The Sick Role
The essential companion to the concept of a sickness career is Talcott Parsons’ sick role model (26l). It is especially important to the issue of patient compliance. But first, let’s look at some of the general distinctions.
Three types of behavior are relevant to anyone serving the needs of patients or potential patients. These are, with definitions:
1. Health behavior: “Any activity undertaken by a person who believes himself to be healthy, for the purpose of preventing disease or detecting disease in an asymptomatic stage”.
- 2. Illness behavior: “Any activity undertaken by a person who feels ill, for the purpose of defining the state of his Health and of discovering suitable remedy”.
- 3. Sick role behavior: “Activity undertaken by those who consider themselves ill for the purpose of getting well” (260).
Hardest of all Health-related behavior to predict is that of the “healthy” individual. Included in such behavior are decisions to obtain preventive care or detection tests as well as activities designed to maintain a state of wellness, such as dental hygiene and good nutrition. The individual has no clear-cut symptoms to prompt such action, yet the time, effort, and money spent on this type of activity are potentially the most productive of those spent on any Health Care activity. The HBM, described earlier, was formulated to explain aspects of Health behavior.
Understanding of the behavior of People when they are ill has been enhanced by viewing this behavior as the “sickness career”. The sickness career begins with a state of wellness. As already noted, being well or healthy will mean something different to different People. There have been a variety of studies of this phenomenon, and the general criteria by which People view themselves as “well” include:
- 1. A feeling of well-being.
- 2. An absence of symptoms.
- 3. An ability to perform normal personal and work functions.
Although these criteria will not be uniform from person to person, their meaning for any given individual will form a baseline of Health against which to judge changes. When a change from a state of wellness is perceived, there will again be varying reactions. Most People - even those who feel well - are able to identify the presence at any time of some symptoms. Often they will view these symptoms as normal, although the symptoms may trigger a desire for further information.
Ultimately a decision must be made by the patient about the significance of symptoms. A variety of factors can go into a patient’s determination of the significance of a symptom. Some examples:
- 1. Interference with normal activities and functions (e.g., bowel habits, work ability, or leisure activity are affected).
- 2. Clarity of symptoms (sharp pains or symptoms visible to family or friends are likely to be judged important).
- 3. Tolerance threshold (some People can tolerate more pain, either because of personal characteristics, cultural factors, or the nature of their work).
- 4. Familiarity with symptoms (common symptoms that one has experienced previously and recovered from are likely to be viewed as less serious than those that have not been previously experienced).
- 5. Assumptions about cause (e.g., in the case of chest pain, it may be viewed as anything from a heart attack to indigestion).
- 6. Assumptions about prognoses (if long-term incapacity or possible death is associated with the symptom, it is likely to be viewed as more serious).
- 7. Interpersonal influence (this item refers to effects of the lay referral system).
- 8. Other life crisis (in some cases, a symptom that might have been viewed as normal assumes greater proportions in the face of family or work crisis).
Symptoms are at the heart of pharmaceutical care. Without them, patients often will not seek assistance. They are the basis for self-medication (read the packages of OTC products). But the response to symptoms is by no means uniform or predictable.
People approach chronic and acute Health problems in different ways.
For chronic ones, they devise strategies of care (determined partly by their roles, attitudes, and resources) over months and years and apply them during flare-ups. For acute problems, decisions about care are made in the short run and hinge mostly on symptoms. Analysis shows that actions complement or substitute for each other. Self-care actions (nonprescription Drug use and restricted activity) tend to co-occur and so do actions based on medical care (prescription Drug use and medical contact). The two domains substitute in one way (nonprescription Drug use greatly reduces chances of prescription Drug use) and join in another (restricted activity increases chances of medical contact).
Whatever sophisticated technical references there may be for her symptoms, the person who has symptoms will be concerned primarily with whether she hurts, faints, trembles visibly, loses energy suddenly, runs short of breath, has had her mobility or speech impaired, or is evidencing some kind of disfigurement. Aside from what these may signify to her about her disease or her life span, such symptoms can interfere with her life and her social relationships. How much they interfere depends upon whether they are permanent or temporary, frequent or occasional, predictable or unpredictable, and publicly visible or invisible, upon their degree (as of pain), their meaning to bystanders (as in disfigurement), the nature of the regimen called for the control of the symptoms, and upon the kinds of lifestyle and social relations that the sufferer has hitherto sustained.
Even minor, occasional, symptoms may lead to some changing of habits. Thus, someone who begins to suffer from minor back pain is likely to learn to avoid certain kinds of chairs and may even discover, to her dismay, that her favorite sitting position is precisely what she must eliminate from her repertoire. Major symptoms, however, may call for the redesigning or reshaping of important aspects of a lifestyle. A stroke patient writes: “Before you come downstairs, stop and think. Handkerchief, money, keys, Book, and so on-if you come downstairs without these, you will have to climb upstairs, or send someone to get them”. People with chronic diarrhea need to reshape their conventional habits like this person did: “I never go to local movies. If I go....I select a large house....where I have a great choice of seats....When I go on a bus....I sit on an end seat or near the door”.
Once a symptom is viewed as significant, a decision must be made whether help is needed, and, if so, what kind of help. The enormity of sales of nonprescription Drugs attests to the fact that self-treatment is often the first treatment choice. If consistent with the sick role, the individual chooses to seek professional help. Often a “lay referral system” is used, either for its own value or to encourage or recommend physician contact.