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ENVIRONMENT AND HEALTH

A series of books edited by
Andrew Baum and Jerome E. Singer

SOCIAL PSYCHOLOGY
OF
HEALTH AND ILLNESS

Baum i»d Epstein • Human Response to Crowding, 1978

Collioan, Pennebaker, i»d Murphy • Mass Psychogenic Illness: A Social
Psychological Analysis, 1982

Sanders «nd Sues • Social Psychology of Health and Illness, 1982

edited by
GLENN S. SANDERS
JERRY SULS
The State University of New York at Albany

1^
1982

LAWRENCE ERLBAUM ASSOCIATES, PUBLISHERS
Hillsdale, New Jersey
London

128

SKELTON AND PENNEBAKER

Ross, L., Lepper, M., & Hubbard, M. Perseverance in self-perception and social perception: Biased
attributional processes in the debriefing paradigm. Journal ofPersonality and Social Psychology,
1975, 35. 880-892.
Ruble, D. Premenstrual symptoms: A reinterpretation. Science. 1977, 197, 291-292.
Schacter, S., & Singer, J. Cognitive, social, and physiological determinants of emotional state.
Psychological Review. 1962. 69. 379-399.
Shontz, F. The psychological aspects of physical illness and disability. New York: Macmillan,
1975.
Skelton, J. A. Suppression offacial responses and directional consistency among subjective, phys­
iological. and expressive indices of emotion. Unpublished masters thesis. University of Virginia,
Charlottesville. 1979. .
Skelton, J. A. Data, theory, and the perception of bodily states. Unpublished manuscript, Depart­
ment of Psychology, University of Virginia, Charlottesville, 1980. (a)
Skelton, J. A. Symptomatic experience and judgments of the health-relevance of verbal stimuli.
Paper presented at the annual meeting of the American Psychological Association, Montreal,
1980. (b)
Skelton, J., & Pennebaker, J. Dispositional determinants of symptom reporting: Correlational evi­
dence. Paper presented at the annual meeting of the American Psychological Association, Toron­
to, 1978.
Snyder, M. Self-monitoring processes. In L. Berkowitz (Ed.), Advances in experimental social
psychology (Vol. 12). New York: Academic Press, 1979.
Stembach, R., & Tursky, B. Ethnic differences among housewives in psychophysical and skin
potential responses to electric shock. Psychophysiology. 1965, 1. 241-246.
Stunkard, A., & Koch, C. The interpretation of gastric motility, 1. Archives of General Psychiatry.
1964. //. 74-82.
Taylor, S. E., & Crocker, J. Schematic bases of social information processing. In E. T.
Higgins, C. P. Herman, & M. P. Zanna (Eds.), Social cognition: The Ontario Symposium,
Volume 1. Hillsdale, N.J.: Lawrence Erlbaum Associates, 1981.
Taylor, S. E., & Fiske, S. T. Salience, attention, and attribution: Top of the head phenomena. In L.
Berkowitz (Ed.), Advances in experimental social psychology (Vol. 11). New York: Academic
Press, 1978.
Tursky, B.. & Stembach, R. Further physiological correlates of ethnic differences in responses to
shock. Psychophysiology. 1967, 4. 67-74.
Tversky. A., & Kahneman, D. Judgment under uncertainty: Heuristics and biases. Science, 1974,
185. 1124-1131.
Zborowski, M. Cultural components in responses to pain. Journal ofSocial Issues. 1952,4. 16-30.
Zborowski, M. People in pain. San Francisco: Jossey-Bass, 1969.
Zola, I. Culture and symptoms: An analysis of patients presenting complaints. American Sociologi­
cal Review. 1966, 31. 615-630.

5

Social Comparison and
Perceptions of Health and
Illness

Glenn S. Sanders
State University of New York at Albany

One of the most striking features of the journey from health to illness and back
again to health is the nearly constant presence of uncertainty. What caused the
problem? Is it serious? Is treatment necessary? Is a given diagnosis accurate?
How long will recovery take? How effective is this treatment? These are but a
handful of the questions that have likely demanded the attention of anyone in
physical distress. Presumably, the best answers to such questions are provided by
health professionals. Nonetheless, it is far from uncommon to observe these
queries being directed to and answered by family, friends, and even strangers,
few of whom have any well-founded idea of what they are talking about. Further­
more, it does not tax the imagination to assume that the practice of having
laypeople reduce each other’s illness-related uncertainty can have serious conse­
quences. People may exacerbate a problem by persisting in behaviors condoned
or encouraged by others; they may postpone treatment until it is too late, having
been told by others that treatment is either hopeless or unnecessary; they may
discontinue an effective therapy, impressed by the negative reactions of their
friends; and so forth.
The following material is an initial exploration into the dynamics of acquiring
medically relevant information from unqualified sources. Chief among the issues
to be considred are: (1) How common is the use of nonexpert opinions for
clarifying illness-related uncertainty? (2) Why do people seek nonexpert opin­
ions, and why are others willing to provide them? (3) What are some determi­
nants of the likelihood of seeking nonexpert information? (4) What are the
possible influences of nonexpert information at various stages of illness and
recovery? (5) What determines the actual content of nonexpert information? and
(6) How does the influence of nonexpert information interact with attempts to
modify health care behavior?

129

130

SANDERS

5.

Due to the scarcity of previous research specifically aimed at these issues,
much of the discussion is somewhat speculative, although relevant data and
theory are supplied when possible. Consequently, the reader is advised to ap­
proach the material with the aim of uncovering problems that may otherwise
have remained hidden, rather than of finding firm answers to long-standing
questions. This is not to say. however, that this chapter is simply fuel for future
research. The ideas presented often have direct implications for layreaders and
students as they are involved in the process of nonprofessional information
exchange and for health professionals as they are affected by it. These implica­
tions are spelled out at the end of each section.
As an organizing framework, the issues to be explored are viewed as instances
of the general process of social comparison (cf. Festingcr, 1954; Suls & Miller,
1977). This term refers to the tendency of people to evaluate various aspects of
themselves through a comparison of their own characteristics (opinions, feelings,
behaviors) with those of other people. In the following discussion, it is assumed
that people often have mixed feelings concerning their health status and what to
do about it. The resulting ambiguity and ambivalence can be resolved by hearing
others' opinions and deciding that those feelings shared by others are more valid
than the remaining nonshared impulses. For example, a person may want to see a
doctor but be afraid of the cost. The cost factor will play more (or less) of an
inhibiting role to the degree it is emphasized (or overlooked) by others. Thus, the
appropriateness of being concerned about cost has been clarified through social
comparison. In general terms, then, the act of seeking medical information from
nonexpert others can be seen as yet another example of the pervasive practice of
using comparison information for self-evaluation and self-direction.

