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From the behavioral model hypotheses were generated concerning individuals' statements about their physical health. A verbal conditioning procedure within the context of a health survey was used. Independent variables were level of utilization of health-care facilities, status of the surveyor, and reinforcement for increased or decreased statements of physical ill health. The consistently positive finding was that over all conditions the changes in subjects' statements were in the reinforced direction. The advantages of supplementing the medical model with the behavioral model and its implications concerning physical illness, especially chronic illness, are discussed.

THE FACT that illness behavior is not determined entirely by physiological factors has been noted by a number of investigators from diverse fields of study.' Margaret Mead's observation of the complete absence of morning sickness among pregnant Arapesh women and accounts of the couvade are two examples which come to mind immediately.2 In the social sciences, research relating illness behavior to social processes has been almost entirely restricted to studies of ethnic, religious, and class differences. For example, Koos observed in his study of Regionville that upper-class persons labeled their symptoms as illness more often than lower-class persons and presented more of their somatic complaints to a physician." Koos also found that although lower back pain was an almost universal condition among lower-class women, it was not recognized as symptomatic of a disorder, but was accepted as part of their everyday existence. Class differences in illness behavior were also studied by Kutner and Gordon who found a relationship between quickness in seeking medical care for cancer symptoms and socioeconomic status.4 There are also numerous studies of ethnic variations in illness behavior. Saunders, Zborowski, and Zola have each independently shown that the relationship between cultural background and sick role perform

Measures of life crisis, manifest distress and maladaptive coping were used to predict future illness behavior in male college students. A group of 92 Ss was screened by an internist's examination as being free from disease, and was administered a series of self-ratings measuring the above dimensions. One year later, 79 of these students were available to be recontacted and were asked to describe their health records during the intervening time; 65 (82%) replied. Of the total number, 23 reported being ill and seeking medical treatment, whereas the remaining 42 either indicated no symptoms or else treated themselves with proprietary medication or rest in bed. Analysis of the 2 groups' premorbid reports indicated that the treatment-seeking Ss had scored significantly higher on each dimension, usingttest comparisons. Secondly, independently established criterion scores were applied to this sample. Chi square analysis indicated that 71% of the cases could be correctly designated using this method--ie, before becoming ill, Ss who later sought care for their symptoms were more likely to have scored above the cut-off points than those who did not eventually seek care. We also scaled degree of incapacitation along a 0-10 continuum and correlated such illness behavior with the premorbid scores. Each measure correlated significantly with the criterion and with each other. A multiple R of 0.43 was obtained when four scale scores were used in a regression equation to estimate degree of incapacitation. These results suggest that premorbid indicators of unresolved life stress accurately predict who will seek care for illness.

(1966). Health Behavior, Illness Behavior, and Sick-Role Behavior. Archives of Environmental Health: An International Journal: Vol. 12, No. 4, pp. 531-541.

Different characterizations of therapeutic intervention suggest alternative approaches for rehabilitation programs. Three such characterizations are described and their implications developed: intrapsychic disturbance, social disability, and illness behavior and the societal reaction. It is argued that an educational model is more appropriate than a medical one to what is frequently attempted in good rehabilitation programs.

Whether a person is sensitive to feelings of discomfort, and how he regards his symptoms, are likely to affect considerably whether he will seek medical care and treatment, and what precautions he will practice. The importance of the norms and values underlying people's behavior makes it necessary to study the various social and cultural patterns that effect the arrival of "ill" persons at medical settings, as well as those that lead to various other treatment alternatives.

means that human groups are more or less regularly confronted with decremental changes in human functioning which we assume are to some extent socially patterned. This in turn suggests that it may be possible to depict in an abstract way fundamental behavioral changes associated with an occurrence of disease. A first step in this direction would be the construction of an analytical model which accounts for the decisions that are made by a person during the time that he is ill. We could term this a model of illness behavior. The purpose of this paper is to put forth, in a preliminary fashion, an admittedly theoretical model of this decision-making process. The model to be discussed does not presume to describe the actual way in which persons make decisions during illness, but rather to offer an abstract account of how such decisions may be viewed or explained. In general, in the discussion that follows the term "disease" is used when reference is made to states that are biologically altered (i.e., chemical, physiological) and the term "illness" when speaking of the complex but socially defined state that forms the bases of decisions about medical treatment.

