1. NİŞANTAŞI ÜNİVERSİTESİ
HEALTH PSYCHOLOGY
NİŞANTAŞI ÜNİVERSİTESİ ©
İktisadi, İdari ve Sosyal Bilimler Fakültesi
iisbf.nisantasi.edu.tr

2. Learning Outcomes
By the end of this chapter, you should have an understanding of:
key theoretical models of symptom perception, interpretation and response
contextual, cultural and individual influences upon symptom perception
the core dimensions upon which illness can be represented
the measurement of illness perceptions and their relationship with illness outcomes
a broad range of influences upon symptom interpretation
factors that influence delay in seeking health-care advice for symptoms

3. Illness or Disease?
Disease: something of the organ, cell or tissue that suggests a physical disorder or underlying pathology.
Illness: ‘what the patient feels when he goes to the doctor’ Cassell (1976); experience of not feeling right.
How do you know when you are getting ill?
Three stages of response:
perceiving symptoms;
interpreting symptoms as illness;
planning and taking action.

4. Symptom Perception Figure 9.2 A simplified symptom perception model
Source: adapted from Kolk et al. (2003).

5. Bodily Signs That Increase Likelihood of Symptom Perception
Painful or disruptive: If a bodily sign has consequences for the person, then the person is more motivated to perceive this as a symptom (Cacioppo et al. 1986, 1989).
Novel: Subjective estimates of prevalence significantly influence (a) the perceived severity of a symptom (b) whether the person will seek medical attention (e.g. Ditto and Jemmott 1989; Jemmott et al. 1988). ‘Novel’ symptom(s) more likely to be considered indicative of something rare/serious.
Persistent: A bodily sign which persists for longer than is considered usual or in spite of self-medication is more likely to be perceived as a symptom.
Pre-existing chronic disease: Past or current illness experience increases the number of other symptoms perceived and reported i.e. has a strong influence upon somatisation (i.e. attention to bodily states) (e.g. Chapman and Martin 2011; Kolk et al. 2003).

6. Attentional States and Symptom Perception
Individual differences exist in the amount of attention people give to their internal and external states
Personal and social influences:
Well-publicised illness increase symptom perception – ‘mass psychogenic illness’ e.g. Swine flu, SARS;
Increased knowledge of symptoms can increase the perception of them e.g. ‘medical student’s disease’;
other relevant distractions reduce symptom perception e.g. athlete winning a race despite injury.

7. Social Influences on Symptom Perception
Perceptions of vulnerability
Stereotypical notions exist about ‘who gets’ certain diseases
e.g. males are associated with vulnerability to heart disease and not females (Martin et al. 2003).
‘I am a young female and so ignore chest pain.’
Social situations
The context influences our motivations to attend and detect illness symptoms
e.g. playing a sport vs. watching TV.

8. Individual Differences and Symptom Perception
Gender
Gender socialisation may increase women’s readiness to perceive bodily signs and symptoms, and men’s likelihood to ignore or avoid them.
Life Stage
Little evidence that older adults attend less or more to internal states.
Limited research with children.
Emotions and Personality Traits
Anxiety and depression increase attention to bodily signs.
Neuroticism/Negative Affectivity (NA) increases attention to somatic symptomatology.
Cognitions and Coping Style
Type A characteristics may reduce attention to internal states.
Individuals who cope by means of repression are less likely to experience symptoms (and may also be high on comparative optimism).
Monitoring vs. blunting coping styles influence symptom perception.
Socialisation – the process by which a person learns – from family, teachers, peers – the rules, norms and moral codes of behaviour that are expected of them.
Neuroticism – a personality trait reflected in the tendency to be anxious, feel guilty and experience generally negative thought patterns.
Negative affectivity – a dispositional tendency to experience persistent and pervasive negative or low mood and self concept.
Repression – a defensive coping style that serves to protect the person from negative memories or anxiety-producing thoughts by preventing their gaining access to consciousness.

9. Symptom Interpretation
There are a wide range of influences that may affect the interpretation of symptoms:
Cultural influences: on readiness to respond to and express bodily signs as symptoms;
Individual differences: such as gender, life stage,
personality, self-identity, illness experience;
Disease prototypes: cognitive schematas, and ‘common- sense’ models of illness.

10. Disease Prototypes
Table 9.1 Disease prototypes

11. Common-Sense Model of Illness
Figure 9.4 The self-regulation model: the ‘common-sense model of illness’
Source: Leventhal, Diefenbach and Leventhal (1992: 147).