FREQUENCY AND IMPACT

The concept of a “lay referral structure” (Friedson, 1961) or “lay conferral
system” (Elder, 1968) has attracted the attention of medical sociologists for the
last 2 decades. This concept describes an informal community-based network of
individuals, most of whom are not medical professionals, whose function is to
provide medically relevant information in the form of diagnoses, treatments, and
professional referrals. Available data indicate that this is a very active and
influential network.
Suchman (1965) reported that unusual physical symptoms were followed by
lay consultation in 74% of his sample and that 16% of the sample talked with two
or more nonexpert others. Lay conferrals were felt to have provided a fairly clear
course of action by 78% of the respondents, and over 70% described others’
opinions as highly influential in determining subsequent action. Similarly, Miller
(1973) found that early signs of head and neck cancer prompted discussion with

SOCIAL COMPARISON AND ILLNESS

131

medically uninformed consultants 62% of the time and that in 55% of these
instances others’ opinions became the guide to action. Davis and Eichom (1963)
asked cardiac patients whether they had asked for others’ opinions of their
doctor-prescribed recovery and prevention regimen. Over 90% of the sample
answered in the affirmative, and 52% said they were more influenced by the
opinions of family and friends than by their physician’s advice. Twaddle (1969)
observed that symptoms resulting in great pain or sudden disability prompted
doctor visits without lay consultation, but that other symptoms, constituting the
majority of cases, triggered a series of nonexpert discussions, with the typical
subject consulting others until finding one that recommended professional atten­
tion. If no such advice was received, the symptoms were usually ignored until
they became much worse. Heinzelmann and Bagley (1970) studied the decision
of potential cardiac victims to participate in a preventive physical activity pro­
gram. They noted an 80% participation rate for subjects whose spouse had a
positive opinion of the program, whereas only 40% participated if their spouse’s
attitude was neutral or negative. Osterweis, Bush, and Zuckerman (1979) found
that the best predictor of patients' adherence to prescribed medicine-taking was
the extent to which other family members used medicine. If others did not
believe in the validity of taking medicine, adherence was extremely limited.
In order to get an even clearer idea of the magnitude of the lay referral system,
I had 220 undergraduates complete a health questionnaire. It first asked how
often in the last year they had experienced unusual physical symptoms with
mixed feelings and no ready explanation. The main response was 2.4, or about
once every 5 months, with only 6% indicating no such occurrences. On the
average, each time uncertainty-provoking symptoms were experienced, 2.7 non­
experts were consulted, and their advice or opinions had a strong directive
influence on reactions to symptoms in 68% of such discussions. Furthermore,
subjects had an average of 1.8 instances in the last year of being given medical
advice by laypersons without having asked for it. The typical subject reported
having offered medical opinions and advice to 3.2 others a total of 5.5 times in
the last year (the distribution on this item was sharply bimodal, with roughly a
third of the sample rarely or never giving advice and the remainder doing so
every 1 or 2 months). Only 13% of the sample reported they would not offer any
opinion due to their lack of expert information if consulted by others with
medically related questions.
In general, subjects reported seeing a doctor to inquire about symptoms .9
times, or about once every 14 months. Whereas professional advice concerning
home treatment, recovery, and/or future prevention was obtained in 74% of these
cases, nonexpert opinions were sought 88% of this time, and unsought advice
and opinions were offered by others in 5 out of every 10 instances. Additionally,
subjects felt that lay information was ar least as influential as professional infor­
mation in determining their feelings and actions in 65% of their postdoctor-visit
experiences.

132

SANDERS

5. SOCIAL COMPARISON AND ILLNESS

Finally, on an overall basis, 81% of the subjects said that they consulted with
others in order to clarify their own feelings and decide on a course of action, as
opposed to just wanting to vent their own feelings, obtain reassurance, or gather
support for decisions they had already made. This last finding again suggests that
the lay conferral system plays an active and influential role in shaping percep­
tions of health and illness. There seems to be little doubt, then, that consultation
with nonexpert others is both a common and important aspect of the experience
of illness.

Implications
Laypersons. Seeking and offering medical advice is apparently com­
monplace among the medically uninformed. As such, these activities are most
likely acceptable and perhaps even expected. People should therefore not hesitate
to seek the opinions of lay consultants because these opinions will usually be
readily offered and failure to accept .them will typically result in prolonged
ambivalence and inaction. Similarly, laypersons need not be too hesitant about
offering medical advice to others (particularly if one has special experiences that
may be relevant) because such advice is probably desired and will probably be
obtained from others if not from oneself. People should also be aware that failure
to engage in lay consultation may be interpreted as indifference, lack of respect,
and so forth (rather than prudent silence in the face of ignorance) due to the
readiness of most people to participate in the lay conferral system.
Health Care Professionals. These data should make it clear that medical
personnel and their patients do not interact in a vacuum. The factors that bring
patients to professionals and mediate recovery and prevention are by no means
confined to a strictly medical domain (cf. e.g., the findings of Zola, 1973, that
various types of physical symptoms are in and of themselves unrelated to the
decision to see a doctor). Rather, the health care professionals must take into
account the fact that their patients' feelings and behavior are strongly influenced
by information received from nonexperts and that such information can ob­
viously be at odds with the professional’s intentions. Particularly in troublesome
cases, some effort should be devoted to determining what information, if any,
the patient is receiving from uninformed others and to understanding that the
patient is being influenced by this information rather than by medical factors
alone.

133

life’s greatest disasters. It is also clear that medicine is an enormously complex
discipline, requiring more years of intense study and practice than most other
professions. How, then, can people be interested in and influenced by the medi­
cal opinions of others who have no such training and who are capable of deliver­
ing a large variety of potentially harmful or even fatal misinformation? At least
intuitively, one would be rather hesitant to seek or heed the advice of an unin­

formed layperson if it pertained to investing life savings or fixing electrical
malfunctions. Yet people seem ready to literally play with their lives and well­
being in a game of unfounded medical opinions.
By the same token, it is also odd that people are willing to offer medical
advice. Again intuitively, it seems that if one knew nothing about cars and was
consulted about a problematic carburetor, the most likely response would be to
claim ignorance, not to suggest a gas-treatment product or urge a costly and time­
consuming visit to a mechanic. Nonetheless, even deeper ignorance of the causes
and implications of symptoms, of the validity of treatment techniques, and so
forth fails to inhibit people from offering health care suggestions with sufficient
confidence to render them influential.
The following sections attempt to explain the high frequency of lay consulta­
tion, although the absence of much relevant data results in a good deal of pure

speculation. Attention is first focused on the recipients of nonexpert information
and then on its providers.
•One of the central points made by Festinger’s (1954) theory of social compari^/
son-is that when an objective basis for'.dcfinirig reality'is not.easily'_ayailabl^
^people will jely.on.a social .definition of reality, produced.by, mutually-shared
•Lgpinion. For example, it would be difficult to decide via purely objective evi­
dence that one is creative, so one either “is” or “is not” creative as a function
of a social consensus. In this manner, it may be that the great complexity of the
medical domain, which should remove it from the influence of uninformed
opinion, instead gives it the appearance of being difficult to define objectively,
and thus leaves it susceptible to social definition. If it is felt that there is no
definitive objective basis for knowing the meaning of a symptom or the efficacy
of a treatment in any single case, then these matters will tend to be “known” by
the opinions of others. That is, if no person can prove medical reality objec­
tively, then every person is entitled to his or her say. In contrast, less involved
matters, such as investment plans, electrical systems, or auto mechanics, are
probably viewed as subject to objective definition—there is a right and a wrong,
and it can be proved which is the case—and therefore, nonexpert opinions would
be neither sought nor heeded. This reasoning leads to the expectation that other
highly complex areas, such as interpersonal relations and mental disorders,

THE IMPETUS FOR LAY CONFERRAL

would likewise be seen as defying objective definition and consequently suscep­
tible to lay consultation. The bottom line here is that nonexpert opinions may be

Although lay consultation is clearly an extensive and influential practice, it is not
readily apparent as to why this is the case. Few people would deny that good
health is one’s most important asset and that improper health care can create

sought and heeded in medical matters because health care professionals them­
selves are viewed as nonexperts in the sense of lacking objective bases for their
opinions.

