ILLNESS BEHAVIOUR OF SOME WHITE SOUTH AFRICANS

Hierdie artikel handel oor ’n studie van die siekte-gedrag van Blanke persone in die Durban area. Dit blyk dat siekte, waar dit verwys na die ervaring van simptome, meer voorkom as wat algemeen geglo word. Persone konsulteer ’n gesondheidswerker slegs vir 'n klein persentasie van hul simptome en verskil ook in hul interpretasie van, en derhalwe reaksie op, simptome. Siektegedrag word verder beinvloed deur persepsies van die vermoeë van gesondheidswerkers en hul interpersoonlike verhoudings. Om doeltreffende gesondheidsdienste te kan lewer moet gesondheidswerkers kennis dra van die faktore wat siektegedrag beinvloed.

T HE author's interest was recently aroused by coming into contact with some of the literature dealing with "illness behaviour".112 1 The study of illness behaviour basically involves an attempt to understand: what makes different people decide that they are ill; what action they take; how long they delay; what in fluences their decisions; and so on.In other words, there is a basic assump tion that people perceive illness dif ferently and that they react to it dif ferently.The author believes it is essential for all health workers to be aware of the complexities of illness behaviour and therefore presents some of the data gathered recently in a study of illness behaviour among White adults in Durban.

SUBJECT AND METHODS.
The population under study con sisted of 47 White Durbanites: 20 out-patients from the provin cial hospital; 18 randomly selected residents from one of Durban's elite suburbs; 9 people currently consulting a chiropractor.
The central technique used was the interview.Interview schedules were divided into seven major sections, only three of which had relevance to the topic under discussion.The first of these dealt with very general health questions (eg "If I asked you to sum up the state of your health in one word, what would you say?") Re spondents were later asked to think back over the two weeks prior to the interview and to indicate which of 28 groups of medicines, nostrums and devices on a check-list they had used (eg "Eye drops, ointment or lotion" or "Cold or congestion medicines").A second check-list was then referred to, this time to establish which of 27 symptoms the respondent had ex perienced during the same two-week period, (eg "Aches in joints, rheuma tism or arthritis" or "Nerves, depres sion or irritability").
Other techniques used in the study included participant observation and a postal survey, but these methods were concerned with aspects of illness behaviour not under dis cussion in this article.

Is illness the statistical norm?
Illness is generally assumed to be a fairly objective and relatively infre quent phenomenon.When we con sider the number of days spent in bed or the number of visits to the doctoi each year, illness does indeed appeal to be an abnormal occurrence.1 Thei.is, however, a growing body of litera ture that casts doubt on this con ception of illness.Dunnell and Cart wright, for example, did a study in Britain and found that each respond ent had experienced an average of 3,9 symptoms in the fortnight prior to the interview.4 In Durban a stag gering mean figure of 6,2 symptoms per person over the two week period was found.The break-down for the three sub-samples was (see also We see thus that even the young, well-off suburbanites had a mean number of symptoms that was con siderably greater than the British mean.Only two of the 47 people interviewed in this study reported having had no symptoms at all over two weeks.Illness in one form or another does appear to be the statisti cal norm in South Africa.
Let us now examine the assump tion that, in general, illness is fairly objective.

Illness versus disease
Several authors have made a dis tinction between illness (the human experience of sickness)1^7 1 and disease (the physical processes in volved in sickness).It has been suggested that medical training all but ignores the treatment of illness; that medical students are graduating as vets who treat humans rather than as doctors..A When the distinction between illness and disease is grasped we can see that people may experi ence any combinations of illness and disease.Consider four people in the community (see also Diagram 1): "A" is not ill and has no disease, "B" is ill (he perceives himself to be sick) and has a disease (eg.pneumonia) "C" is ill but has no disease (eg.psychosomatic headaches) "D" is not ill but has a disease (eg.carcinoma in an early stage).
The important aspect for health workers to note is that only two of these people are likely to seek help of any kind, to display illness behaviour in a public manner."A" does not need help and will not seek it; "B" is ill, is experiencing his disease, and will find help somewhere -not necessarily from a doctor as we shall see; "C" is also ill and despite the fact that there is nothing physically wrong, he will look for help; "D", perhaps the sickest of all, will continue his life as usual for many months, making no effort to seek help for his disease.From this example it be comes evident that their personal, subjective experience of symptoms -not the objective presence of disease -is what drives people to seek health care.
To take the argument one step further, let us consider two people, "X" and "Y", who have exactly the same objective problems; they both have very swollen ankles."X", an upper-class and well-educated lady, perceives her problem to be an ab normality -a sign that she must consult her doctor immediately."Y", a lower-class lady, accepts the swell ing as a normal part of ageing and overwork and regardless of the fact, carries on working.Their differential perceptions of the same problem thus cause very different patterns of illness behaviour.
Such perceptual processes would partially account for the fact that, for example, of the fourteen hospital re spondents who reported having had "backache or pain in the spine" in the two weeks prior to the interview, only seven were taking prescribed treatment; four were doing nothing; two were trying exercises; and one was consulting a chiropractor.In sum, different people perceive symp toms differently and therefore react to them differently.As far as illness behaviour is concerned, illness must be thought of as more than merely an objective phenomenon.

