British Journal of Clinical Psychology (1992), 31, 339-349
Printed in Great Britain
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0 1992 The British Psychological Society
Representations of health, illness and medicines : Coping strategies and healthpromoting behaviour Agustin Echebarria Echabe*, Ctsar Sanjuan Guillen and J. Agustin Ozamiz Department of Social Pychology and Methodology, Alto de Zorroaga, S N , Universio of the Basque Country, San Sebastiin, 20014 (Gu+qcoa) Spain This study focuses on the different representations of health, illness and medicines that are held by the population of the Basque Country. In addition, relationships between these representations and both coping strategies towards first symptoms of disease and health-promoting actions were studied. Three different representations were found : (u) an active/‘against medicines’ representation ; (b) a ‘magical/promedicines’ representation ; and (c) a representation that combines aspects of the previous representations. These representations were anchored in different social groups (defined by age, educational background, etc.) and were related to different coping strategies in the event of first symptoms of illness, and to differences in health-promoting behaviour.
The use of medicines is becoming a significant problem for the Government Health Department of the Basque Country. Seventeen per cent of the budget of this Department is spent on subsidizing the purchase of medical drugs and it is possible that the rising rate of medicine consumption could be explained, to some extent, by this financial support coming from Public Health institutions. However, we think that people’s beliefs about health and medicines also play an important role in this rising rate of consumption. It is important to remember that the hygienic movement of the late 19th and early 20th centuries produced a reduction in mortality by eradicating the main infectious diseases which had been the most important cause of mortality during the 19th century. However, the reduction in infectious diseases was largely attributed to the effects of pharmaceutical products. This attribution created expectations about the almost ‘magical ’ possibilities of drugs which were considered the main tools with which to cope with the increase in diseases (Leventhal, Safer & Panagis, 1983). It is therefore surprising to notice the limited number of studies carried out on the beliefs shared by people about the properties and utilities of medicines. The importance of beliefs about health and illness and their influence on behaviour towards mental patients (Herzlich, 1986 ; Jodelet, 1990u) or physically handicapped people (Echebarria & PBez, 1989; Weiner, Perry & Magnusson, 1988) and on coping strategies towards first symptoms of illness (Leventhal & Cameron, 1987; Leventhal, Meyer & Nerenz, 1980; Leventhal, Prohaska & Hirschman, 1985; Leventhal, Safer & Panagis, 1983) have been demonstrated in several studies. Prohaska, Leventhal, *Requests for reprints.
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Leventhal & Keller (1985) pointed out that a broad range of factors such as beliefs in the ability of some health practices to prevent illness, representations of illness, etc. can be important in promoting health strategies. Ideas about illness, health and medicines vary and it appears that these ideas are shaped by the information people get from social sources (Moscovici, 1990) and by their own past experience with illness. These common-sense theories play an important role in directing the subject’s behaviour (Leventhal e t af. 1980). Thus, in order to understand the reasons why people engage in self-promoting and selfmedicating behaviour it may be essential to know how subjects construct their own representations of health and illness. Leventhal e t al. (1980) found three basic beliefs about illness : ‘an acute episodic model’ which attributes the onset of symptoms to situational stress; ‘a cyclic model’ which attributes the onset of symptoms to commencing some kind of diet, drinking and other risky behaviours; and a ‘chronic model’ according to which the onset of symptoms is caused by age or hereditary factors. Jodelet (1990~)found a ‘contagious model’ of mental disease which appeared in the everyday practices of medical staff in contact with mental patients, while in another study Echebarria & Piez (1989) found a ‘generalized and social ’ explanation as opposed to a ‘blaming and rejecting’ representation of AIDS. These representations were associated with different behavioural intentions towards seropositive people. Jodelet (1990b) also found two similar representations of AIDS : (a) a moral representation which attributes AIDS to vice and excessive freedom; and (b) a biological representation. Each representation was associated with both a different behaviour towards seropositive people and different attitudes towards preventive behaviour. Moscovici (1986) mentioned two general representations of health and illness : (i) an organic representation in which disease is attributed to genetic factors and medicines are seen as the unique resource for recovering from sickness; and (ii) a representation of illness in which disease is attributed to dangerous ways of living and to negative changes in the environment. This latter representation was related to a more active attitude towards recovering from sickness. Janis & Rodin (1986) found that among patients who suffered from a chronic and serious disease a self-blaming representation of disease appeared. As we have already noted, belief in the success of medicines in coping with infectious diseases may have led to a positive representation of medicine. Herzlich (1986) pointed out, however, that representations are subject to historical change. For example, social controversy about medicine and the recent interest of some social groups (especially young people) in alternative ways of coping with disease may have produced more negative representations of physicians and medicines. It is also clear that representations are anchored in different social groups and that they change during the life-span reflecting variation in the type of health problems one faces (Felton & Revenson, 1983; Prohaska, Keller, Leventhal & Leventhal, 1987). For example, Leventhal e t al. (1985) found that older people are more likely to believe that control of affect is effective in preventing disease. Cockerham (1988) noted that people from a lower socio-economic background tend to have an external locus of control beliefs concerning factors which influence health.
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The present research focused on analysing representations of health, illness and medicines and the influence of such representations on coping with first symptoms of illness and engaging in health-promoting actions. As research studies of this kind are scarce, no specific hypotheses were formulated. Method Subects The sample was composed of 902 subjects (450 males and 452 females). The sample size was chosen to allow us to generalize results from the sample to the general Basque population (errork5 per cent). Subjects were randomly approached and asked to take part in the study in public health services. Of the subjects approached, 5 per cent refused to answer the questionnaire. Our sample reproduced the percentages of sex, age and geographical distribution of the general population groups. The distribution of the age groups was as follows: younger than 25 years = 10.6 per cent; 25-40 years = 22.3 per cent; 4 1 4 4 years = 33.4 per cent; older than 64 years = 33.8 per cent. Subjects were asked to respond individually to the following questionnaire.
Measures A pilot study was carried out in order to construct the questionnaire which was to be used in the final research. There were some theoretical reasons for using this approach. It was assumed that beliefs about health and medicines are deeply influenced by social and cultural factors and that there were strong differences between the North American culture (where most of the research about health has been carried out) and the Basque culture. It is for this reason that we preferred not to use a questionnaire designed for another cultural milieu. We were also mindful of the dangers of researchers imposing their own categories of responses when they design an instrument. From the social representation framework it is important to use categories which are both relevant and meaningful for lay people. In the pilot study four discussion groups were conducted. Each group was made up of 15 subjects. All groups were composed of five subjects of less than 25 years, five subjects aged between 25 and 40 years, five subjects aged between 40 and 65 years and five subjects older than 65 years (retired senior citizens). Subjects were initially asked to respond individually to three open questions: ‘What do you spontaneously think about.. . (u) health ; (b) illness; and (c) medicines? ’ Once the individual interview was finished the subjects were asked to take part in a group discussion. The group discussions were focused on the same three topics mentioned above and every session was tape-recorded and transcribed. A group of experts prepared a dictionary which included all the answers given individually by the subjects and also in the group session. These categories were used to construct the final questionnaire. Appendix 1 gives the items used to measure locus of control, representations of health, representations of medicines, and causes of health and illness (all answered on a scale where 1 = disagreement and 6 = agreement). Subjects were also asked to indicate their attitudes towards medicines (1 = very negative and 6 = very positive). Appendix 1 also gives the items written to assess coping strategies as soon as first signs or symptoms of illness appeared. Subjects were asked how frequently they made 13 different responses when they felt sick (1 = never, 4 = always). The internal reliability (alpha) coefficients of these scales were: .82 for the Locus of Control Scale; .76 for the Health Representation Scale; .78 for the Medicine Representation Scale; .85 for Causal Beliefs Scale; and .71 for the Coping Scale. After answering these items subjects were asked to indicate (u) if they were suffering some kind of chronic illness; (b) what kind of medicines they were taking; and (6) who prescribed these medicines. They were also asked to report the frequency of four health-promoting actions. (i) Eat a balanced diet (format : 1 = not at all; 2 = I take some care in what I eat ;3 = I follow some kind of diet; or, 4 = I follow a strict diet). (ii) Do some physical exericse (format: 1 = not at all; 2 = not often; 3 = regularly; or 4 = every day).