Growing interest in the psychological and social aspects of physical illness and disability has extended to all facets of the behavior of patients. The ways in which people cope with the stress and challenges of disease is the subject of this paper. The writer presents a tentative framework for conceptualization of this aspect of illness behavior. A brief discussion of the major determinants of coping is given. The latter include intrapersonal, disease-related and environmental variables. Coping behavior is a resultant of multiple factors reflecting a patient's specific dispositions as well as characteristics of his total situation during a given episode of illness and its different phases. The way in which the patient copes with his illness spells the difference between optimum recovery or psychological invalidism. It is the doctor's task to recognize his patient's mode of coping and help him employ the most adaptive and effective coping strategies.

1NTRODUCTION THE USE of clinical records in epidemiological studies may raise the questions of whether illness or a response to illness is being studied. An individual’s utilization of available clinical services, a prerequisite to an entry in the records, is dependent upon a number of variables besides the presence or absence of a given disorder. It depends upon his own or someone else’s sensitivity in the recognition of the disorder, his own or someone else’s judgement that medical care is indicated, and his own or someone else’s initiative toward the acquisition of medical care. An epidemiological study based upon clinical records may, then, in some circumstances properly be considered as a study of medical care and include questions relating to both the prevalence of disease and the utilization of services. One such question concerns the definition of an illness. If an illness is operationally defined as a disorder for which people think medical care is indicated, then the severity and type of disorder which is considered to be an illness may vary with individuals and over time. Variation in people’s definitions of illness would lead to variations in their rates of medical consultation which would be, to a certain extent, independent of the prevalence of disorder. Little attempt has been made to relate familial patterns of medical care utilization to familial patterns of illness behavior. It has been pointed out that in addition to the presence of disorder a variety of psychological, emotional, cultural, and social factors influence decisions to seek medical aid [l-4]. It seems likely that such factors may operate within families to produce a tendency for their members to agree as to which problems are to be defined as illnesses and occasions for the adoption of a sick role and which are not. Such variations in definitions of illness would produce variations in consultation rates. It may be of interest to examine, with this idea in mind, some aspects of an epidemiological investigation of families based on the records of a Scottish general practice. The cost of medical services is not a factor which could have influenced their

Illness behavior — the manner in which people differentially perceive, evaluate and respond to symptoms — may be viewed from at least three general perspectives. Such patterns of behavior may be seen (a) as a product of social and cultural conditioning, (b) as part of a coping repertoire or (c) in terms of their usefulness for the patient who obtains certain advantages from the “sick role”. — The importance of such factors in determining whether people recognize symptoms, make contacts with doctors, accept or reject advice about treatment, and remain under or discontinue medical supervision, is reviewed; with particular reference to the analogies between such patterns, responses to various types of pain and placebo reactions. The implications of considering “secondary” social and psychological components of disease, as well as “primary” biological aspects, are discussed in terms of their value for the patient and their relevance to planning medical services.

Samoan families involved in a disastrous fire in a West Coast city in 1964, and medical and agency personnel who worked with fire victims were interviewed 5 years after the fire to determine individual, family, and community response to the fire and its aftermath. Medical personnel uniformly remarked on the extraordinary stoical response of patients to pain, death of loved ones, lasting disfigurement and related potential stressors. Samoans reported considerable initial distress, but, in contrast with published reports of American burn patients, there were few acute or lasting emotional problems. Specific Samoan cultural, social, and religious patterns which appear to have mitigated or even precluded widespread emotional problems are suggested. It is commonly acknowledged that cultural factors contribute significantly to responses to pain, injury, death and other universal potential stressors of man. This paper explores some of the broader aspects of what Mechanic has called “illness behavior” —the manner in which pain and symptoms are defined, labeled, perceived and reacted to. The fire described here resulted in 17 deaths and some 70 moderate to severe burn injuries. The survivors of this fire experienced a variety of potential stresses triggered by severe burn injuries, long hospitalization and recuperation periods, and resulting permanent physical disfigurement. Yet the Samoan response offers a remarkable contrast to that customarily reported in the literature.

