2 Accounting for health
Until relatively recently most of the information available to us about how people think about health and illness was concerned with non-Western societies. There was a time when a search in a good anthropological library in Britain would reveal more about the everyday health beliefs of the peoples of, say, African, Asian or South American countries than could be discovered about the everyday health beliefs of the people of the British Isles. Good (1994), in his book Medicine, Rationality and Experience, has pointed out that this anthropological tradition is based on the assumption that Western medical knowledge is true knowledge and that ‘lay beliefs’ connote error or falsehood. Or as Bury, a medical sociologist, puts it ‘lay people have beliefs and doctors have knowledge’ (1997, p. 20), the assumption being that ‘lay beliefs’ are irrational. Two significant changes have occurred in the literature on lay views. One is that attention has turned from non-Western to Western societies, and the other is that the focus has made a subtle shift from investigating health beliefs to health accounts. As well as having irrational connotations, health beliefs also suggest a more deep-rooted static quality, whereas health accounts tell us about what people say about health based on their knowledge and experience, which has a much more dynamic quality. Accounts also tell us much more about health needs and health status.
Systematic investigation of the health accounts and health practices of lay people in Western societies has only begun to gather momentum in the past 25 years or so. Four classic studies have influenced current thinking.
An early and influential study was carried out in France by Herzlich (1973). She conducted in-depth interviews with lay people, predominantly middle-class, in urban and rural settings (Paris and Normandy) and identified three different conceptions of health:
health as something to be had – a reserve of strength, a potential to resist illness, determined by temperament or constitution;
health as a state of doing – the full realisation of a person's reserve of strength, characterised by equilibrium, wellbeing, happiness, feeling strong, getting on well with other people;
health as a state of being – the absence of illness.
In Aberdeen in Scotland, Williams (1983), in a study of the ‘health histories’ of older people (men and women over 60, both middle and working-class), identified four contrasting categories, with no obvious differences by social class:
health as the absence of illness and disease;
health as stamina, an ability to keep going;
health as inner strength, a reserve of fitness;
health as the capacity to cope with illness or endure chronic pain.
Also in Scotland, studies have been made of the views on health of a sample of married women and of ‘grandmothers’ in 58 working-class families (Blaster and Paterson, 1982; Blaster, 1983). The views identified among these women included the following:
health as a good constitution;
health as a reserve of fitness or strength;
health as the capacity to cope with pain and illness;
health as strength of character: a matter of willpower, self-discipline, self-control.
Calnan (1987), from a study of the views on health of a sample of 60 women in south-east England, has pointed to the need to look systematically at differences between different social classes. He found four different concepts of health, as follows:
health as never being ill;
health as being able to get through the day, to carry out routines;
health as being fit, being active, taking exercise;
health as being able to cope with stresses and crises in life.
The first two of these concepts were more likely to be quoted by working-class women, while middle-class women made more frequent reference to the latter two. However this was only true when the women were asked to talk in general terms about health. When they were asked to talk about their own personal health, the class differences were much less apparent.
Let's pause to consider these four studies.
Activity 4: Reviewing the four studies
List the main features of lay health accounts as revealed in these studies.
Among the features of lay health accounts recorded here you may have noted the following:
they cover a range of diverse explanations and they include several different levels of meaning: physical, social and psychological;
health can coexist with or be independent of disease so that, according to some accounts, it is possible to be healthy even when disease or infirmity is present;
some separate the physical from the emotional, but many do not – they emphasise wholeness or integrity of the person (even when disease is present and may be serious);
some cite a moral dimension, making reference to individual ‘character’ or willpower.
Already some significant differences based on gender and social class have emerged. Inequalities in health status and patterns of morbidity and mortality are receiving much more attention than they used to. We will now begin to look at the different ways people in different social groups account for health.