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(iii) Smoke (format: 1 = not at all; 2 = less than five cigarettes a day; 3 = less than a packet a day; or 4 = more than a packet a day). (iv) Drink alcohol (format: 1 = more than two glasses every day; or 2 = less than two glasses every day). Finally they were asked to report their educational background.
Results In order to analyse the different representations of health, illness and medicines a cluster analysis was performed. The scales included in this analysis were locus of control, beliefs about health and medicines, and causal explanations of health and illness. The coping scale was excluded because theoretically it was not regarded as an aspect of these representations but rather as a behaviour that is influenced and guided by them. In other words, coping strategies are regarded as variables that are explained by representations. Three clusters of beliefs were found. For each clustering variable, quick cluster prints a univariate F test for the derived cluster. The F test is only descriptive and the resulting probabilities should not be interpreted as a test of the null hypothesis of no differences among cases. For this reason, a complementary discriminant analysis is recommended (see SPSS-X user’s guide, p. 794). The cluster memberships were saved. The discriminating variables were those used in defining the previous cluster. Given the redundant information provided by the cluster analysis and the discriminant analysis, only the results of the discriminant analysis are shown in Table 1. The proportion of subjects correctly classified by the discriminant canonical functions was 90.58 per cent. These data support the goodness-of-fit of the chosen solution (the use of three clusters). The first cluster grouped most subjects (69.74 per cent). This cluster was characterized as follows : (a) Health is considered as the result of a balance between the body and the mind; illness is seen as a break in this balance, and symptoms are thought to be signs of emotional disturbances. (b) Illness is thought to be caused by the following factors: lack of exercise, stress at work, bad moods and also by environmental pollution and poverty. (c) The locus of control of health and illness is focused on the subject’s own behaviour: illness is a challenge which can be solved by oneself; one’s own behaviour, diet, exercise and a good mood are important in being healthy. ( d ) Medicines are valued negatively : subjects stress the negative consequences of medicines which are considered useless and big business for some enterprises. We decided to label this representation as ‘activelemotionallagainst medicines ’. The second cluster grouped 12.18 per cent of the subjects. This representation was characterized by the following factors : (a) Health is seen as synonymous with being able to work and enjoy life. Sadness is seen as an important pathogenic factor. (6) Illness is explained by different factors such as poverty, inheritance, and food adulteration, but also by having too much freedom and by vice. (c) The locus of control of health and illness is focused on diet and exercise, but also on external factors such as luck or God. Illness is seen as unavoidable. Physicians, medicines and diagnosis are considered the major factors that contribute to recovery from sickness. ( d ) The attitude towards medicine is positive. Medicines are considered to be the best resource that help one to recover from sickness, and ease pain. They are good for the
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Table 1. Discriminant analysis : Beliefs about health, illness and medicines Group 1
Group 2
Group 3
XI
SDl
X2
SD2
X3
SD3
F
Sign.
4.99 3.95 4.82
0.77 1.27 0.74
4.94 4.94 4.71
0.84 0.93 0.90
4.34 3.73 3.94
1.05 1.35 1.25
34.58 31.11 58.45
0.000 0.000 0.000
3.37 3.59 3.91 4.29 5.30 4.16 4.53 5.30 4.64 4.50
1.60 1.35 1.37 1.09 0.58 1.13 0.91 0.60 0.94 0.94
5.04 4.57 4.81 3.84 5.17 5.20 5.25 5.19 4.72 4.15
1.03 1.19 1.14 1.28 0.63 0.63 0.59 0.62 0.92 1.18
2.53 3.16 3.57 3.59 4.84 3.90 4.12 4.85 3.78 3.34
1.45 1.48 1.51 1.30 0.85 1.30 1.22 0.97 1.25 1.12
80.95 31.82 24.93 23.38 28.28 43.17 41.33 23.69 45.65 76.23
0.000 0.000 0.000 0.000
4.61 4.48 4.77 5.00 4.62 4.07 4.13
1.11 1.09 0.95 0.71 0.97 1.28 1.28
5.15 4.56 4.82 4.95 4.35 3.94 4.14
0.68 0.96 0.92 0.64 1.15 1.30 1.26
3.69 3.74 3.74 4.46 4.09 3.26 3.07
1.35 1.31 1.31 0.96 1.10 1.38 1.28
57.08 27.28 61.47 29.05 16.32 22.10 40.48
0.000 0.000 0.000 0.000 0.000 0.000 0.000
3.74
1.22
2.30
1.27
2.90
0.83
94.56
0.000
3.86 4.39 4.68 4.56 4.54 3.38 2.46 3.67 4.44 4.54
1.15 1.03 0.87 1.04 0.96 1.37 1.35 1.27 0.96 1.14
5.03 3.23 4.35 3.10 5.09 4.54 3.33 3.54 3.34 3.28
0.62 1.27 1.18 1.31 0.84 0.94 1.61 1.36 1.39 1.29
3.93 3.90 3.61 3.43 3.73 3.10 2.21 2.55 3.56 3.52
1.19 45.84 1.08 71.62 1.28 66.11 1.24 109.43 1.29 58.24 1.36 37.80 1.25 21.01 1.03 47.44 1.16 77.76 1.36 73.13
0.000 0.000 0.000
Causal explanations of health and illness Health = exercise 5.18 Environmental pollution 5.34 Food adulteration 4.74 Genetic factors 4.03 Poverty 3.85 3.96 Money is not health 4.19 More money is more health 4.29 Vice and excessive freedom 5.03 Stress
0.61 0.60 0.91 1.12 1.40 1.33 1.22 1.38 0.68
5.06 5.23 4.93 4.43 3.72 3.43 4.24 4.99 4.62
0.67 0.63 0.94 1.11 1.40 1.52 1.34 1.03 0.95
4.64 4.69 3.71 3.46 3.15 3.66 3.83 3.45 4.49
0.99 0.97 1.14 1.10 1.33 1.38 1.31 1.49 0.87
0.000 0.000 0.000 0.000 0.000 0.000 0.007 0.000 0.000
Variables Locus of control: Health and illness depend on:
Diet and exercise Physicians Illness is a challenge to be solved by oneself God Luck Impossible to avoid disease In one’s own hands Mood and feelings Medicines Medical check-ups Feelings influence recovering To know how medicines work Recovering depends on one’s own behaviour Representations of health and illness Health is to work Health is to enjoy life Illness = sadness and malaise Balance between body and mind Illness = emotional disturbances Illness = imbalance Good social relations = health Representations of medicines Conceal illness but don’t restore health Are good resources Have side-effects Produce dependence Are useless Relieve pain Help for the body Are magical Placebo effect Negative effects Business
33.61 50.92 74.66 23.86 14.49 7.84 4.96 39.12 34.94
0.000
0.000 0.000 0.000 0.000 0.000
0.000 0.000
0.000 0.000 0.000 0.000 0.000
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Lack of diet and exercise Infection Lack of money Mood and feelings Attitude towards medicines Canonical discriminant functions 1
5.00 2.47 4.30 5.09 2.98
0.61 1.14 1.15 0.69 0.94
4.79 2.60 4.44 4.88 3.94
Variance Chi-squared
67.27% 2 32.73% Grouped cases correctly classified: 90.58 %
1035.3 384.1
0.88 1.17 1.15 0.78 0.82
4.68 2.38 3.67 4.31 3.35
0.77 1.03 1.20 1.16 0.90
13.81 1.05 18.70 52.92 47.49
0.000 0.349 0.000 0.000 0.000
Sign. 0.0000 0.0000
Note. Group 1 = members of cluster 1 ; Group 2 = members of cluster 2; Group 3 = members of cluster 3.