12. Common-Sense Model of Illness: Illness Representations (IRs)
Leventhal et al. (1980,1992) found 5 themes in IRs:
Identity: variables that identify the presence or absence of the illness
e.g. ‘I am shivery and my joints ache, I think I have flu’
Consequences: Perceived short and/or long-term effect(s) of illness on life; physical, emotional, social, economic, or a combination
e.g. ‘because I am ill, I cannot go to the gym today’
Cause: Perceived cause(s) of illness.
May be: biological (e.g. germs), emotional (e.g. stress), psychological (e.g. personality), genetic or environmental (e.g. pollution), or as a result of the individual’s own behaviour (e.g. smoking).

13. Illness Representations (Cont.)
Timeline: Perceived time frame for the development and duration of the illness. Can be acute (or short term, with no long-term consequences); chronic (or long term) and episodic (or cyclical).
e.g. ‘I think my flu will last only three or four days’
Curability or controllability: Lau and Hartmann (1983) added questions to assess the extent to which individuals perceive they, or others, can control, treat or limit progression of their illness.
e.g. ‘If I take my medicine it will help to reduce my symptoms’

14. How do we measure IRs?
Illness Perceptions Questionnaire (IPQ; Weinman et al. 1996)
Child-specific version (CIPQ; Walker et al. 2006)
Inconsistency in ‘personal control/potential for cure’ subscale in both versions
IPQ-Revised (Moss-Morris et al., 2002; Moss-Morris and Chalder, 2003)
Distinguished between beliefs of personal control and treatment control
Added two dimensions; ‘emotional representations’ and ‘illness coherence’
Has also been tested as satisfactory in children, except for timeline and treatment control (i.e. children under 12 needed further explanation of terms)

15. Illness Representations and Outcomes
Illness representations have been shown to have direct effects on a wide range of outcomes:
seeking, using and adhering medical treatment;
engagement in self-care behaviours or behaviour change;
attitudes towards use of brand-specific vs. generic medicines, and treatment choices;
illness-related disability and return to work;
caregiver anxiety and depression;
quality of life.
*Effects of IRs also indirect via an effect on coping.

16. Influences on Symptom Interpretation
Further influences on symptom interpretation include:
Self identity: people may have several social identities that effect the salience of symptoms and their interpretation.
Illness experiences: clear differences in the perceptions of breast cancer between healthy women and those with a breast cancer diagnosis e.g. Buick and Petrie (2002).
Causal attributions: where the ‘cause’ for symptoms is placed can influence how symptoms are interpreted e.g. internal vs. external; stable vs. unstable; global vs. specific cause.
Culture: beliefs in supernatural causes, controllability, etc. can vary between cultures.
Attributions – a person’s perceptions of what causes beliefs, feelings, behaviour and actions (based on attribution theory).

17. Responding to Symptoms
Once people recognise a set of symptoms, label them and realise that they could indicate a medical problem, they therefore have the option of:
ignoring the symptoms and hoping they recede;
seeking advice from others (lay referral system);
presenting themselves to a health professional.
Some people will do all three over time.
Lay referral system – an informal network of individuals (e.g.. Friends, family, colleagues) turned for advice or information about symptoms and other health-related matters. Often but not solely used prior to seeking a formal medical opinion.

18. Delay Behaviour
An individual’s delay in seeking health advice despite illness symptoms
Appraisal delay – the time it takes a person to infer that they are ill on the basis of their symptom(s)
Illness delay – the person considers whether or not they need medical attention
Utilisation delay – the time taken between deciding one needs medical attention and actually acting on that by making an appointment or presenting to a hospital

19. Delay Behaviour (Cont.)
Figure 9.5 The delay behaviour model
Source: adapted from Safer et al. (1979).

20. Seeking Health Care
Table 9.2 Reasons for seeking, delaying in or not seeking a medical consultation

21. Influences on Delay Behaviour
Symptom type, location and perceived prevalence i.e. visible, painful, disruptive, frequent generally lead to action
Financial concerns i.e. costs of health care; losing work through illness
Culture i.e. language barriers; perceived responsibility for control/cure
Age i.e. younger and older groups use most health care
Gender i.e. women tend to present to health services more than men
Influence of others e.g. lay referral model can encourage/discourage help
Treatment beliefs e.g. seeing treatment as necessary and beneficial reduces delay
Emotions and traits e.g. fear, anxiety and denial increase delay behaviour