of London that for all symptom complaint groups discussed, the use of non-medically prescribed medication far exceeded that which was medically prescribed. Sixty-eight per cent of the complaints reported were self-diagnosed. For every medicine prescribed by a physician, two were taken either on the respondent’s own initiative or on the advice of some other lay person. There was a positive relationship between the number of complaints and the amount of medically prescribed medicine taken. Women took medications mote often than men, with the difference once again narrowing among persons over 50 years of age.

Perhaps the most comprehensive study of medication behavior in Great Britain was conducted by Dunnell and Cartwright in 1969 [36]. Parliamentary constituencies were utilized to select a stratified sample of the British population. It was found that four-fifths of the adults had used some medicine during the 2 weeks prior to the interview. Self-prescribed medications outnumbered prescribed ones by 2 to 1. Women used mote medications than men in all age groups. There was little variation with age in the avet- age number of medications taken among those under 65. The proportion of persons taking any medication. however, increased with age due to an increase in the proportions taking prescribed medicines.

Persons who took only prescribed medicines did not differ from those who took only non-prescribed medicines on either the number of symptoms reported or the number of medications used. However, those more often reporting the use of prescription drugs also reported more physician consultations. Ninety- nine per cent of the homes studied were found to contain one or more medical products. The average number was 10.3 of which three were prescription medicines and 7.3 non-prescription.

In a survey of the patients on the medical and sut- gical wards of a London teaching hospital, Lader [37] found the incidence of self-medication repotted for the year prior to the interview was 80”“. Of the patients interviewed 68”” had been self-medicating acute conditions and 27”” chronic conditions. While there were no sex differences in the proportions medicating chronic conditions (women self-medicated acute conditions more often than men) self-medication of symptoms decreased with age.

684 KATHRYN DEAN

The pattern of non-prescription drug use relative to the use of prescription drugs may be similar in the United States to that reported for Great Britain. Knapp and Knapp for instance found a pattern corre- sponding to the findings reported by Dunnell and Cartwright of relative prescription/non-prescription drug consumption in Great Britain. However, the basic differences in the research designs of these studies make it difficult to draw comparative conciu- sions.

Household stocking of drugs in the United States appears, however, quite different from that found in Great Britain. While, as mentioned, British homes averaged 7.3 non-prescription and 3.0 prescription medicines, the mean numbers of medicines found in United States homes were 17.2 and 5.3 respectively

~291. Carlsen et al. [38] investigated drug consumption

in Elsinore, Denmark. It was found that 370,; of the respondents had taken one or more drugs during the 7-day study period. However, no distinction was made between prescription and non-prescription drugs. The proportions of persons who consumed medications generally increased with age, markedly so after age 65, and was higher among females than among males. One exception was that boys 14 years of age ‘and younger had a higher proportion of drug consumers than both the same age group of females and the older age groups. Women also reported a greater number of doses than men, and the increase in drug consumption with age was steeper among women than among men.

An investigation into stocks of drugs in Danish homes was made on a sub-sample of the Elsinore sample. An average stock of 9.2 drugs per household was found. All households were found to contain at least one drug and the highest number found was a stock of 26 drugs [393.

Pedersen’s analysis, discussed above, of self-treatment of symptoms prior to professional consultation in his private general practice included information on self-medication. Of the various self-treatment behaviors practised prior to consultation, self-medication was the most frequent response to symptoms. A surprisingly large amount of the medicine used for self-treatment was found to be prescription medicine obtained at an earlier time. Prescribed medicine was used for 39% of the self-treated diagnoses, while non- prescription medicine was used for just under 25% of the cases [21]. A partial explanation for this finding may be the relatively more stringent requirements for drugs which require prescriptions in Denmark. Once again, the self-treatment was considered to be relevant in 90% of the cases, and of benefit in 6272 of the cases.

In a Norwegian study, Christie [40] was interested in possible social class differences in the consumption of vitamin and iron preparations, and of analgesics, sedatives and tranquilizers. Consumption of all the preparations was found to be greater among females. In addition, there were social class variations in the findings. Lower class respondents both reported more symptoms and used more analgesics and sedatives. At the same time, there was a positive relationship between the use of vitamin and iron preparations, and the social status of the respondents.

A survey of self-medication prior to consultation

with 28 general practitioners in Singapore was conducted by Guan and Chung [41]. It was found that of the 6571 patients interviewed. 1646 or 25”” had medicated their symptoms before consulting the doctor. There was a large amount of variation between practice populations. from a high of 83”,, to a low of 4”,, in the proportion of patients reporting self-medication prior to consultation. Variations in the demographic characteristics of the practices were not reported.