body and they have a magical character. We decided to label this representation the ‘religious-magical/pro-pharmacological’. The third cluster grouped 18.35 per cent of the subjects. This cluster was in a halfway position between the previous clusters. Medicines are seen as contributing to recovery from sickness. One’s own behaviour is thought to be important in being healthy and recovering from sickness but medicines, physicians and check-ups are also important. Attitudes towards medicine are situated between those attitudes reported by the members of previous clusters. We decided to label this representation as the ‘combined ’ one. In our introduction it was suggested that these representations are anchored in different demographically defined groups, and that they are also influenced by experience with illness. Our results confirm that representations are affected by 6 )63.66,p < .OOOO), experience with a chronic illness educational background ( ~ ~ ( = ( ~ ~ (= 2 16.62, ) p < .0002) and age ( ~ ~ ( =6 75.14, ) p < .OOOO). The percentage of subjects who share the ‘combined ’ representation increases with educational background (basic studies = 11.9 per cent; primary studies = 21.6 per cent; technical studies = 22.4 per cent; university studies = 43.3 per cent). The opposite was true for those who shared the ‘magic/religious/pharmacologicaI ’ representation (basic studies = 17.8 per cent; primary studies = 9.9 per cent; technical studies = 4.2 per cent; university studies = 3.0 per cent) or supported an ‘active/against medicines/own focused’ representation (basic studies = 70.3 per cent ;primary studies = 68.5 per cent; technical studies = 73.4 per cent; university studies = 53.7 per cent). Those subjects suffering a chronic illness are over-represented in the group with a ‘magic/religious/pharmacological representation ’ (chronic illness = 17.3 per cent ; non-chronic illness = 8.1 per cent) and are under-represented in the other groups (67.4 vs. 70.2 per cent for the active representation and 15.3 vs. 21.7 per cent for the combined representation). With regard to age, the incidence of the ‘magic/pro-medical ’ representation is greater among older subjects (less than 25 years = 1.2 per cent ;25-40 years = 2.7 per cent; 41-64 years = 12.5 per cent; more than 65 years = 21.9 per cent); the opposite is true for the ‘combined’ representation which is less common in older subjects (less than 25 years = 34.5 per cent; 2 5 4 0 years = 26.6 per cent; 41-64 years = 17.1 per cent ;more than 65 years = 8.9 per cent). The ‘against medicines ’ representation does not vary with age. We also suggested that representations of illness and health play an important role in guiding the coping strategies that appear with the first signs of symptoms of
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illness. Before relating coping strategies to representations, a factor analysis was performed on the coping scale items (Varimax solution). No prior number of factors was imposed. The results are shown in Table 2. Table 2. Factor analysis : Coping strategies towards first symptoms of disease Variables Get information from friends Ask somebody for counselling Get information from family To become pessimistic Feel nervous Attribute symptoms to social/emotional disturbances Go to medical check-ups Get information from physician Not ask physician for information Avoid taking symptoms seriously and delay medical check-ups Avoid focusing attention on symptoms Look after self Not ask for check-ups Use alternative medicines Go to physicians Eigenvalues Variance (%)
Factor I
Factor I1 Factor I11 Factor IV Factor V
.88 .83 .80 .84 .82 .65 .82 .76 .52 .82 .78 .72 .56 .52 .39
.35
2.74 18.2
1.87 12.4
1.65 11.0
1.40 9.4
1.05 7.0
The items making up the coping scale were grouped into five factors. The first factor was defined by the fact of getting information from the social network (friends, family, etc.). The second factor reflects an emotional reaction towards the first signs or symptoms of illness (pessimism, getting nervous, attributing symptoms to some emotional/social problem). The third factor is defined by the fact of getting medical information and undergoing medical check-ups. The fourth factor reflects the strategy of avoiding focusing attention on symptoms and minimizing their importance. The fifth factor is characterized by using medicines without medical prescription. Five coping subscales were created by adding the items grouped in each factor. A discriminant analysis was then performed to compare the coping subscales associated with each representation of health, illness and medicines. In Table 3 we can see that members of different clusters differ significantly in two coping strategies. Subjects who share a ‘combined ’ representation get more information from their social network (friends, family, etc.), followed by those sharing an ‘against medicines ’ representation. These last subjects were those who delayed most undergoing medical check-ups, followed by members of the ‘combined ’ representation. Finally, we investigated whether different representations were associated with more habitual use of medicines and with using medicines because of medical prescriptions or because of one’s own initiative. Subjects who had a magical/pro-
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Table 3. Discriminant analysis : Representations and coping strategies Group 1
Group 2
Group 3
Coping strategies
X1
SD1
X2
SD2
X3
SD3
F
Sign.
Get information from social network Emotional reaction : Nervous/pessimism Ask for medical check-ups Delay medical check-ups Self-medication Canonical discriminant function 1
4.38
1.68
4.07
1.66
4.71
1.84
3.90
0.02
5.79 8.31 4.11 6.82
2.03 1.88 1.47 1.72
5.65 8.73 3.64 6.40
2.32 1.91 1.62 1.75
5.46 8.48 3.83 6.72
2.10 2.01 1.37 1.81
1.38 2.10 4.81 2.29
0.25 0.12 0.00 0.10
2
Variance 58.30Yo
41.70%
Chi-squared
Sign.
25.78 10.77
0.00 0.02
Note. Group 1 = members of cluster 1; Group 2 = members of cluster 2 ; Group 3 = members of cluster 3.
medicines representation were more likely to be regular than irregular users of medicines (67.01 against 32.99 per cent; x2(2) = 5 . 7 9 , ~ < .05) and were less likely to be taking these on their own initiative than on prescription (12 against 88 per cent, ~ ~ (= 2 9.99,) ) < .006).