134

SANDERS

A second reason for initiating and responding to lay consultation could in­
volve the frequently high costs of relying on expert information. These costs can
include: (1) time and effort (e.g., it will usually be easier and faster to consult
family, friends, or colleagues than to see a doctor); (2) ease of disclosure (e.g., it
will usually be more comfortable to discuss personal problems with familiar
others than with a relatively unknown and possibly unsympathetic health profes­
sional); (3) pain and discomfort (e.g., lay consultants will probably be far less
likely than professionals to recommend painful or difficult medical tests and
curative or preventive procedures); (4) bad news (e.g., nonexpert others are
probably motivated to avoid giving unpleasant information, cf. Tesser& Rosen,
1975, whereas professionals are bound to do so if the case merits it); (5) re­
crimination (e.g., familiar others are probably less likely than professionals to
chide the subject for bad health habits or failure to follow advice); (6) commit­
ment (e.g., people may feel at liberty to disregard the opinions of lay consultants
if they are not pleased with what they hear, whereas seeking professional infor­
mation tends to commit one to abiding by their opinions); (7) individuality (e.g.,
people are likely to feel they are a unique and important object of concern when
presenting their problems to familiar others, whereas the constant stream of cases
handled by professionals may produce in people a sense of being a mere slot in
the schedule book and of no great moment, lost in the crowd of patients rather
than the center of attention); and, last but not least (8) money (e.g., seeking
professional information often introduces the vivid possibility of major or even
ruinous expenses). In short, cost considerations suggest that people may use lay
consultants to reduce medically related uncertainty not because they necessarily
value such opinions but because they fear the consequences of consulting
professionals.
A third factor promoting lay consultation may be a desire to avoid or mini­
mize responsibility for important decisions. There are many ways in which
people can appear foolish (or worse) to themselves and others when subjected to
possible or real illness. If they take too much action, they may appear hysterical
or hypochondriacal. Too little action would constitute negligence, making them
“responsible” for their problems and removing them from entitlement to sympa­
thy and support. A decline in health following abandonment of a prescribed
regimen could lead to charges of stupidity or self-destructive tendencies, whereas
a sudden decline in health following adoption of a treatment program could
reflect a lack of common sense in choosing the program and/or being the dupe of
a physician's desire to push a pet theory. The basic problem confronting people
is that there are a variety of unforeseeable consequences that could make their
health-related decisions seem unwise in retrospect. A considerable amount of
protection from the implications of negative consequences would be gained by

5.

SOCIAL COMPARISON AND ILLNESS

135

their self-recrimination if they knew that other nonexperts shared their opinions
and would bavc acted similarly.
One final impetus for initiating lay consultation may be the sense of helpless­
ness and passivity imposed by physical impairment and high levels of uncertain­
ty. As discussed by Parsons (1958), a major component of the “illness role” is
the relinquishment of personal responsibility. People with physical problems are

not generally expected to cure themselves or to choose courses of action indepen ­
dently, but rather are properly passive and malleable objects entrusting them­

selves to the guardianship of well, strong others. The origins of this concept of
“proper" behavior is beyond our focus here, but the illness role does seem to be
widely accepted both within and across most cultures. An obvious consequence
of this general linkage of dependence with illness is that people who feel or
suspect themselves to be ill will be obliged to consult with others before making
decisions. For the other reasons reviewed earlier, this consultation will not be
limited to or even centered on health care professionals.
Having at least made intelligible the high frequency of initiating lay consulta­
tion, let us now tum to the other side of the coin—the fact that nonexperts are
virtually always willing to offer medical opinions when consulted and will even
do so frequently when not explicitly asked about their feelings. For example.
Miller (1973) reports that a woman with a persistent sore throat (which turned out
to be sympotomatic of neck cancer) was told in strong terms by her family that
she was malingering and should ignore the problem because it would certainly
fade away. One explanation for this seemingly irresponsible behavior stems from
the illness-role concept just discussed. In the same way that people with physical
problems feel obliged to consult with others, the consultants themselves may feel
it is their duty to provide some basis for action. Failure to offer an opinion would
be tantamount to shrugging one’s shoulders when told by a child that she cannot
find her parents.
The obligation to respond produced by the illness role may be intensified by
the highly self-revealing nature of seeking medical opinion. To discuss one’s real

or potential infirmities is a major act of self-disclosure—of opening oneself up
for others’ inspection. This form of giving of oneself probably induces a pressure
for reciprocity—an implicit demand that the consultant give something in return.
It is as if the initiator were saying, “1 have revealed something important, made
myself vulnerable, and taken a real chance that you won’t dangerously mislead
me—the least you can do is to get involved in my problem and take a chance in
offering some basis for action.”
Another force operating on the consultant could be the implicit flattery of
being asked for opinions on important matters and the resultant reluctance to
forego the status of being “doctor-for-a-day.” Health care professionals are

seeking and responding positively to others’ opinions. Family, friends, and
colleagues would be far less likely to point an admonishing finger if they were

almost universally regarded as having the highest occupational prestige, and to
be consulted on even a casual basis is to ascend to that level instantly. The role of

directly involved in the questionable decisions. Additionally, people could ease

medical expert is offered to the consultant, and it is a difficult role to refuse. A

136

SANDERS

desire for this role may also underlie the frequent offering of unsolicited
information.
The complexity and ambiguity of medical processes and outcomes may also
make it easier for consultants—prompted and tempted by the factors just re­
viewed—actually to go out on a limb and offer potentially dangerous informa­
tion. The idea here is that it is usually very difficult to know whether one's
medical opinions are helpful or harmful, involving as they do a one-subject
sample with no control groups. When someone’s health gets worse following
action precipitated by a consultant’s opinions, who is to say that alternate courses
of action would have been any better? If a relapse follows discontinuation of a
therapy triggered by a consultant’s opinion, how can one know if the relapse
wasn’t inevitable anyway or if it wouldn't have been even worse had therapy
been allowed to proceed? If a friend’s suggested home remedy is ineffective,
how was he or she to know that you were one of those rare individuals unrcceptive to its powers? In many cases, if not most, the consultant can effectively deny
responsibility for negative consequences because what constitutes proper and
accurate information versus dangerous misinformation is frequently seen as a
matter of debate even among professionals (of course, some opinions lend them­
selves more readily than others to denial of responsibility and therefore should

5.

SOCIAL COMPARISON AND ILLNESS

137

grain of salt due to obvious lack of expertise. Great care should be taken in the
choice of consultants and in the consultant ’s choice of words.

Health Care Professionals.