Persons who self-medicated were more often male and younger than those who had not medicated symptoms prior to consultation. Family members and other relatives were the most influential source in recommending self-medication. In an evaluation of the safety of the self-decision, it was judged that 3”,, either resulted in adverse drug reactions or were considered ill-advised.

Self-medication with prescription drugs

Before leaving the discussion of self-medication. it should be observed that even within prescription medication behavior there is a significant amount of self-treatment. As Pratt [6] has pointed out, patient ‘error’ and ‘non-complicance’ with the prescription medications ordered by physicians are alterations of professional treatment by the patient. The extent to which this is conscious, deliberate judgement rather than non-attention, carelessness. or other types of behavior commonly mentioned to fault patients is un- known. Stimson [42]. in discussing data collected in a Wales community, suggests that patients, rather than being passive, unquestioning recipients of medical instructions, evaluate doctors’ advice and use their own judgement. The most direct form of self-medication with prescription drugs is patient request for specific medications from physicians. Although no empirical data on the extent of this practice exists, the frequent references in medical literature regarding the importance of physician resistence to patient pressure indicates that it is widespread [6].

DISCUSSION

Although limited the literature reviewed clearly demonstrates that self-evaluation of symptoms and self-treatment are the basic and predominant forms of primary health care. Yet. of all the levels of care, self- care has been the most neglected in basic research and in policy and program development. Little consideration has been given to self-care as the basic level of care. The studies reviewed generally are limited in scope or method, if not both, as many were designed for purposes other than the study of self-care behavior. Thus the findings reported are often bi-products of data collected for other purposes. They are generally limited to descriptive information comparing non-prescription drug use with prescription drug use and/or an examination of physician consulting behavior for symptoms of illness.

Those few investigations designed specifically to study lay responses to illness often define self-care/ self-treatment along different dimensions. Most studies make simple reference to prescription and nonprescription drugs without further detailing the factors involved. The legal requirements regarding prescription drugs. however, differ from country to


country. Furthermore, non-prescription drugs suggested by doctors have sometimes been classified as prescription medications. while prescription medicines taken as directed by physicians have been labelled as self-decisions.

Some investigators consider self-care and professional consultation as contrasting behavior. Others conceptualize self-care as a continuum of responses to illness in which professional consultation is one option which may or may not result from the self- evaluation of symptoms. Few studies have investigated the range of self-care responses to illness. There is often an implicit assumption that symptoms should be treated. Therefore, decisions to do nothing about symptoms may not be given equal consideration with other types of behavioral responses in the analysis of data.

The national surveys of self-care behavior proposed by the conferees of the U.S. National Center of Health Services Research meeting in 1976 have not materialized. Only Dunnell and Cartwright. Dean and the Belgian Primary Health Care Project studied national populations. Several of the investigations were conducted on patient populations. Limiting the study of self-care illness responses to groups of patients neglects the study of behavior which is not associated with the use of professional services. Con- sideration of the range of behavior which precedes or follows interaction with the professional sector is thus neglected. Information on the self-care behavior of people who seldom or never consult the professional sector is excluded.

Studies which include only certain sections of general populations in the sample frames, such as persons with low incomes. families with small children or persons living in working class residential areas, preclude analysis of the comparative effects of those social or demographic factors. Furthermore, comparisons with the findings from other investigations are hampered.

The results of these investigations nevertheless do provide an information base on the extent of self-care in the general system of health care. Furthermore, the findings help define areas toward which future research could fruitfully be directed. Perhaps the most consistent relationships seen were those involving sex differences in the illness behaviors reported. Domin- ant in this regard was the essentially unvarying pro- pensity for women to use more medicine than men. Sex differences in morbidity and the utilization of professional services have been widely documented. However. little is known about the reasons for these differences. Investigations which focus on differences in self-care responses among women rather than differences in male and female behavior are needed at this time.*

The second characteristic consistently related to differential patterns of response to illness was age. Increase in the use of medications with age is a finding common to virtually all studies of illness behavior.

* Based on a review of data concerned with variations in illness experience among women in relation to three explanatory models. Nathanson [43] concluded that a model of illness behavior based on the number and character of women’s role obligations offers more potential explanatory value than the two other models considered.

Dean found the more extensive use of medications by older people to be only part of a general pattern of illness responses differentiating persons in more advanced stages of the life cycle from younger people. The self-care responses to common illness conditions tended to assume a medical and ameliorative character among older persons while the symptom responses of younger people were more often directed toward the cause of the problem or toward reliance on social rather than medical resources. It appeared that greater reliance on the medical sector by older people was related to differences in their social networks.