Discussion We found three representations of health, illness and medicines. The first one was an ‘active/against medicines ’ representation. This representation is quite similar to the one defined by Herzlich (1986) and was shared by 2/3 of our sample. The second representation (the ‘magical/pro-medicines ’ representation) shares some elements with the representation Moscovici (1986) labelled as ‘ organic ’. In this representation, recovery from sickness is attributed to the physician, medicines and undergoing medical check-ups. However, in the representation found in our study vice and excessive freedom were additionally viewed as causes of disease. The third representation was located halfway between the previous representations. In this representation, to be healthy or to recover from sickness does not depend completely either on the physician and drugs or on one’s own behaviour. Medicines are seen both as good resources that aid recovery but also as dangerous substances which must be used carefully. This representation was more frequent among young people and among those who had a higher educational background. The ‘magical/promedicines ’ representation was associated with considering medical check-ups as the major coping strategy in the event of first symptoms of disease. In contrast, the major coping strategies endorsed by subjects who shared the other representations were to delay medical check-ups and to get advice from their social network (friends, family, etc.). Finally we would like to emphasize the implications of this sort of research for designing any kind of educational intervention for the general population (for example, trying to reduce high rates of self-medicating behaviour). This kind of intervention may be of little value if existing social representations of medicines are unknown. It appears from our previous work (Echebarria & Pbez, 1989) that
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existing beliefs influence the kind of information which attracts an individual’s attention and as a consequence influence what information is processed and stored.
References Cockerham, W. C. (1988). Medical sociology. In N. J. Smelser (Ed.), Handbook of Sociology. Beverly Hills, CA : Sage. Echebarria, A. & Paez, D. (1989). Social representations and memory: The case of AIDS. European Journal of Social Prychology, 19, 543-552. Felton, B. & Revenson, T. (1983). Age differences in coping with chronic illness. Paper presented at the Annual Meeting of the Gerontological Society of America, San Francisco. Herzlich, C. (1986). Representations sociales de la sante et de la maladie et leur dynamique dans le champs social. In W. Doise e t al. (Eds), L’Etude des Repre’sentations Sociales. Lausanne: Delachaux & Niestle. Janis, I. L. & Rodin, J. (1986). Attribution, control, and decision making: Social psychology and health care. In G. C. Stone e t al. (Eds), Health Pycbology. A Handbook. San Francisco: Jossey-Bass. Jodelet, D. (1990~).Folies e t Repkentations Sociales. Paris : Presses Universitaires de France. Jodelet, D. (1990 b). Representations sociales : Une domaine en expansion. In D. Jodelet (Ed.), Les Reprisentations Sociales. Paris : Presses Universitaires de France. Leventhal, H. & Cameron, L. (1987). Behavioural theories and the problem of compliance. Patient Education and Counseling, 10, 117-138. Leventhal, H., Meyer, D. & Nerenz, D. (1980). The common sense representations of illness danger. In S. Rachman (Ed.), Medical Pychology, vol. 11. Elmsford, NY: Pergamon Press. Leventhal, H., Prohaska, T. R. & Hirschman, R. S. (1985). Preventive health behaviour across the life span. In J . C. Rosen & L. J. Solomon (Eds), Prevention in Health Prycbology, vol. 18. Hanover: University Press of New England. Leventhal, H., Safer, M. A. & Panagis, D. (1983). The impact of communications on the self-regulation of health beliefs, decisions, and behaviour. Health Education QuarterCy, 10, 3-29. Moscovici, S. (1986). L’ere des representations sociales. In W. Doise et ul. (Eds), L’Etude des Reprisentutions Sociales. Lausanne : Delachaux & Niestlt. Moscovici, S. (1990). Preface. In D. Jodelet (Ed.), Folies e t Reprisentutions Sociales. Paris: Presses Universitaires de France. Prohaska, T., Keller, M. L., Leventhal, E. A. & Leventhal, H. (1987). Impact of symptoms and aging on attribution of emotions and coping. Health Prycbology, 6, 495-514. Prohaska, T., Leventhal, E. A., Leventhal, H. & Keller, M. L. (1985). Health practices and illness cognition in young, middle aged and elderly adults. Journal of Gerontology, 40, 569-578. S P S S - X User’s Guide (1986). New York: McGraw-Hill. Weiner, B., Perry, R. P. & Magnusson, J. (1988). An attributional analysis of reactions to stigmas. Journal of PersonaliQ and Social Pycbology, 55, 738-748.
Received 12 November 1990: revised version received 3 March 7992
Appendix 1 Locus of control 1. We can avoid illness by eating a balanced diet and doing some exercise. 2. Recovery from sickness nearly always depends on the physician. 3. Illness is a challenge which can be solved by oneself. 4. Both health and illness depend on God. 5. Chance plays an important role in both health and illness. 6. It is impossible to avoid illness. 7. It depends on us to stay healthy or to recover from sickness. 8. Feelings play an important role in both health and illness. 9. Recovering from sickness depends completely on getting both a good diagnosis and good medicines.
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10. Recovering from sickness depends nearly always on medicines. 11. One’s mood is important in recovering from sickness. 12. In order to recover from sickness it is important to know how the medicines work. 13. One’s own behaviour is the most important factor in recovering from sickness.
Representations of health 1. To be healthy is mainly to be able to work and to be active. 2. To be healthy is mainly to enjoy life. 3. The most important features ‘of illness are sadness and malaise. 4. Health is keeping a balance between the body and the mind. 5. Symptoms are frequently signs of emotional disturbances. 6. Illness is abnormality. 7. Social relationships play a very important role in being healthy or being sick.
Representations of medicines 1. Medicines conceal illness but they do not restore one to health. 2. Medicines are the best resource with which to recover from sickness. 3. Medicines have side-effects. 4. We have to be careful with medicines because they produce dependence. 5. Most medicines are useless. 6. Medicines relieve pain. 7. Medicines are good for the body. 8. Medicines are magical. 9. Medicines have a placebo effect. 10. Medicines restore health but they also produce negative consequences for a person. 11. Medicines are big business for some enterprises.
Causes of health and illness 1. Physical exercise. 2. Environmental pollution. 3. Adulterated food. 4. Genetic factors. 5. Poverty. 6. To have money is not the same as being healthy. 7. It is easier to recover from sickness if you have money. 8. Excessive freedom and vice. 9. Stress produced by work. 10. Lack of exercise and of a balanced diet. 11. Infection. 12. Emotional disturbances. 13. Lack of money.
Coping strategies 1. Use drug-store remedies without medical prescription. 2. Get information from friends, family, etc. 3. Ask friends for advice. 4. Go for a medical check-up. 5. Get information from the physician. 6. Ask for more medical information if you are not satisfied with the information provided by your physician.
Representations of health, illness and medicines 7. Look after yourself with no advice from either the physician or your friends. 8. Use alternative medicines (herbs, etc.). 9. Attribute symptoms to some social or emotional disturbance. 10. Avoid taking symptoms seriously and delay a medical check-up. 11. Avoid focusing your attention on the symptoms. 12. Feel nervous. 13. Become pessimistic.