ONE OF the principal tasks of the medical sciences is to understand and determine the conditions under which particular symptoms or disease entities arise either in individuals or among groups of individuals. Public health physicians have the further problem of effecting the arrival of “ill” persons at medical settings so that treatment can be effectively administered. Whether we concern ourselves with the necessary conditions for building adequate etiological theories or those for bringing treatment to persons most in need of such help, it is necessary that we understand the influence of a variety of norms, values, fears, and expected rewards and punishments on how a symptomatic person behaves. Such considerations lead us to propose a concept of illness behaviour. By this term we refer to the ways in which given symptoms may be differentially perceived, evaluated, and acted (or not acted) upon by different kinds of persons. Whether by reason of earlier experiences with illness, differential training in respect to symptoms, or whatever, some persons will make light of symptoms, shrug them off, and avoid seeking medical care; others will respond to the slightest twinges of pain or discomfort by quickly seeking such medical care as is available. In short, the realm of illness behaviour falls logically and chronologically between two major traditional concerns of medical science : etiology and therapy. Variables affecting illness behavior come into play prior to medical scrutiny and treatment, but after etiological processes have been initiated. In this sense, illness behavior even determines whether diagnosis and treatment will begin at all. We are here dealing with an area important for public health and medical sociology and it becomes a matter of both theoretical and practical concern to discover the sources and consequences of different illness behaviors. And if, in given populations, there are systematic differences in illness behavior, this fact has obvious implications for public health programs [5]§, estimated needs for medical care, medical economics, and our understanding of health and illness in general. That the behavioral sciences can shed some light on such questions is indicated, for example, by the researches of Koos and Saunders. Koos [7] found that upper class

In the expanding field of medical sociology, the frequency of visits to a free medical facility has become an important form of illness behavior. Such behavior not only reflects the individual's physical health, but also his perception of it, and his decision what to do about it. Involved here are also his attitudes toward doctors and medical care, his psychological make-up, and his phenomenological well-being. Various studies have been able to relate the frequency of dispensary visits to such variables as occupational status, self-esteem and self-acceptance, perceived stress, and the readiness to assume the sick role. The present study was concerned with relating the frequency of dispensary visits to the following variables: disturbances of mood (reported well-being) and self-report measures of aggressive tendencies and of control over impulsiveness and over feelings of anger. The same variables were also related to three diagnostic categories: rheumatoid arthritis, hypertension, and ulcer. The major findings, obtained on an industrial population of over 300 male workers, are summarized below: 1. 1. Subjects who obtained high scores on the Mood Scales labeled Aggressive, Jittery, and Depressed had a greater frequency of illness behavior (dispensary visits for illness and illness absences). 2. 2. Subjects who scored high on a self-report scale reflecting a tendency to engage in overt aggressive behavior, had a greater frequency of illness behavior. 3. 3. The above test and questionnaire data were unrelated to control variables, not indicative of illness behavior: hernia, dispensary visits for injuries, and absences for personal leaves. 4. 4. When the measures of control over impulsiveness and over feelings of anger were considered jointly with the other scales, then it was apparent that the amount of control affects the association of illness behavior with mood and overt aggressiveness: strong control reduces the association and weak control enhances it. 5. 5. If the scales reflecting tendency to engage in overt aggressive behavior and to control impulsiveness and angry feelings are used to construct a two-dimensional space, then the following placements of the different diagnostic categories are possible: 5.1. (a) Hypertensive men tend to be low on overt aggressiveness and high on control. 5.2. (b) Rheumatoid arthritics tend to be high on overt aggressiveness and high on control. 5.3. (c) Men with ulcers tend to be low on overt aggressiveness and low on control. 5.4. (d) Subjects with a high frequency of illness behavior tend to be high on overt aggressiveness and low on control.