It is important to realize that patients have a

strong need for information. Any tendency to keep them in the dark, for practical
or ethical reasons or because of personal discomfort, will probably intensify a
preexisting tendency for lay consultation. Concerns with patients’ emotional
reactions to bad news or feelings that it is pointless or too much effort to inform
them of details need to be balanced by the fact that professional silence could
well be replaced by the uninformed but influential opinions of family and
friends. Care should also be taken to present information in a coherent, systemat­
ic fashion, rather than as isolated fragments, in order to compete favorably with
the potentially well-developed intuitive theories offered by lay consultants. Fur­
thermore, professionals should try, when feasible, to minimize the costs (re­
viewed earlier) of seeking and heeding their opinion. Perhaps the easiest ways to
cut these costs is to assume an informal and approachable manner, to convince
patients that they are unique and important, to avoid stem lectures and recrimina­
tion, and to adopt a flexible, bargaining style in giving information, rather than

trying to instill a sense of absolute commitment to prescriptions. In brief, the

more likely be offered, as is discussed in a later section of this chapter).
Finally, there is some evidence that many people, and perhaps most, have
intuitive theories of illness that are fairly systematic and internally consistent.
Harwood (1971), for example, described a hot-cold theory espoused by many

most successful professional consultation may be that which comes closest to
simulating the atmosphere of lay consultations.

Puerto Ricans in New York City. Essentially, various symptoms and treatments
were seen as either hot (e.g., rashes and penicillin) or cold (e.g., colds and fruit
juices), and treatment consisted of prescribing cold-type cures for hot-type prob­
lems or vice versa. There are doubtless many other cultural and idiosyncratic
medical belief systems, and their existence probably serves to facilitate the
offering of opinions greatly. That is, it is not as if the lay consultant has to grab
advice out of thin air due to a lack of expertise; rather, the opinions are often
dictated by a well-established, readily available, and possibly compelling medi­
cal theory. It may also be supposed that people who possess a coherent intuitive
theory would be less likely to experience confusion when experiencing a physical
difficulty and thus less likely to seek clarification through the lay conferral

SOURCES OF VARIATION
IN FREQUENCY AND IMPACT

system.

Implications
Laypersons. Both recipients and providers of lay consultation should realize
that there are strong pressures acting on people to offer information with confi­
dence and to be significantly influenced by that information. It is not safe to
assume that ignorance of the facts will prevent a consultant from readily offering
opinions, nor is it safe to assume that one’s opinions will be taken with a large

Despite the pressures operating on people to engage in lay consultation, it is still
the case that there is significant variation in both its frequency and impact. For
example, Suchman (1965) observed that 26% of his sample did not discuss
symptoms with nonexpert others and that 22% of those who initiated lay con­
sultation felt the discussion had not provided a clear course of action; Miller
(1973) reported that 45% of his sample rejected as invalid the opinions of their
lay consultants; and I found that almost 25% of the respondents to my health
questionnaire indicated that they never offered medical opinions. The following
discussion highlights some of the major sources of individual differences in lay
consultation.
Inasmuch as medical discussions with nonexpert others can be seen as a form
of social comparison, we can begin with one of the central postulates of compari­
son theory—the similarity hypothesis. Festinger (1954) proposed that compari^

son'information would be most desired and^most influential .wher?ft was avail- 'f
.able' from others who were similar to the subject; His reasoning, was Jhaff
dissimilar others may have motives or viewpoints that the subject does not share.'Lv
and consequently, differences of opinion may signify differences in motives or in- f

138

SANDERS

orientation to the issue rather than the.possibility that one’s feelings are invalid./
The similarity hypothesis in essence supposes the subject to say, “How can you
know what is right for me if you are not like me?" For example. Democrats
would not try to clarify their feelings about a political candidate by comparing
opinions with Republicans because their definition of what constitutes a good
candidate may be so dissimilar that either agreement or disagreement would be
highly ambiguous. ^As discussed by Goethals and Darley (1977), the emphasis orr
similar others is particularly strong when one is concerned With'decidin'g on a/
course of action of with evaluating personal attributes such as capacities, anty

emotions—the most likely topics in lay consultation.
When applied to the clarification of medical issues, the similarity hypothesis
suggests that the absence of lay consultants who share the subjects' basic con­

cerns and general outlook will inhibit the desire for and impact of nonexpert
information. In two illustrations of this principle, I had subjects play the role of a

student with physical problems and then react to comparison information from
different types of sources (§anders~d9g.Q). The first situation assessed the impact
of lay opinions on the decision to see a doctor about the appearance of unusual
but nondebilitating symptoms. Lay consultation was much more influential if the
source was fellow students rather than inner-city housewives. Presumably, this
result was due to the fact that other students would be fairly attuned to the
meaning of the symptoms for the subject—a student—and to the problems asso­
ciated with a student's decision to see a doctor. In contrast, the housewives may
have had peculiar theories of disease, may have been insensitive to the problems
created for a student by the symptoms, or may have used irrelevant criteria for

determining when a visit to the doctor was needed.
The second situation involved playing the role of a patient who had just been
urged by a physician to enroll in a difficult and painful treatment program. In this
case, the opinions of inner-city housewives who had physical problems similar to
the subject were much more influential than the opinions of fellow students and

friends who were in good health. Here it was the housewives who were most
similar to the subject by virtue of their common ailments. Whereas the opinions
of healthy fellow students may be based on general principles or unskilled
imagination of the subject’s circumstances, the afflicted housewives are likely to
have more meaningful opinions based on careful consideration of and full ex­
posure to the same uncertainties experienced by the subject.
Another illustration of the importance of similarity between subject and con­
sultant in determining perceptions of health and illness is provided by Fillcnbaurn
(1979).,He found that elderly males' perceptions of how well they were could 6e
predicted from the relationship of their actual health (according to professional
diagnosis) with that of other elderly males; but these perceptions were unrelated
to their standing within more general populations. That is, subjects felt thay were
in good health if they were doing better than similar others, but they were
uninfluenced by the superior or inferior health of dissimilar others. It seems that

5.

SOCIAL COMPARISON AND ILLNESS

139

they were concerned not with “good health” but with “good health considering
that one is an elderly male.” In the same manner, my role-playing subjects were
concerned not with "appropriate behavior” but with “appropriate behavior
considering that one is a student or that one has received this diagnosis.” The
overall point of this discussion of the similarity hypothesis is that lay consultation
will have a frequency and impact proportional to the consultants' ability to place
themselves in the subject's position and offer self-relevant information.