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0 1992 The British Psychological Society
Representations of health, illness and medicines : Coping strategies and healthpromoting behaviour Agustin Echebarria Echabe*, Ctsar Sanjuan Guillen and J. Agustin Ozamiz Department of Social Pychology and Methodology, Alto de Zorroaga, S N , Universio of the Basque Country, San Sebastiin, 20014 (Gu+qcoa) Spain This study focuses on the different representations of health, illness and medicines that are held by the population of the Basque Country. In addition, relationships between these representations and both coping strategies towards first symptoms of disease and health-promoting actions were studied. Three different representations were found : (u) an active/‘against medicines’ representation ; (b) a ‘magical/promedicines’ representation ; and (c) a representation that combines aspects of the previous representations. These representations were anchored in different social groups (defined by age, educational background, etc.) and were related to different coping strategies in the event of first symptoms of illness, and to differences in health-promoting behaviour.
The use of medicines is becoming a significant problem for the Government Health Department of the Basque Country. Seventeen per cent of the budget of this Department is spent on subsidizing the purchase of medical drugs and it is possible that the rising rate of medicine consumption could be explained, to some extent, by this financial support coming from Public Health institutions. However, we think that people’s beliefs about health and medicines also play an important role in this rising rate of consumption. It is important to remember that the hygienic movement of the late 19th and early 20th centuries produced a reduction in mortality by eradicating the main infectious diseases which had been the most important cause of mortality during the 19th century. However, the reduction in infectious diseases was largely attributed to the effects of pharmaceutical products. This attribution created expectations about the almost ‘magical ’ possibilities of drugs which were considered the main tools with which to cope with the increase in diseases (Leventhal, Safer & Panagis, 1983). It is therefore surprising to notice the limited number of studies carried out on the beliefs shared by people about the properties and utilities of medicines. The importance of beliefs about health and illness and their influence on behaviour towards mental patients (Herzlich, 1986 ; Jodelet, 1990u) or physically handicapped people (Echebarria & PBez, 1989; Weiner, Perry & Magnusson, 1988) and on coping strategies towards first symptoms of illness (Leventhal & Cameron, 1987; Leventhal, Meyer & Nerenz, 1980; Leventhal, Prohaska & Hirschman, 1985; Leventhal, Safer & Panagis, 1983) have been demonstrated in several studies. Prohaska, Leventhal, *Requests for reprints.
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Leventhal & Keller (1985) pointed out that a broad range of factors such as beliefs in the ability of some health practices to prevent illness, representations of illness, etc. can be important in promoting health strategies. Ideas about illness, health and medicines vary and it appears that these ideas are shaped by the information people get from social sources (Moscovici, 1990) and by their own past experience with illness. These common-sense theories play an important role in directing the subject’s behaviour (Leventhal e t af. 1980). Thus, in order to understand the reasons why people engage in self-promoting and selfmedicating behaviour it may be essential to know how subjects construct their own representations of health and illness. Leventhal e t al. (1980) found three basic beliefs about illness : ‘an acute episodic model’ which attributes the onset of symptoms to situational stress; ‘a cyclic model’ which attributes the onset of symptoms to commencing some kind of diet, drinking and other risky behaviours; and a ‘chronic model’ according to which the onset of symptoms is caused by age or hereditary factors. Jodelet (1990~)found a ‘contagious model’ of mental disease which appeared in the everyday practices of medical staff in contact with mental patients, while in another study Echebarria & Piez (1989) found a ‘generalized and social ’ explanation as opposed to a ‘blaming and rejecting’ representation of AIDS. These representations were associated with different behavioural intentions towards seropositive people. Jodelet (1990b) also found two similar representations of AIDS : (a) a moral representation which attributes AIDS to vice and excessive freedom; and (b) a biological representation. Each representation was associated with both a different behaviour towards seropositive people and different attitudes towards preventive behaviour. Moscovici (1986) mentioned two general representations of health and illness : (i) an organic representation in which disease is attributed to genetic factors and medicines are seen as the unique resource for recovering from sickness; and (ii) a representation of illness in which disease is attributed to dangerous ways of living and to negative changes in the environment. This latter representation was related to a more active attitude towards recovering from sickness. Janis & Rodin (1986) found that among patients who suffered from a chronic and serious disease a self-blaming representation of disease appeared. As we have already noted, belief in the success of medicines in coping with infectious diseases may have led to a positive representation of medicine. Herzlich (1986) pointed out, however, that representations are subject to historical change. For example, social controversy about medicine and the recent interest of some social groups (especially young people) in alternative ways of coping with disease may have produced more negative representations of physicians and medicines. It is also clear that representations are anchored in different social groups and that they change during the life-span reflecting variation in the type of health problems one faces (Felton & Revenson, 1983; Prohaska, Keller, Leventhal & Leventhal, 1987). For example, Leventhal e t al. (1985) found that older people are more likely to believe that control of affect is effective in preventing disease. Cockerham (1988) noted that people from a lower socio-economic background tend to have an external locus of control beliefs concerning factors which influence health.
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The present research focused on analysing representations of health, illness and medicines and the influence of such representations on coping with first symptoms of illness and engaging in health-promoting actions. As research studies of this kind are scarce, no specific hypotheses were formulated. Method Subects The sample was composed of 902 subjects (450 males and 452 females). The sample size was chosen to allow us to generalize results from the sample to the general Basque population (errork5 per cent). Subjects were randomly approached and asked to take part in the study in public health services. Of the subjects approached, 5 per cent refused to answer the questionnaire. Our sample reproduced the percentages of sex, age and geographical distribution of the general population groups. The distribution of the age groups was as follows: younger than 25 years = 10.6 per cent; 25-40 years = 22.3 per cent; 4 1 4 4 years = 33.4 per cent; older than 64 years = 33.8 per cent. Subjects were asked to respond individually to the following questionnaire.
Measures A pilot study was carried out in order to construct the questionnaire which was to be used in the final research. There were some theoretical reasons for using this approach. It was assumed that beliefs about health and medicines are deeply influenced by social and cultural factors and that there were strong differences between the North American culture (where most of the research about health has been carried out) and the Basque culture. It is for this reason that we preferred not to use a questionnaire designed for another cultural milieu. We were also mindful of the dangers of researchers imposing their own categories of responses when they design an instrument. From the social representation framework it is important to use categories which are both relevant and meaningful for lay people. In the pilot study four discussion groups were conducted. Each group was made up of 15 subjects. All groups were composed of five subjects of less than 25 years, five subjects aged between 25 and 40 years, five subjects aged between 40 and 65 years and five subjects older than 65 years (retired senior citizens). Subjects were initially asked to respond individually to three open questions: ‘What do you spontaneously think about.. . (u) health ; (b) illness; and (c) medicines? ’ Once the individual interview was finished the subjects were asked to take part in a group discussion. The group discussions were focused on the same three topics mentioned above and every session was tape-recorded and transcribed. A group of experts prepared a dictionary which included all the answers given individually by the subjects and also in the group session. These categories were used to construct the final questionnaire. Appendix 1 gives the items used to measure locus of control, representations of health, representations of medicines, and causes of health and illness (all answered on a scale where 1 = disagreement and 6 = agreement). Subjects were also asked to indicate their attitudes towards medicines (1 = very negative and 6 = very positive). Appendix 1 also gives the items written to assess coping strategies as soon as first signs or symptoms of illness appeared. Subjects were asked how frequently they made 13 different responses when they felt sick (1 = never, 4 = always). The internal reliability (alpha) coefficients of these scales were: .82 for the Locus of Control Scale; .76 for the Health Representation Scale; .78 for the Medicine Representation Scale; .85 for Causal Beliefs Scale; and .71 for the Coping Scale. After answering these items subjects were asked to indicate (u) if they were suffering some kind of chronic illness; (b) what kind of medicines they were taking; and (6) who prescribed these medicines. They were also asked to report the frequency of four health-promoting actions. (i) Eat a balanced diet (format : 1 = not at all; 2 = I take some care in what I eat ;3 = I follow some kind of diet; or, 4 = I follow a strict diet). (ii) Do some physical exericse (format: 1 = not at all; 2 = not often; 3 = regularly; or 4 = every day).