T he Iceberg T h eory o f D ise a se
Medical agencies aware of symptoms \ Medical agencies not \ aware of symptoms ± 5% have no symptoms in a two week period

T he iceberg th eo ry o f disease
The figures quoted above for re sponses to backache introduce another important point: only a small percentage of the total "pool" of diseases is ever treated by a medi cal agency -in other words, only the tip of the iceberg is ever glimpsed by health workers.Dunnell and Cart wright's study confirmed this theory: 91% of adults reported symptoms in the two week period but only 16% had consulted a doctor during that time.4 In the Durban study 45 (96%) of the total 47 respondents indicated that they had symptoms in the two weeks and only 36% had seen a doctor or surgeon.This last figure is somewhat greater than the British one because twenty of these re spondents were out-patients at the time.If we look at the figures for the suburban and chiropractic sub samples only, we find that 93% had symptoms and only 19% had seen a doctor or surgeon.So the "iceberg theory" is very applicable to South African practice.(See Diagram 2.) The fact that many illnesses are not treated by medical agencies has far-reaching consequences of which all health workers should be aware.Consider the implications for our national health statistics which are gathered largely from medical insti tutions.Are we getting even a glimpse at the realities of morbidity and mortality in South Africa?The pro vision of health services might also be entirely inadequate if decisions are made in the absence of detailed studies of the actual incidence of disease in the population.The same applies to health education: is the present focus largely on irrelevant problems?

P e o p le 's p ercep tio n s o f their h ealth
From overseas literature it is known that people tend to judge themselves far healthier than a doctor would.9This tendency was noted in the Durban study.Several people with many symptoms which were potentially very serious reported being in "excellent health" or " 100% fit".Health is so highly valued that it seems as though some people are reluctant to admit its absence.This tendency to overrate health status and de-emphasise the importance of various symptoms could largely account for the "iceberg theory" dis cussed above.People think of them selves as being healthier than their objective condition warrants -they merely gloss over the symptoms they experience from day to day.
In general, the criterion used to judge health status seemed to be the n u m ber of different symptoms ex perienced in a period rather than their seriousness in medical terms.(This is illustrated in Table I).
21% had few symptoms (three or less), of whom 80% reported good health; 51% had an average number of symptoms (4 to 8), of whom 67% reported good health; 28% had many symptoms (9 or more), of whom 23% reported good health.
The conclusion can thus be made that people generally over-rate their health and judge it according to in appropriate criteria.Health edu cators should make it one of their major tasks to impress on the public that certain signs and symptoms simply cannot be ignored even if the person fe e ls well and has no other complaints.It may be that once the m edical significance of symptoms becomes common knowledge people will present themselves for treatment much earlier.

The prevalent sy m p to m s
The symptoms that were reported in the Durban study most often were "headache" and "nerves, depression or irritability".Each of these symp toms were mentioned 28 out of 47 times."Backache or pain in the spine" was the next most prevalent, being reported 27 times (57%)."Arthritis, rheumatism or pain in the joints" was reported in 19 cases (40%), followed by "sleeplessness" (38%) and "undue tiredness" (29%).
The remarkable point here is the prevalence of mental symptomsnotably "nerves, depression or irrita bility".Many of the headaches were probably stress-related or psychoso matic and when the problems of sleeplessness and undue tiredness (often considered to be signs of stress, emotional strain or mental disturbance) are also taken into account, mental symptoms are by far the major health problem among urban Whites in this country.Are the training of doctors and nurses and the organization of health services geared to meet these needs?