A second potential mediator of lay consultation resides in the nature of the
medical difficulties themselves. For one thing, some symptoms or treatments or
difficulties with professionals, and so on, are more likely to be talked about than
others. It is more probable, for instance, that the appearance of blotches on the
arm will be brought to the attention of others than will a genital rash; resistance to
a doctor’s advice will become the subject of lay consultation more often if it is
based on the doctor's self-contradictions than if it stems from the physician’s
facial resemblance to an incompetent uncle; one's degree of success at recovery
will less likely be a matter of lay discussion for serious cases, when one still
looks and feels awful despite improvement, than for mild ills, when it is a less
painful topic even without improvement (cf. the discussion of communication
with cancer patients by Wortman & Dunkel-Schetter, 1979).
Another consideration is that some problems, due to their exotic nature or
complexity, offer little hope of resolution through lay consultation. The consul­
tant may have something to offer for a persistant headache or a recommended
liquid diet, but nonexpert information is probably less attractive and compelling
in reference to pain produced by blinking or to a recommended chemoradiation
treatment. It would seem that many problems would lead subjects to conclude
that they have never heard of such a thing and that there is no reason to assume
potential consultants to be any better informed. Consultants themselves should
also be less willing or able to offer influential opinions when faced with very
unusual or involved issues.
One final property of medical problems per se, which may mediate the fre­
quency and impact of lay consultation, is the degree to which these difficulties
interfere with normal activities. The discussion of illness roles by Parsons (1958)
has as its basis the idea that people will engage in special role-prescribed sickness
behaviors when their ability to execute their normal roles (e.g., worker, parent,
etc.) is impaired. Because one of these sickness behaviors is to rely passively on
others' guidance, I would expect lay consultation to increase in frequency and
impact when medical uncertainties are related to the inability to perform normal
functions. In another role-playing study, I again had subjects imagine they expe­
rienced a particular set of symptoms. A marked increase in their desire for
comparison information from fellow students was produced by the addition of a
phrase indicating that the symptoms interfered with taking notes in class. The
idea of normal role disability may help to explain why: (1) Suchman (1965)
found that for a general sample of symptoms, some involving impairment of

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normal functions. 74% of the respondents discussed their problems with others,
and over 70% were influenced by the information they received; whereas (2)
Miller (1973) found that for a sample of head and neck cancer symptoms, none
of which involved normal role interference, only 62% engaged in lay consulta­
tion, and only 55% of these were influenced by the comparison information.
Despite the apparent importance of role interference in mediating information
discussions of medical problems, it should be noted that this factor may be
culturally specific; Antonovsky (1972) reported high levels of lay consultation

independent of role interference in an Israeli sample.
Personal characteristics of both subject and consultant are probably a third
major governor of the lay conferral system. To begin with, certain personality
variables should facilitate the relevant processes. Some people are more habitu­
ally self-evaluative than others (cf. Carver & Glass, 1976; Scheier, 1980). These
self-evaluative types may be especially likely to be aware of and concerned by
unusual symptoms and to clarify their self-evaluations via lay consultation. In
contrast, those with little introspective tendency may continue to focus on exter­
nal problems until the symptoms either disappear or worsen to the point where
the need for professional attention is obvious. Mullen and Suls (1980) have
obtained evidence suggesting that subjects high in self-awareness are more likely
to engage in some form of stress-management tactic than subjects who rarely
view themselves as objects of contemplation. This result may be due to the
greater awareness possessed by self-evaluators in experiencing internal difficul­
ties and in understanding the need to determine the precise nature of the problem
and to embark on some remedial action. If this is the case, self-focused people
should be particularly attracted to and influenced by the clarifying and action­
facilitating properties of lay consultation.
A second relevant personality variable is the locus of control construct (Rot­
ter, 1966) and, more specifically, the health locus of control orientation (WalIston, Wallston, Kaplan, & Maides, 1976). This variable refers to people’s
tendency to see self-relevant events such as illness and its treatment as being
determined primarily by one’s own efforts (internal locus of control) or by
environmental forces beyond one’s influence such as fate or powerful others
(external locus of control). It would seem that people with a strong belief in the
role of fate or luck would be unlikely to engage in lay consultation or to offer
helpful advice because they would adopt a fatalistic attitude toward the difficulty
in question and would assume that deliberate action was irrelevant to the eventual
outcome. On the other hand, those who believe that events are determined
primarily by one’s own actions and/or those of powerful others would want to
clarify the problem they were facing so that effective action could be taken;
hence, they would be much more likely to seek and heed others’ opinions and to

offer action-oriented information.
Other individual differences that could directly influence lay consultation are:

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141

1.
Seif-disclosure (Jourard, 1964). Some people find it easier to discuss
intimate personal topics, whereas others feel either too vulnerable or intrusive
when such issues are brought up. It is likely that someone who is comfortable in

revealing weaknesses will be more likely to initiate and respond to lay consulta­
tion than someone who finds self-disclosure unpleasant. Similarly, those who
feel at ease in discussing personal problems should be especially likely to listen
carefully to others' complaints and confusion, thus drawing out the discussion
and instilling an interest in and respect for their opinions.
2.
Self-esteem. People with little respect for the validity of their opinions and
the wisdom of their actions should be predisposed to initiate and respond to lay
consultation; in contrast, those with high self-esteem should be most confident
and persuasive in their analyses of others’ problems.
3.
Extraversion. Gregarious individuals will have developed a larger network
of potential consultants than introverts and should feel easier in approaching
others about their difficulties due to their greater social experience.
4.
Dominance/submissiveness. Some people like to lead; others like to be
led. It is clear that submissive types should find it easier to seek and heed others’
opinions, whereas dominant types should be more compelling when offering
opinions.
5.
Trust. Again, it is true almost by definition that the greater one’s belief in
the capability and goodwill of others, the more likely one is to be a candidate for
an influential lay consultation.

A somewhat different category of personal characteristics that probably exerts
as much influence on lay consultation as personality variables is the individual's
social standing. One prominent element of this category is socioeconomic status
(SES). Miller (1973) reported that SES was inversely related to both the frequen­
cy and impact of lay consultation. That is, poorer people with less education are
particularly likely to seek and respond positively to uninformed medical opin­
ions. This tendency could be partly due to a greater prevalence of intuitive
medical theories in lower-class areas, but is probably also the result of the fact
that the higher one’s SES, the more likely one is to number medical experts
among personal acquaintances. Thus, members of the middle and upper classes
are more likely to have the option of informal consultation with professionals to
counter or obviate the impact of nonexpert information. Furthermore, one of the
principal barriers to immediate professional consultation—financial cost—is of

course more of a problem for low SES individuals.
Another aspect of social standing orthogonal to SES is one’s depth and
breadth of social and family interaction. The more people one encounters and/or
the more intense one's relationships, the greater the probability that someone will
be available who is similar to the subject, at ease with self-disclosures, or in
possession of a compelling medical theory—in short, someone who inspires an

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influential lay consultation. Although no directly relevant data are available,
several findings are consistent with the assumption that being married, having a
strong family authority figure, and engaging in frequent superficial and/or in­
tense relationships are all factors that increase the frequency and impact of lay
consultation (e.g., Cobwin & Pope, I974; Geertsen, Klauber, Rindflesh, Kane,
& Gray, 1975; Hessler, Kubish, Kong-Ming, Ellison, & Taylor, 1971).
Although the preceding discussion of mediators of the lay conferral system’s
operation is by no means exhaustive, it should suffice to suggest the range of
potential facilitating and inhibiting factors. The fact remains, however, that lay

consultation is in general very common and influential, despite the numerous
ways in which it might be short circuited. Thus, the basic pressures acting on
people to participate in the lay conferral system, discussed in the previous sec­
tion, must be quite strong indeed to be able to overcome so many potential
sources of resistance.