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(iii) Smoke (format: 1 = not at all; 2 = less than five cigarettes a day; 3 = less than a packet a day; or 4 = more than a packet a day). (iv) Drink alcohol (format: 1 = more than two glasses every day; or 2 = less than two glasses every day). Finally they were asked to report their educational background.
Results In order to analyse the different representations of health, illness and medicines a cluster analysis was performed. The scales included in this analysis were locus of control, beliefs about health and medicines, and causal explanations of health and illness. The coping scale was excluded because theoretically it was not regarded as an aspect of these representations but rather as a behaviour that is influenced and guided by them. In other words, coping strategies are regarded as variables that are explained by representations. Three clusters of beliefs were found. For each clustering variable, quick cluster prints a univariate F test for the derived cluster. The F test is only descriptive and the resulting probabilities should not be interpreted as a test of the null hypothesis of no differences among cases. For this reason, a complementary discriminant analysis is recommended (see SPSS-X user’s guide, p. 794). The cluster memberships were saved. The discriminating variables were those used in defining the previous cluster. Given the redundant information provided by the cluster analysis and the discriminant analysis, only the results of the discriminant analysis are shown in Table 1. The proportion of subjects correctly classified by the discriminant canonical functions was 90.58 per cent. These data support the goodness-of-fit of the chosen solution (the use of three clusters). The first cluster grouped most subjects (69.74 per cent). This cluster was characterized as follows : (a) Health is considered as the result of a balance between the body and the mind; illness is seen as a break in this balance, and symptoms are thought to be signs of emotional disturbances. (b) Illness is thought to be caused by the following factors: lack of exercise, stress at work, bad moods and also by environmental pollution and poverty. (c) The locus of control of health and illness is focused on the subject’s own behaviour: illness is a challenge which can be solved by oneself; one’s own behaviour, diet, exercise and a good mood are important in being healthy. ( d ) Medicines are valued negatively : subjects stress the negative consequences of medicines which are considered useless and big business for some enterprises. We decided to label this representation as ‘activelemotionallagainst medicines ’. The second cluster grouped 12.18 per cent of the subjects. This representation was characterized by the following factors : (a) Health is seen as synonymous with being able to work and enjoy life. Sadness is seen as an important pathogenic factor. (6) Illness is explained by different factors such as poverty, inheritance, and food adulteration, but also by having too much freedom and by vice. (c) The locus of control of health and illness is focused on diet and exercise, but also on external factors such as luck or God. Illness is seen as unavoidable. Physicians, medicines and diagnosis are considered the major factors that contribute to recovery from sickness. ( d ) The attitude towards medicine is positive. Medicines are considered to be the best resource that help one to recover from sickness, and ease pain. They are good for the
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Table 1. Discriminant analysis : Beliefs about health, illness and medicines Group 1
Group 2
Group 3
XI
SDl
X2
SD2
X3
SD3
F
Sign.
4.99 3.95 4.82
0.77 1.27 0.74
4.94 4.94 4.71
0.84 0.93 0.90
4.34 3.73 3.94
1.05 1.35 1.25
34.58 31.11 58.45
0.000 0.000 0.000
3.37 3.59 3.91 4.29 5.30 4.16 4.53 5.30 4.64 4.50
1.60 1.35 1.37 1.09 0.58 1.13 0.91 0.60 0.94 0.94
5.04 4.57 4.81 3.84 5.17 5.20 5.25 5.19 4.72 4.15
1.03 1.19 1.14 1.28 0.63 0.63 0.59 0.62 0.92 1.18
2.53 3.16 3.57 3.59 4.84 3.90 4.12 4.85 3.78 3.34
1.45 1.48 1.51 1.30 0.85 1.30 1.22 0.97 1.25 1.12
80.95 31.82 24.93 23.38 28.28 43.17 41.33 23.69 45.65 76.23
0.000 0.000 0.000 0.000
4.61 4.48 4.77 5.00 4.62 4.07 4.13
1.11 1.09 0.95 0.71 0.97 1.28 1.28
5.15 4.56 4.82 4.95 4.35 3.94 4.14
0.68 0.96 0.92 0.64 1.15 1.30 1.26
3.69 3.74 3.74 4.46 4.09 3.26 3.07
1.35 1.31 1.31 0.96 1.10 1.38 1.28
57.08 27.28 61.47 29.05 16.32 22.10 40.48
0.000 0.000 0.000 0.000 0.000 0.000 0.000
3.74
1.22
2.30
1.27
2.90
0.83
94.56
0.000
3.86 4.39 4.68 4.56 4.54 3.38 2.46 3.67 4.44 4.54
1.15 1.03 0.87 1.04 0.96 1.37 1.35 1.27 0.96 1.14
5.03 3.23 4.35 3.10 5.09 4.54 3.33 3.54 3.34 3.28
0.62 1.27 1.18 1.31 0.84 0.94 1.61 1.36 1.39 1.29
3.93 3.90 3.61 3.43 3.73 3.10 2.21 2.55 3.56 3.52
1.19 45.84 1.08 71.62 1.28 66.11 1.24 109.43 1.29 58.24 1.36 37.80 1.25 21.01 1.03 47.44 1.16 77.76 1.36 73.13
0.000 0.000 0.000
Causal explanations of health and illness Health = exercise 5.18 Environmental pollution 5.34 Food adulteration 4.74 Genetic factors 4.03 Poverty 3.85 3.96 Money is not health 4.19 More money is more health 4.29 Vice and excessive freedom 5.03 Stress
0.61 0.60 0.91 1.12 1.40 1.33 1.22 1.38 0.68
5.06 5.23 4.93 4.43 3.72 3.43 4.24 4.99 4.62
0.67 0.63 0.94 1.11 1.40 1.52 1.34 1.03 0.95
4.64 4.69 3.71 3.46 3.15 3.66 3.83 3.45 4.49
0.99 0.97 1.14 1.10 1.33 1.38 1.31 1.49 0.87
0.000 0.000 0.000 0.000 0.000 0.000 0.007 0.000 0.000
Variables Locus of control: Health and illness depend on:
Diet and exercise Physicians Illness is a challenge to be solved by oneself God Luck Impossible to avoid disease In one’s own hands Mood and feelings Medicines Medical check-ups Feelings influence recovering To know how medicines work Recovering depends on one’s own behaviour Representations of health and illness Health is to work Health is to enjoy life Illness = sadness and malaise Balance between body and mind Illness = emotional disturbances Illness = imbalance Good social relations = health Representations of medicines Conceal illness but don’t restore health Are good resources Have side-effects Produce dependence Are useless Relieve pain Help for the body Are magical Placebo effect Negative effects Business
33.61 50.92 74.66 23.86 14.49 7.84 4.96 39.12 34.94
0.000
0.000 0.000 0.000 0.000 0.000
0.000 0.000
0.000 0.000 0.000 0.000 0.000
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Lack of diet and exercise Infection Lack of money Mood and feelings Attitude towards medicines Canonical discriminant functions 1
5.00 2.47 4.30 5.09 2.98
0.61 1.14 1.15 0.69 0.94
4.79 2.60 4.44 4.88 3.94
Variance Chi-squared
67.27% 2 32.73% Grouped cases correctly classified: 90.58 %
1035.3 384.1
0.88 1.17 1.15 0.78 0.82
4.68 2.38 3.67 4.31 3.35
0.77 1.03 1.20 1.16 0.90
13.81 1.05 18.70 52.92 47.49
0.000 0.349 0.000 0.000 0.000
Sign. 0.0000 0.0000
Note. Group 1 = members of cluster 1 ; Group 2 = members of cluster 2; Group 3 = members of cluster 3.
