Mental Representations Of Health And Illness Research Paper

1. Understanding Mental Representations Of Health And Illness

Although the biological nature of disease remains constant from one culture to another, the evidence is very clear that how diseases, and health and illness in general, are understood varies dramatically. This variation occurs from culture to culture as well as between individuals and subgroups within the same culture. As such, illness, which refers to the experiential component of disease and ill health, is best understood as a social and cultural construction. Whereas disease refers to objective pathology, illness, as experience, is constructed on the basis of shared understandings in addition to individual experience (Angel and Thoits 1987, Landrine and Klonoff 1992).

This construction of health and illness has been described in various ways. At one level it can be described in terms of structured vocabularies used by people to define and express feelings of distress. The basic idea is that culture and experience provide people with categories for defining experience as well as a language for expressing feelings of distress. For example, the common concept of influenza provides many people with a category for understanding the experience of fever, chills, headache, nasal congestion, sore throat, and general achiness, whereas the concept of susto pasado is a Mexican-American category used for understanding the experience of stomach trouble, diarrhea, lack of appetite, lethargy, irritability, and loss of weight after experiencing a strong fright.

A useful approach to understanding the shared nature of health and illness concepts is via the theory of social representations. The key idea in this approach is that in the process of attempting to understand their bodily experience, people create socially shared representations of health and illness that then become part of the heritage of the society as a whole or of a subgroup within the society. These representations influence the way that individuals think about health and illness but are a property of the larger social collective. This approach emphasizes the essential social nature of concepts of health and illness and the way in which they are shared between individuals, a key prerequisite for communicating private bodily experience to others. A good example of this approach is Herzlich’s (1973) examination of illness beliefs in France.

A contrasting but complementary perspective is the information processing approach that examines the cognitions which individuals have about health and illness. This approach has its roots in cognitive psychology and, in particular, work on cognitive schemata and prototypes. Research using this approach has shown that people have implicit theories of disease that exert a strong influence on how they cope with health problems as well as how they deal with treatment. For example, Leventhal and Diefenbach (1991) have shown that the mental representations held by hypertension and cancer patients strongly influence their behavioral response to treatment. Research using this approach has also pointed out that such mental representations operate at different levels (sensory, affective, and conceptual) and have a number of components. These component include the identity of the condition (the label it is given as well as the symptoms involved), its cause, time line (expected length and course), consequences, cure, and perceptions of the type of person who gets the condition. Taken together these components make up the prototype that a person has of a particular disease. For example, a common prototype of ‘heart disease’ among British young people includes symptoms of lack of stamina, breathlessness, and chest pains as well as the beliefs that it is caused by lifestyle and high blood pressure, is serious but can be cured by surgery, and mainly affects older people (Lalljee et al. 1993). These prototypes, in turn, affect the recognition of disease conditions as well as the person’s illness behavior. Research from the information processing perspective has also explored the cognitive organization of disease concepts, noting that these concepts are organized cognitively in characteristic ways that have implications for how people interpret illness threats and how they respond to people with particular diseases (Bishop 1991).

2. Cultural Differences In Mental Representations

One of the more striking features of health and illness concepts is the way in which they vary from culture to culture. This variation is obvious even to the casual observer, as concepts common in one culture or society may not even exist in another. Although there are any number of ways in which health and illness concepts may vary, three major ways stand out. First, cultures show substantial variation in conceptions of the basic nature of health and illness. For example, in Western societies placing a strong emphasis on the scientific understanding of health and illness, these concepts are understood in natural terms with disease considered as pathology deriving from natural causes, such as germs, injury, or genetic aberrations. By contrast, in other societies, as well as among some ethnic-cultural minorities within Western societies, illness is understood more in interpersonal as well as supernatural terms. For example, illness may be seen as resulting from violations of standards of interpersonal behavior or other social norms, particular emotions (such as jealousy or envy), transgressions of moral and/or religious taboos, or such quasinatural agents as hot–cold foods, drinks, weather, ‘balance,’ or particular characteristics of one’s blood (e.g., thin, weak, or bad) (Landrine and Klonoff 1992). These differences in the general nature of health and illness are then reflected in the beliefs people hold about specific conditions.