Implications
Laypersons. People will often feel incapable of or uncomfortable about
discussing medical problems with others due to considerations similar to those
just reviewed. An alternative, and potentially dangerous, method of coping is to
minimize the significance of the difficulties and try to ignore them. An aware­
ness of the sources of resistance to lay consultation may help overcome them so
that one can gain some degree of emotional clarity and initiate meaningful

action. For example, it may be realized that a consultant's opinions do not seem
helpful because he or she cannot be expected to share the subject’s perspective
(i.e., the consultant is a dissimilar other). If so, the subject has an idea of who to
consult to obtain more useful information rather than continuing to feel that
meaningful opinions simply are not available. A second implication of this
section is that the urgency with which opinions are sought may not reflect the
seriousness of the problem, but may instead be at least partly a function of
medically irrelevant aspects of the interpersonal relationship, the nature of the
problem, and the personal characteristics of the participants. Similarly, people
should be aware that some opinions may seem more cogent than others not
because they are more valid but. again, because of medically irrelevant factors
such as those just reviewed.
Health Care Professionals. Particular attention should be devoted to provid­
ing information to patients who are unlikely to engage in lay consultation, as they
would otherwise be trapped with their uncertainties and could become quite
difficult to handle. On the other hand, patients who are especially susceptible to
lay conferral should be asked about what they have heard so that serious miscon­
ceptions can be corrected. If it seems probable that the patient is consulting with
particularly influential but nonexpert others (e.g., a similar, high self-esteem.

5. SOCIAL COMPARISON AND ILLNESS

143

authoritative family member), it may be advisable to co-opt such others into the
medical team so that they can be used to reinforce the professional's viewpoint
rather than be left free to subvert it.

POTENTIAL INFLUENCES
OF SOCIAL COMPARISON
Thus far, we have been concerned with the general process of obtaining medical
information from nonexperts. In the next two sections, attention is focused on the

specific content of such information. The possible ways in which lay consulta­
tion may influence medically relevant behavior is discussed first; the determi­
nants of the actual information obtained by social comparison are explored in the
following section. In general, influence may be exerted at five different stages of
health and illness: (1) behaviors that prevent or induce illness; (2) decisions about
the meaning of symptoms; (3) decisions about the treatment of symptoms; (4)
responses to professional care; and (5) recovery from illness. Each of these
stages can be considered in turn.

7. Behaviors Relevant to the Onset of Illness. Although many medical
problems may occur independently of consciously controlled behavior (e.g.,
congenital diseases), a great variety of difficulties can be forestalled or induced
via particular activities. Such activities can range from the Type A workaholic
syndrome that has been linked to coronary heart disease (cf. Friedman & Rosenman, 1974), through general exercise and dietetic patterns that can affect overall
susceptibility to bodily malfunctions, to specific habits or acts linked to specific
problems (e.g., smoking or taking birth control pills). Two forms of social

comparison may influence the probability of an individual choosing to engage in
or continue these behaviors. The first form is nonverbal and consists simply of
comparing the frequency and intensity of one’s own behaviors with those of
salient others. This comparison will indicate the extent to which each behavior is
normative or deviate within the reference sample. In turn, these estimates can
encourage the individual to continue with or adopt behavior seen as normative, to
abandon behavior seen as deviate, or to establish a sense of individuality by
adopting, maintaining, or intensifying deviate behaviors and/or abandoning nor­
mative ones. The second form of social comparison influence is verbal, and this
consists of individuals' clarifying ambivalent feelings toward a behavior by
comparing their reactions with others’ opinions. These ambivalences can involve
decisions to adopt the behavior (temptations balanced against fears), to intensify
the behavior (increased benefits balanced against unknown consequences or
increased costs balanced against potential new benefits), or to abandon the be­
havior (reduced costs balanced against unknown consequences or reduced bene­
fits in opposition to potential new benefits). Influence will be exerted by com­

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parison sources adding more credence to one or the other set of conflicting
beliefs and feelings through personal adherence to that set. Influence can also be
exerted by creating ambivalence and setting the stage for behavioral change.
This would occur via the expression of beliefs and feelings contrary to those held

by the subject but previously not considered by him or her.
2.
Decisions Relevant to the Meaning of Symptoms. When people become
aware of some unusual bodily condition, they are usually interested in determin­
ing if this condition is symptomatic of some medical problem. Again, there are
two forms of influence that can be exerted through social comparison. In the
nonverbal form, one simply observes the frequency with which such bodily
conditions (e.g., headache, shortness of breath) appear in others. On the one
hand, a high frequency may suggest to the individual that the condition is a
common, normal one, and nothing to cause alarm (“everybody gets head­
aches”). Alternatively, a high frequency may suggest the presence of some
potent force to which both oneself and others have been exposed and therefore
may favor the conclusion of some medical difficulty (“there’s an epidemic”).
The verbal form of comparison-based influence stems from discussions of possi­
ble antecedents of the condition in question. Attempts at clarification can focus
on whether the antecedent was itself a medical problem; for instance, was a
headache caused by too much time in the sun (not a medical problem per se) or
by a flu virus (a problem in its own right)? Attempts can also focus on whether
the antecedent is likely to produce additional symptoms; for instance, is the
headache likely to be followed by a sore throat? In either case, the lay consulta­
tion is oriented at this stage toward determining if the symptoms can be safely

ignored.

3.
Decisions Relevant to the Treatment of Symptoms. If a person decides
that it is not safe to ignore symptoms, the next stage of lay consultation is
intended to provide some basis for action. Such action can take three basic
forms. In symptom monitoring, the issues involve charting the time course of
symptoms and/or being on the lookout for the appearance of additional symp­
toms. In addition, symptom monitoring may involve establishing criteria for
determining whether danger has passed or intensified. Lay consultation can
influence expectations about the symptom’s time course and about potential new

symptoms, and it can help establish criteria for further action as well as encour­
age the general monitoring approach. The second basic form of action at this
stage involves pursuing some form of home remedy. These remedies can take the
form of stopping behaviors suspected to have caused the symptoms, initiating
behaviors thought to stimulate the appropriate bodily defenses, and/or taking
some kind of nonprescription medical agent. Lay consultation can influence both
the general and precise forms of home remedy to be adopted as well as support
this overall course of action. The third basic action that can be taken if it is felt

5. SOCIAL COMPARISON AND ILLNESS

145

that symptoms are medically significant is to seek professional care. Aside from
promoting this option, lay consultation can influence decisions involving the
general kind of professional most likely to help (e.g., family doctor, emergency
room, chiropractor, etc.); the choice of particular individuals on the basis of their
interpersonal style, past success with certain symptoms, and so forth; and strat­

egies of self-presentation when consulting professionals (e.g., exaggerate the
difficulties so they will be taken seriously vs. act unconcerned so that unneces­

sary tests will not be hastily administered).