Illness frequency and physician utilization were examined in relationship to preferred support from a significant other (one's spouse) in the illness role. Illness data were collected from a sample of 290 husbands and wives quarterly over a period of 1 year. Preferred sick role legitimacy was significantly related to “illness frequency”, but not to the pattern of physician utilization. This, along with the findings of other investigators, suggests that presenting one's complaints to a nonprofessional relevant other and to a member of the medical profession may be qualitatively different illness phenomenon. The former being more responsive to social-psychological processes and the latter to situational variables as income or family size.

AN adequate and representative sample is an important prerequisite for competent studies of etiologic processes in disease. Most medical studies, however, depend largely on populations of sick pers...

seek medical care. The concept of "illness behavior" is introduced and the relative effects of stress and the tendency to adopt the sick role upon frequency of medical visits made by 614 male freshmen are investigated. Results indicate that the tendency to adopt the sick role is the more powerful variable. The significance of this social-psychological variable is discussed in relation to future etiological studies of stress and illness. THE research reported here is concerned with the relative influence of stress as compared with the tendency to adopt the sick role upon the frequency of known illness. It was undertaken to resolve some questions posed by research purporting to find a direct relationship between stress and "illness in general," i.e., regardless of specific diagnosis. Hinkle and Wolff,' for example, studied the long-term patterns of health and illness among 2934 employees of a large organization which had maintained excellent medical records for its personnel. They found that, over long periods of time, the frequency of known illnesses (including the more com

In a population survey of illness behavior, the form of social organization with nwhich an individual was associated was found to be highly related to his medical orientation with "cosmopolitan" types of groups being more likely to hold a "scientific" health orienitation while "parochial" groups adhered to "popular" health orientation. This relationship existed independent of demographic characteristics or medical status. In turn, demographic characteristics were found to be related to both health status and source of medical care, although these latter two variables were not strongly related either to form of social organization or medical orientation. A framework is proposed which views medical orientation and responses as intervening variables between social structure and medical care. The implications of these findings for public health and medicine and for social action in general ar e discussed.

Illness frequency, physician utilization, and perceived legitimacy to the sick role were examined in relationship to SES and family size. A household respondent in each unit from 67 threegeneration families was interviewed quarterly over the period of one year. SES and family size were inversely related to perceived right to assume the sick role. However SES was not significantly related to the frequency of reported illnesses or physician utilization. In contrast, the latter were inversely related to family size. The association between "illness behavior" and family size was specified when controlling for age (generation) and social class. Family size was inversely related to both illness frequency and doctor visits in the lower class, but not in the middle class or among respondents in the grandparent generation.

AS THE SCOPE of psychiatry has broadened, the psychiatric consultant has been requested by his colleagues in internal medicine and surgery to offer assistance with an increasing variety of problems. 2,3,16 Prominent among these is management of "difficult" and "uncooperative" patients on medical and surgical wards, and psychiatrists have increasingly become aware that these patients may be responding not only to their individual psychopathology but also to the milieu within which they find themselves. It is the purpose of this paper to discuss and illustrate one aspect of the patient's milieu which may contribute to his illness behavior, 11 and which may lead to the request for psychiatric assistance. This feature of the patient's environment shall be called "the obligation to remain sick." The focus for this discussion derives from the concept of the sick role which has been defined by Parsons. 14,15 He has pointed out that "being sick" constitutes a role in society for which there

The paper deals with the organizational context of medical practice, help-seeking, and illness behavior in a manner which attempts to show their relevance to more extensive sociological issues. In the first part of the paper, both the advantages and costs of bureaucratization of medical practice are discussed in relation to changes in society itself. The second part of the paper deals with the strategy for developing a social psychological help-seeking model. Although the entire paper attempts to identify strategic areas for research in medical sociology, the third part of the paper is more specifically directed to needed areas in research.

Case interviews are used to explore variations in illness behavior and Parsons' sick role formulation. A decision-making model, focusing on the influence of status and role definers (significant others), produced findings relative to the nature of being "well", assignment of a "sick status", and illness behavior. While Parsons' formulation describes modal categories when each component is taken alone, his total configuration describes only a minority of responses. Seven sick role configurations are identified. In addition to interpersonal influence, the nature of "well roles" and the nature and severity of the illness are important variables for the study of illness behavior.

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