body and they have a magical character. We decided to label this representation the ‘religious-magical/pro-pharmacological’. The third cluster grouped 18.35 per cent of the subjects. This cluster was in a halfway position between the previous clusters. Medicines are seen as contributing to recovery from sickness. One’s own behaviour is thought to be important in being healthy and recovering from sickness but medicines, physicians and check-ups are also important. Attitudes towards medicine are situated between those attitudes reported by the members of previous clusters. We decided to label this representation as the ‘combined ’ one. In our introduction it was suggested that these representations are anchored in different demographically defined groups, and that they are also influenced by experience with illness. Our results confirm that representations are affected by 6 )63.66,p < .OOOO), experience with a chronic illness educational background ( ~ ~ ( = ( ~ ~ (= 2 16.62, ) p < .0002) and age ( ~ ~ ( =6 75.14, ) p < .OOOO). The percentage of subjects who share the ‘combined ’ representation increases with educational background (basic studies = 11.9 per cent; primary studies = 21.6 per cent; technical studies = 22.4 per cent; university studies = 43.3 per cent). The opposite was true for those who shared the ‘magic/religious/pharmacologicaI ’ representation (basic studies = 17.8 per cent; primary studies = 9.9 per cent; technical studies = 4.2 per cent; university studies = 3.0 per cent) or supported an ‘active/against medicines/own focused’ representation (basic studies = 70.3 per cent ;primary studies = 68.5 per cent; technical studies = 73.4 per cent; university studies = 53.7 per cent). Those subjects suffering a chronic illness are over-represented in the group with a ‘magic/religious/pharmacological representation ’ (chronic illness = 17.3 per cent ; non-chronic illness = 8.1 per cent) and are under-represented in the other groups (67.4 vs. 70.2 per cent for the active representation and 15.3 vs. 21.7 per cent for the combined representation). With regard to age, the incidence of the ‘magic/pro-medical ’ representation is greater among older subjects (less than 25 years = 1.2 per cent ;25-40 years = 2.7 per cent; 41-64 years = 12.5 per cent; more than 65 years = 21.9 per cent); the opposite is true for the ‘combined’ representation which is less common in older subjects (less than 25 years = 34.5 per cent; 2 5 4 0 years = 26.6 per cent; 41-64 years = 17.1 per cent ;more than 65 years = 8.9 per cent). The ‘against medicines ’ representation does not vary with age. We also suggested that representations of illness and health play an important role in guiding the coping strategies that appear with the first signs of symptoms of
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illness. Before relating coping strategies to representations, a factor analysis was performed on the coping scale items (Varimax solution). No prior number of factors was imposed. The results are shown in Table 2. Table 2. Factor analysis : Coping strategies towards first symptoms of disease Variables Get information from friends Ask somebody for counselling Get information from family To become pessimistic Feel nervous Attribute symptoms to social/emotional disturbances Go to medical check-ups Get information from physician Not ask physician for information Avoid taking symptoms seriously and delay medical check-ups Avoid focusing attention on symptoms Look after self Not ask for check-ups Use alternative medicines Go to physicians Eigenvalues Variance (%)
Factor I
Factor I1 Factor I11 Factor IV Factor V
.88 .83 .80 .84 .82 .65 .82 .76 .52 .82 .78 .72 .56 .52 .39
.35
2.74 18.2
1.87 12.4
1.65 11.0
1.40 9.4
1.05 7.0
The items making up the coping scale were grouped into five factors. The first factor was defined by the fact of getting information from the social network (friends, family, etc.). The second factor reflects an emotional reaction towards the first signs or symptoms of illness (pessimism, getting nervous, attributing symptoms to some emotional/social problem). The third factor is defined by the fact of getting medical information and undergoing medical check-ups. The fourth factor reflects the strategy of avoiding focusing attention on symptoms and minimizing their importance. The fifth factor is characterized by using medicines without medical prescription. Five coping subscales were created by adding the items grouped in each factor. A discriminant analysis was then performed to compare the coping subscales associated with each representation of health, illness and medicines. In Table 3 we can see that members of different clusters differ significantly in two coping strategies. Subjects who share a ‘combined ’ representation get more information from their social network (friends, family, etc.), followed by those sharing an ‘against medicines ’ representation. These last subjects were those who delayed most undergoing medical check-ups, followed by members of the ‘combined ’ representation. Finally, we investigated whether different representations were associated with more habitual use of medicines and with using medicines because of medical prescriptions or because of one’s own initiative. Subjects who had a magical/pro-
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Table 3. Discriminant analysis : Representations and coping strategies Group 1
Group 2
Group 3
Coping strategies
X1
SD1
X2
SD2
X3
SD3
F
Sign.
Get information from social network Emotional reaction : Nervous/pessimism Ask for medical check-ups Delay medical check-ups Self-medication Canonical discriminant function 1
4.38
1.68
4.07
1.66
4.71
1.84
3.90
0.02
5.79 8.31 4.11 6.82
2.03 1.88 1.47 1.72
5.65 8.73 3.64 6.40
2.32 1.91 1.62 1.75
5.46 8.48 3.83 6.72
2.10 2.01 1.37 1.81
1.38 2.10 4.81 2.29
0.25 0.12 0.00 0.10
2
Variance 58.30Yo
41.70%
Chi-squared
Sign.
25.78 10.77
0.00 0.02
Note. Group 1 = members of cluster 1; Group 2 = members of cluster 2 ; Group 3 = members of cluster 3.
medicines representation were more likely to be regular than irregular users of medicines (67.01 against 32.99 per cent; x2(2) = 5 . 7 9 , ~ < .05) and were less likely to be taking these on their own initiative than on prescription (12 against 88 per cent, ~ ~ (= 2 9.99,) ) < .006).