The findings regarding lay referral reported in the Belgian Primary Health Care Project also point to the influence of family and social networks on self- care responses to illness. The lay advisers counselling respondents to do nothing about the symptoms provided reassurance and support. On the other hand, a greater proportion of the lay persons consulted advised medical consultation, and a medical contact was the most frequent behavior reported in the stage of illness following lay referral. Elliot-Binns found that wives were considered the source of the soundest advice regarding treatment of symptoms, while husbands usually suggested medical consultation. It appears that supportive and nurturing behavior provided by the wife/mother contrasted with the tendency of husbands to refer their wives’ complaints to professionals may be a factor to consider in the study of self-care responses to illness.

The extent to which self-treatment serves as a substitute or suppliment for professional consultation has been widely discussed. The findings reported in the investigations reviewed are mixed in regard to this question. Kessel and Shepherd found that self-medication, rather than substituting for professional care. was extensive among both persons who had not consulted a physician in over two years and among those who had recently visited the doctor. Jeffreys et ul. likewise observed that self-medication functioned as a supplement as well as a substitute for physician consultation. Pedersen found that those patients who had self-treated their symptoms prior to consultation tended to consult earlier than those who had not done so, suggesting that self-treatment and professional consultation were supplementary behaviors for these persons.

Dunnell and Cartwright, however, found lower rates of physician consultation among people who had used only non-prescription medications. Similarly Anderson et ul. found that persons who treated their own symptoms contacted doctors less often than those who practised no self-treatment. A substitution effect was also reported by Rabin and Bush. In relation to the studies reported here, it appears that the inconsistent findings regarding this subject may be at least partially accounted for by age differences in the populations studied. It appears that the age distribu- tion in the studies in which supplementation was concluded may be narrower than in those where substitution was suggested. Jefferys er al. studied a population composed predominantly of young married couples with children. while the studies of KesSel and Shep- herd and of Pedersen included only persons registered in two suburban middle class general practices. Dun- nel and Cartwright. on the other hand. studied a

686 KATHRYN DEAN

national population while Rabin and Bush studied a general urban population. Although Anderson et ul. do not report the demographic characteristics of the 10 general practices from which their sample was selected, they were apparently drawn from different areas of London. Most studies report increases in the use of medications with age. The increase is, however, usually reported in relation to prescription medications. It may be that among younger persons there is a greater tendency to supplement professional care with self-treatment, while older persons rely more directly on professional care. However, it is not possible to arrive at a conclusion until studies are designed to produce results which are more comparable.

Finally, the important role of individual and family care in the treatment of illness and injury is evident. The limited data available suggests, however, that the family may not be well prepared for this function. Litman found low levels of health knowledge and ability to perform even simple home care techniques. Pratt found that the type of families exhibiting the most effective health behavior were rare and that for- mal health care systems are not organized for effective family interaction with professional care. Elliot-Binns found the mean age of the medical guides used in the homes of his patients was about 2’7 years. It appears that effort could be fruitfuIly directed toward strengthening self-care skills.

CONCLUSION

While some basic information is available on self- care responses to illness, little is known about the range of behavioral reactions and the forces which shape self-care practices in various sub-groups of the population. Few investigations have been directly concerned with self-care behavior. Furthermore, the limited data available generally are not suitable for comparative purposes, a factor which markedly con- strains the accumulation of knowledge regarding the subject. One of the more important areas in need of clarification is in relation to the factors shaping the self-care practices of older people. Especially important to consider is the extensive use of medications among the efderiy.

In order to determine the extent to which self-treatment is a substitute or supplement for professional services, studies should be designed with this subject as the central focus. Clarification on this point is necessary in order that self-treatment can be appro- priately and effectively integrated into the continuum of services. Information might also be provided regarding inappropriate use of professional services.

Most important at this time is the design of studies with more uniform definitions of variables, especially definitions of self-care and self-medication. Studies of general populations, preferrabiy national samples, are needed both to chart the dimensions of self-care behavior and to determine the forces which shape illness responses in various segments of populations. Finally, cross-national studies of self-care behavior are necessary to investigate the influence of different forms of health service organization and the effects of different patterns of social interaction on responses to illness.

itcknor~lecfgemenrs-The author gratefully acknowledges the comments and suggestions made by Drs David Dunlop and Richard Smith on a draft version of this paper.

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Self-care responses to illness: A selected review

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