Responses to symptoms
It has been shown that people will, depending on their subjective inter pretation, react differently to symp toms.In the study the actual re sponses varied greatly and the options open to urban Whites appear to be: -to do nothing at all about the symptom; -to mix some home-remedy, take a pill bought over the counter, or otherwise treat oneself; -to visit a doctor, clinic, hospital or other orthodox institution; -to consult an alternative healer (such as chiropractor, herbalist or homeopath).
A person may decide on any one, or a combination of two or more, of these courses of action.(For example, many instances of people taking pre scribed medicines and visiting alterna tive healers for the same problem were found.They seemed reluctant to "put all their eggs in one basket".) Table II shows the actual re sponses to individual symptoms in two weeks in the different sub samples.
From the above it is evident that the most common reaction to symp toms in very passive, 46% were not treated at all; people simply wait for the body to recover.Hospital out patients treat a great number of their symptoms with prescribed treatments, thus the image of the overworked doctor scribbling out prescriptions is probably quite accurate.Only about one in five symptoms is self-treated -a heartening statistic, considering the very toxic nature of many of the o v e r -th e -c o u n te r preparations.
Finally, the table shows that only a small number of people used alterna tive practitioners in the two week period.
The responses to the mental symp toms were often alarming.People used such remedies as hot cocoa or headache tablets for depression (14%); three people (11%) said they would try to "snap out of it", "buck up" or "pray about it"; eight respon dents (28%) were taking prescribed drugs (eg.tranquillizers or anti-depressants); and thirteen (46%) were doing nothing at all.Only one woman admitted seeing a psychiatrist for her "nerves"; all the others on prescribed medicines were careful to state that their "doctor" had given them the medication.The stigma associated with psychiatry, even among welleducated people, was very evident.When asked if they had ever visited a psychiatrist only 19% reported such contact and most of these added a hasty qualification such as: "He said he didn't know why the doctor had sent me"; "He said I was just a bit overtired".

Perceptions of healers
The subjective processes involved in illness behaviour have been stressed and hopefully readers are convinced that illness is a complicated pheno menon with many factors influencing reactions to it.It has been shown that two people with exactly the same objective problems may perceive them very differently and that people per ceive different problems as serious or deserving of medical treatment.(The role of culture, class, education, pre vious exposure to medicine influence these perceptions.)One last factor influencing illness behaviour which must be considered is patients' per ceptions and evaluations of the various healers.
It has been suggested that people carefully weigh up the pros and cons of various plans of treatment open to them.1 They may give themselves a time limit and vow to consult a doctor after a week if the pills from the supermarket don't help or they may decide to spend a day in bed and then only visit a chiropractor if the fibrositis doesn't improve.The author is convinced that this type of rational planning does in fact occur before people proceed to action.
If this is the case, perceptions of various therapies and practitioners must play an essential role in illness behaviour.A man who considers orthopaedic surgeons to be largely unsuccessful in the treatment of back ache will surely consider other healers instead -such as chiropractors, herbalists and acupuncturists.Should he subsequently develop pneumonia, however, he may not hesitate to see a doctor believing that antibiotics are called for.
What is being proposed therefore -with Fabrega1 -is a rational de cision-making process in illness be haviour.It appears to be highly sig nificant that people are taking certain symptoms to certain healers for treat ment.Chiropractors were treating a large amount of backache and fibrositis.Homeopaths were getting a great number of the hormonal complaints and acupuncturists seemed to be treating many joint problems.This appears to indicate that particular healers have developed reputations for highly effective treatment of certain problems and that people decide who to consult depending on their specific health needs at the time.Such decisions are evidently being made with less and less concern about the professional status of the prac titioner -people want results and are willing to go almost anywhere to get them.
The above refers to peoples' per ceptions of the healer's ability to cure physical ailments.A last crucial per ception is the patient's view of the practitioner as a humane, caring, interested healer.If you were deciding whether to visit "P" practitioner or "Q" and the only difference between them was that "P" was always abrupt, rushed and unkind, while "Q" was re assuring, explained things to you, and greeted you in a kind manner, is there any question about who you would consult?
It is a sad reflection on medical workers that respondents often re ported dissatisfaction with doctors in terms of their social behaviour.Alternative healers received flying colours in this regard.The alterna tives were often as busy as doctors, so could not spend more time with their patients.They simply managed to use the limited time available in the best way.The figures for the quality of relationships with doctors over the whole sample were: 45% good 28% mediocre 28% poor.
The equivalent figures for the quality of relationships with alterna tive healers were: 77% good 19% mediocre 4% poor.
If health workers want patients to report regularly to clinics, to take their medicines compliantly and to encourage their family and friends to seek medical advice when necessary, they will simply have to improve the quality of interpersonal relationships between themselves and their patients.Nurses probably contribute greatly to improving patients' impressions in this regard, but they cannot bear the responsibility alone.Doctors must be made aware of the fact that their behaviour as social beings is causing widespread dissatisfaction.

CONCLUSION
Several factors which influence ill ness behaviour among White South Africans have been examined.The author believes that only when we know about the actual health prob lems in the population, about the public's perceptions, expectations, dissatisfactions and about their dayto-day health practices, can we work to provide really suitable and effective health services at all levels.

BOOK REVIEW BOEKRESENSIE C A N C E R N U R S I N G -S U R G IC A L
Robert Tiffany (Ed) Faber en Faber.London.1980.

Graph 1
Symptoms experienced by respondents in a two-week period in a British study and in the Durban study.