Discussion We found three representations of health, illness and medicines. The first one was an ‘active/against medicines ’ representation. This representation is quite similar to the one defined by Herzlich (1986) and was shared by 2/3 of our sample. The second representation (the ‘magical/pro-medicines ’ representation) shares some elements with the representation Moscovici (1986) labelled as ‘ organic ’. In this representation, recovery from sickness is attributed to the physician, medicines and undergoing medical check-ups. However, in the representation found in our study vice and excessive freedom were additionally viewed as causes of disease. The third representation was located halfway between the previous representations. In this representation, to be healthy or to recover from sickness does not depend completely either on the physician and drugs or on one’s own behaviour. Medicines are seen both as good resources that aid recovery but also as dangerous substances which must be used carefully. This representation was more frequent among young people and among those who had a higher educational background. The ‘magical/promedicines ’ representation was associated with considering medical check-ups as the major coping strategy in the event of first symptoms of disease. In contrast, the major coping strategies endorsed by subjects who shared the other representations were to delay medical check-ups and to get advice from their social network (friends, family, etc.). Finally we would like to emphasize the implications of this sort of research for designing any kind of educational intervention for the general population (for example, trying to reduce high rates of self-medicating behaviour). This kind of intervention may be of little value if existing social representations of medicines are unknown. It appears from our previous work (Echebarria & Pbez, 1989) that
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existing beliefs influence the kind of information which attracts an individual’s attention and as a consequence influence what information is processed and stored.
References Cockerham, W. C. (1988). Medical sociology. In N. J. Smelser (Ed.), Handbook of Sociology. Beverly Hills, CA : Sage. Echebarria, A. & Paez, D. (1989). Social representations and memory: The case of AIDS. European Journal of Social Prychology, 19, 543-552. Felton, B. & Revenson, T. (1983). Age differences in coping with chronic illness. Paper presented at the Annual Meeting of the Gerontological Society of America, San Francisco. Herzlich, C. (1986). Representations sociales de la sante et de la maladie et leur dynamique dans le champs social. In W. Doise e t al. (Eds), L’Etude des Repre’sentations Sociales. Lausanne: Delachaux & Niestle. Janis, I. L. & Rodin, J. (1986). Attribution, control, and decision making: Social psychology and health care. In G. C. Stone e t al. (Eds), Health Pycbology. A Handbook. San Francisco: Jossey-Bass. Jodelet, D. (1990~).Folies e t Repkentations Sociales. Paris : Presses Universitaires de France. Jodelet, D. (1990 b). Representations sociales : Une domaine en expansion. In D. Jodelet (Ed.), Les Reprisentations Sociales. Paris : Presses Universitaires de France. Leventhal, H. & Cameron, L. (1987). Behavioural theories and the problem of compliance. Patient Education and Counseling, 10, 117-138. Leventhal, H., Meyer, D. & Nerenz, D. (1980). The common sense representations of illness danger. In S. Rachman (Ed.), Medical Pychology, vol. 11. Elmsford, NY: Pergamon Press. Leventhal, H., Prohaska, T. R. & Hirschman, R. S. (1985). Preventive health behaviour across the life span. In J . C. Rosen & L. J. Solomon (Eds), Prevention in Health Prycbology, vol. 18. Hanover: University Press of New England. Leventhal, H., Safer, M. A. & Panagis, D. (1983). The impact of communications on the self-regulation of health beliefs, decisions, and behaviour. Health Education QuarterCy, 10, 3-29. Moscovici, S. (1986). L’ere des representations sociales. In W. Doise et ul. (Eds), L’Etude des Reprisentutions Sociales. Lausanne : Delachaux & Niestlt. Moscovici, S. (1990). Preface. In D. Jodelet (Ed.), Folies e t Reprisentutions Sociales. Paris: Presses Universitaires de France. Prohaska, T., Keller, M. L., Leventhal, E. A. & Leventhal, H. (1987). Impact of symptoms and aging on attribution of emotions and coping. Health Prycbology, 6, 495-514. Prohaska, T., Leventhal, E. A., Leventhal, H. & Keller, M. L. (1985). Health practices and illness cognition in young, middle aged and elderly adults. Journal of Gerontology, 40, 569-578. S P S S - X User’s Guide (1986). New York: McGraw-Hill. Weiner, B., Perry, R. P. & Magnusson, J. (1988). An attributional analysis of reactions to stigmas. Journal of PersonaliQ and Social Pycbology, 55, 738-748.
Received 12 November 1990: revised version received 3 March 7992
Appendix 1 Locus of control 1. We can avoid illness by eating a balanced diet and doing some exercise. 2. Recovery from sickness nearly always depends on the physician. 3. Illness is a challenge which can be solved by oneself. 4. Both health and illness depend on God. 5. Chance plays an important role in both health and illness. 6. It is impossible to avoid illness. 7. It depends on us to stay healthy or to recover from sickness. 8. Feelings play an important role in both health and illness. 9. Recovering from sickness depends completely on getting both a good diagnosis and good medicines.
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10. Recovering from sickness depends nearly always on medicines. 11. One’s mood is important in recovering from sickness. 12. In order to recover from sickness it is important to know how the medicines work. 13. One’s own behaviour is the most important factor in recovering from sickness.
Representations of health 1. To be healthy is mainly to be able to work and to be active. 2. To be healthy is mainly to enjoy life. 3. The most important features ‘of illness are sadness and malaise. 4. Health is keeping a balance between the body and the mind. 5. Symptoms are frequently signs of emotional disturbances. 6. Illness is abnormality. 7. Social relationships play a very important role in being healthy or being sick.
Representations of medicines 1. Medicines conceal illness but they do not restore one to health. 2. Medicines are the best resource with which to recover from sickness. 3. Medicines have side-effects. 4. We have to be careful with medicines because they produce dependence. 5. Most medicines are useless. 6. Medicines relieve pain. 7. Medicines are good for the body. 8. Medicines are magical. 9. Medicines have a placebo effect. 10. Medicines restore health but they also produce negative consequences for a person. 11. Medicines are big business for some enterprises.
Causes of health and illness 1. Physical exercise. 2. Environmental pollution. 3. Adulterated food. 4. Genetic factors. 5. Poverty. 6. To have money is not the same as being healthy. 7. It is easier to recover from sickness if you have money. 8. Excessive freedom and vice. 9. Stress produced by work. 10. Lack of exercise and of a balanced diet. 11. Infection. 12. Emotional disturbances. 13. Lack of money.
Coping strategies 1. Use drug-store remedies without medical prescription. 2. Get information from friends, family, etc. 3. Ask friends for advice. 4. Go for a medical check-up. 5. Get information from the physician. 6. Ask for more medical information if you are not satisfied with the information provided by your physician.
Representations of health, illness and medicines 7. Look after yourself with no advice from either the physician or your friends. 8. Use alternative medicines (herbs, etc.). 9. Attribute symptoms to some social or emotional disturbance. 10. Avoid taking symptoms seriously and delay a medical check-up. 11. Avoid focusing your attention on the symptoms. 12. Feel nervous. 13. Become pessimistic.
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