Second, cultures often differ in their disease vocabularies. In some cases the differences may result from using different terminology for what appears to be the same condition. For example, Kleinman (1980) notes that symptoms that are often diagnosed as depression in the West are interpreted as neurasthenia in China. In other cases, however, a condition defined in one culture may have no referent in another. For example, conditions such as susto, empacho, caida de mollero, and mal de ojo, experienced by some Mexican Americans, have no direct referent among conditions known to Anglo–Americans or to medical professionals.

Third, the underlying structure of illness representations often differs between cultures. Work using techniques such as multidimensional scaling and factor analysis has shown that the mental representations people have of different diseases show characteristic organization in memory and that this organization differs between different cultures. For example, research with Anglo-Americans has found that disease representations appear to be organized along with dimensions of contagiousness and severity, whereas those of Mexican-Americans were organized according to concepts of ‘hot’ vs. ‘cold’ and whether a disease was associated with children or old people (D’andrade et al. 1972). As one might expect, the organization of disease concepts is closely related to the general models of health and illness that people are exposed to. Thus among Anglo-Americans whose folk model of health derives primarily from the biomedical model, contagiousness, and severity, central concepts in the biomedical model, have been found to be prime organizing dimensions. However, among Chinese in Singapore where Chinese traditional medicine exists side-by-side with Western scientific medicine, disease concepts are organized according to dimensions deriving from both Chinese and Western medicine (Bishop 1998).

3. Implications

The mental representations that people have of health and illness, and cultural differences in these representations, have a number of implications for health and illness related behavior. First, the disease concepts that people have can be expected to have a strong influence on their interpretation of symptoms and bodily experience in general. In brief, having specific disease concepts make its possible, and perhaps likely, that a person will interpret bodily experience in line with that concept. Thus, having available the concept of susto makes it possible for Mexican-Americans to experience this condition, an experience that is not available to others not possessing this concept. Along these same lines, the relative currency of the concept of neurasthenia in China and of the concept of depression in North America increases the likelihood that the similar symptoms associated with these two conditions will be interpreted, and perhaps experienced, differently in these two cultures.

Second, and following from this, health and illness representations have implications for what people do when they experience distress. For one thing, these representations provide a definition for when bodily distress represents illness and requires assistance from a medical professional or other healer. For example, research with heart attack patients points out that one reason for delay in seeking treatment is that the person misinterpreted the symptoms and failed to recognize the seriousness of the situation. In addition, disease representations serve to direct the person’s help seeking behavior. For example, research in Singapore has noted that degree of adherence to beliefs associated with Chinese traditional medicine is a key determinant of whether the person seeks help from a practitioner of Western or Chinese traditional medicine (Bishop 1998).

Third, once help is sought, disease representations play an important role in determining whether the person stays in treatment and follows the treatment advice. A good example of this is research with hypertension patients showing that the cognitive ‘model’ they had of hypertension and its relationship to specific symptoms was a major determinant of whether they stayed in treatment (Leventhal and Diefenbach 1991).

Finally, illness representations play a key role in how people respond to potential health threats. Specifically, the beliefs that people have about particular diseases, how they are contracted, and their consequences have a strong influence on how they respond to people having the condition as well as what precautions, if any, they take to prevent the disease. For instance, beliefs among some Africans that any-one who has ever had sex with a person who has died of AIDS will automatically die as well appear to lead to refusal on the part of those holding such beliefs to seek medical advice, be tested for HIV, or change their sexual behavior so as to reduce their risk of infection (Ankrah 1991).

4. Remaining Questions

In many respects work to date has only scratched the surface of this fascinating topic. As noted, progress has been made in the theoretical understanding of mental representations of health and illness but much more can be done to flesh out this understanding and, in particular, explicitly account for cultural differences. Also much remains to be done in further exploring the content of health and illness concepts in different cultures and relating these to other aspects of the cultures in question as well as to dimensions, such as individualism-collectivism and power distance, used to describe cultures.

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