4.
Responses to Professional Care. A large number of uncertainties can
arise from professional care, and the manner in which these are resolved can
have strong effects on the success or continuation of the professional/client
relationship. The most common issues are probably: (1) the quality of the in­
teraction—how much warmth, courtesy, and interest is the professional exhibit­
ing, and are these levels typical? (2) the competence of the professional—are pet
theories, prejudice, or ignorance interfering with the professional’s ability to
understand and treat the difficulty, and should additional expert opinion be
sought? (3) the openness of the professional—is information being kept from the
patient, and if so, what are the secrets, why are they being kept, and how can
they be brought into the open? (4) the appropriateness of the patient’s feelings,

attitudes, and behavior—is too much being hoped for, will complaining do any
good, should this cure-related side effect be mentioned, and so forth? (5) alterna­
tives to current professional care—are there easier, cheaper, or more effective
ways to deal with the difficulty than are currently being pursued, and if so, what
are they and how can they be implemented? Furthermore, are there any draw­
backs to discontinuing the current approach, and if so, what are they and how can
they be avoided? Depending on the specific opinions given, lay consultation can
either greatly facilitate or seriously interfere with the effectiveness of profes­
sional care.
5.
Recovery. Social comparison can exert a variety of influences on a pa­
tient’s recovery from illness, independent of resolving the uncertainties produced
by professional care. In its simplest form, lay conferral consists of comparisons
between one’s own capacities and feelings and those of others who are either in
good health or who are afflicted with similar or dissimilar problems (cf. the
discussion of typical comparison strategies by Sanders & Kardinal, 1977). Being
surrounded by others who are in better health than oneself can lead to subjective
exaggeration of one's difficulties, whereas seeing that others are doing worse
than oneself can lead to unrealistic optimism about future developments. On the
other hand, comparing unfavorably with others could spur determination to
improve, and favorable comparisons could lift flagging spirits. Aside from sim­
ply observing their relative standing, people can use social comparison with

nonexperts to clarify many uncertainties unique to the recovery phase. Typical

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5. SOCIAL COMPARISON AND ILLNESS

147

problems that can be influenced by lay consultation include: the meaning of
unanticipated side effects or of irregular periods of progress, backsliding, and
status quo; the appropriate timing of the resumption of normal activity and/or
termination of phases of treatment; and the chances of achieving certain results
within a given interval. Answers to these problems can seriously affect the speed

would react to performing normative or deviate acts. Attention should also be
paid to whether the patient’s recovery is being affected by favorable or unfavora­
ble comparisons with the health or progress of others.

and completeness of recovery.
Although the preceding review of potential sources of social comparison
influence is largely speculative and incomplete, it should serve to illustrate the
central point of this section. And that point is that lay consultation is not only
deep in terms of frequency and impact, but it is also broad in that it can, at least
in principle, interact with and possibly affect in crucial ways virtually every
aspect of every phase of the journey from health to illness and back again to

DETERMINANTS
OF COMPARISON INFORMATION

health.

Implications
Laypersons. Decisions relevant to health care are not only affected by delib­
erate consultations with others but also by impressions of how often others
perform particular behaviors, how many others possess certain bodily condi­
tions, and how healthy others are relative to oneself. In turn, these impressions
can influence the attractiveness and probability of health-relevant behavior pat­
terns, the anxiety produced by the appearance of symptoms, and perceptions of
and reactions to one’s rate of recovery. Awareness that perceptions of health and
illness are not strictly a function of one’s actual health, nor even of one’s
conscious attempts to clarify feelings through lay or professional consultation,
may help one achieve a more fully rational consideration of appropriate health

behavior. It may also help one realize that the experience of illness can create a
great amount of uncertainty along a large number of dimensions so that feelings
of confusion and the inability to make independent decisions should not be
viewed as an indication of personal inadequacy or of being at the mercy of
unusually severe and debilitating problems. Those who serve as lay consultants
may be impatient, overwhelmed, or flattered by the steady stream of issues they
are asked to help resolve, but they should try to keep in mind that this can be a
normal part of illness and does not necessarily reflect on either their own
strengths or on the information-seeker’s weaknesses.
Health Care Professionals. The provision of health care will almost cer­
tainly generate at least some uncertainty, and it would be desirable to anticipate
the difficulties, bring them out into the open, and resolve them, rather than
having them resolved by lay consultants or by having patients endure the stress of
confusion. When making recommendations involving the adoption or termina­
tion of specific behaviors, some consideration should be given to the frequency
of these behaviors in the patient’s reference groups as well as to how the patient

Unfortunately, there are no relevant data that would enable us to specify the
relative probability of each of the influences that have been reviewed. Without
knowing how often lay consultants provide particular types of information, it is
impossible to determine the overall harm or good produced by the medical
opinions of nonexperts. As a first step in making such a determination, this
section discusses various pressures acting on consultants to offer or withhold
certain kinds of opinions. Some flavor of the total impact of lay consultation
should emerge, but obviously this cannot substitute for empirical research into
this central issue.
The concept of intuitive theories of illness was discussed earlier (e.g., the
hot-cold theory), and these theories are probably a major determinant of the
content of nonexpert opinions. Opinions resulting from intuitive systems arc also
likely to be particularly influential because the subject’s problems are treated as
exemplars of general and well-established rules, rather than as unique aberrations
that require guesswork and trial-and-error solutions. It is therefore important to
gain some empirical insight into the prevalence of such intuitive systems, their
scope and depth in terms of the range of problems they typically address, and
their general tendency to complement or interfere with professional treatment.

One speculation can be hazarded at this point, however. The more coherent and

comprehensive the theory and the more firmly embedded it is within a culture or
community, the less likely it is to interfere seriously with the mantenance or
restoration of good health. Such theories must have a considerable grounding in
observation and experience and thus could not easily advocate policies with
obviously undersirable consequences. If home remedies, for example, were
markedly inferior to professional treatment, this difference would eventually be
noticed and incorporated into the theory. From this viewpoint, it would appear
that people are in greater danger of receiving harmful information when consult­
ing about very unusual problems that cannot be placed in the domain of an
established intuitive theory.
A related source of lay opinions is the set of attitudes specified by the Health
Belief Model (cf. Becker, 1974). This set includes estimates of the susceptibility
of various individuals to various problems, the severity of consequences pro­
duced by the problems, and the benefits and drawbacks of specific courses of
action. The general effect of these attitudes is to tailor general theories to particu­
lar cases. Thus, it might be believed that in general sweating in a cold breeze will

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induce a fever, but that Joe or Betty will violate this rule owing to idiosyncratic
characteristics, or that heat is a good cure for sore throats, but that Joe or Betty
will experience dangerous side effects. These attitudes should serve to reduce the
possibility of dangerous lay opinions further if it is assumed that, just as intuitive
theories reflect general experience, health belief attitudes will usually be
grounded in individual experience. However, as the individual yields a smaller
number of observations than a collectivity, the possibility of erroneous conclu­
sions is probably greater for specific health beliefs than for comprehensive gener­
al theories.
One final and even more specific source of nonexpert medical opinions is
generalization from a single experience. For example, if a certain diet was
followed by the disappearance of a stiff back, the same diet might be recom­
mended for a stiff elbow; if a specialist was successful in controlling a migraine
headache, a visit to that individual might be recommended for any complaint
involving stress; if a broken toe heeled without a cast, someone with a broken
arm might be dissuaded from following the doctor’s recommendation of a cast;
and so forth. Because such opinions are based on a single observation and
because even slight changes in circumstances can seriously alter the impact of a
given behavior, generalization probably represents the most potentially dan­
gerous source of lay medical opinions.
There are a number of factors that may modify the tendency to express
opinions solely on the basis of intuitive theories, health beliefs, and generaliza­
tion. As discussed earlier, lay consultants are somewhat free of responsibility
from the consequences of their information owing to the complexity of medical
processes and the absence of control groups not exposed to their opinions.
However, certain opinions are safer than others. This is particularly true of
sentiments that professional advice should be sought or heeded. Even if negative
consequences follow from seeing physicians and adhering to their prescriptions,
the lay consultant who favored these actions can escape responsibility by placing
it on the shoulders of the professionals. In contrast, if a suggested home remedy
backfires or if advice to discontinue treatment results in a relapse, it is much
more difficult for the consultant to avoid the feeling of contributing to those
problems. Thus, rather than a random distribution of the contents of nonexpert
information, a bias in favor of placing and maintaining people in the hands of
professionals might be expected. Geertsen et al. (1975) found that the presence
of a strong family authority figure or a network of close friends, both of which
should increase the use and impact of lay consultation, has the effect of increas­
ing an individual's use of professional health care facilities. This observation
supports the idea that nonexpert opinions tend to be biased in favor of seeking
and heeding professional advice. Similarly, Cobwin and Pope (1974) reported
that the number and intensity of one’s friendships were both positively related to
the incidence of preventive vaccinations and medical and dental checkups. Fur­
thermore, Davis and Eichom (1963) found that 50% of those who indicated they

5. SOCIAL COMPARISON AND ILLNESS

149

were strongly influenced by lay consultation complied with a cardiac recovery
regimen, whereas only 34% of those who rejected lay opinions complied with the
regimen. Again, it seems that lay consultants tend to channel people into the
formal medical system. In two more illustrations of this tendency, Suchman
(1965) reported that 54% of the consultants presented with symptoms recom­
mended seeing a doctor, and Apple (1960) found that if a nonexpert felt a person
was ill, a doctor visit was urged in 81% of the cases. Interestingly, Apple also
noted that professional care was suggested more often if the symptoms were
unfamiliar to the lay consultant. Unfamiliar symptoms should reduce the ap­
plicability of intuitive theories, health beliefs, and generalization, and therefore
should increase the pressure to avoid responsibility by advising doctor visits.
A rather different bias in the content of social comparison information is
related to the concept of role interference, discussed earlier. At least in contem­
porary American culture, there seems to be a tendency to encourage action only
when medical difficulties impair the performance of normal functions (i.e., if
one cannot operate effectively in social or work roles because of the problem).
Apple (1960) found that the tendency of symptoms to interfere with role behavior
was the major determinant of whether the symptoms were viewed as constituting
medical problems and that role-interference symptoms were 50% more likely to
elicit the recommendation of some action from lay consultants. Additionally,
Amarasingham (1980) observed that it is commonly believed that medicine
should only be taken for as long as one feels sick, with sickness in turn determin­
ed largely by role interference. Friedson (1961) also concluded that nonexperts
will tend to react to noninterfering complaints as part of one’s normal ups and
downs and discourage remedial action as well (see also Hartley, 1961, for a
developmental perspective on this issue). Although more extensive data are
needed, it may be tentatively concluded that lay consultants will tend to resolve
medically related uncertainties by minimizing the need for concern or action if
the subject is capable of pursuing normal activities. Furthermore, the results of
Miller’s (1973) study suggests that when action is recommended for noninterfer­
ing complaints, lay opinions are much more likely to favor home remedies and
monitoring than the aforementioned tendency to channel people into the profes­
sional health care system.

Two more influences shaping the content of nonexpert opinions may be
tentatively advanced. First, Twaddle (1969) noted that when people are for­
mally, officially under the care of a professional, their reliance on lay consultants
is markedly diminished. Similarly, observations by Skipper, Tagliacozzo, and

Mauksch (1967) and by Wortman and Dunkel-Schetter (1979) indicate that hos­
pitalized patients feel frustrated in attempts to clarify their situation through
discussions with both experts and nonexperts. Although there are probably a
number of valid explanations for this reduction, one likely possibility is that lay
consultants feel uncomfortable about expressing their true opinions to people
whose problems are sufficiently intense to require professional care. This dis­

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5.

SOCIAL COMPARISON AND ILLNESS

151

comfort, in turn, could arise from the ambivalence created by a confrontation
with others' serious problems. On the one hand, there is a desire to offer sympa­

unpleasant problems, and to raise threatening possibilities may all interact with
these idiosyncratic contents of comparison information in complex and unknown

thy and encouragement, which may be irrelevant to the patient’s current con­
cerns. At the same time, there is a tendency to avoid discussing clearly unpleas­
ant topics, partly out of fear that they will aggravate the patient’s condition and
partly because they are depressing and upsetting to the consultants themselves.
The result of this ambivalence would be a suppression of true feelings, mixed
messages of encouragement and aversion to the patient, and/or a total avoidance
of illness-related discussion (cf. Wortman & Dunkel-Schetter, 1979). None of
these tendencies would provide the patient with very confident or useful opin­
ions. In short, lay consultants may be willing to expound calmly and infor­
matively on what a functioning colleague should do about unusual lumps or what
a patient in remission should do to prevent a relapse, but when faced with the
emotional concerns of people who are clearly suffering or frightened, half­
hearted and ambiguous opinions are more likely to be the bill of fare.
A second and final speculation on the forces shaping nonexperts’ opinions
arises from a study by Campbell (1975). He found that mothers had a tendency to
see symptoms as being more serious if they appeared in their children than if they
were manifest in the mothers themselves. Again, there is a variety of plausible
explanations for what Campbell termed an "attributional double standard," but
one intriguing possibility is that subjects are motivated to suppress the threaten­
ing implications of their medical uncertainties, whereas observers/consultants are
more likely to respond objectively. For example, unusual lumps may be dis­
counted by a subject who is unconsciously fearful of cancer, whereas a lay
consultant would feel remiss in not at least suggesting the possibility of malig­
nancy; the difficulties of breaking off a long relationship and finding a new
physician may lead a subject to accept the competence of professional advice,
whereas a consultant would be more apt to raise questions; and a subject may try
to avoid thinking of the pain involved in a treatment program, whereas the
negative overtones likely to surface in a consultant’s reactions may force a
consideration of this factor. On an overall basis, then, the opinions of lay consul­
tants may be likely to emphasize negative possibilities avoided by the subject
because of the threat they pose to the self. Although this proposed tendency of
lay consultants to emphasize the threatening aspects of medical uncertainty could
have diverse effects, it would almost certainly help clarify the subject’s feelings
by bringing covert fears into the open where they can at least potentially be
resolved.
In summary, the content of nonexperts' opinions is probably determined
primarily by idiosyncratic, intuitive medical theories, health beliefs, and general­
izations (which are probably least, more, and most potentially misleading, re­
spectively). In addition, general pressures to place and maintain subjects in the
professional health care system, to encourage action only when role interference
occurs, to offer unsatisfactory information when faced with clearly serious and

ways. To be sure, much of the discussion in this section has been speculative,
and it is best viewed as a guide for empirical research rather than a definitive
statement of the issues. However, two implications of this review seem basically
sound. First, the number of forces shaping the content of lay opinions, as well as
the diversity of these forces, is probably sufficiently large to insure that subjects
stand a good chance or being exposed to a range of information reaching from
greatly beneficial through innocuous to lethal. Second, the factors that have been
reviewed do not point to the lay conferral system as a necessarily inept or
undesirable institution but rather allow for the possibility that it does more good
than harm. Given the frequency and impact of lay consultation, this is a comfort­
ing thought that invites an empirical test. On an even more global level, Hessler
et al. (1971) found that a high level of social interaction, which could reflect a
large amount of lay consultation, was negatively associated with both physical
and psychological disorders. Of course, interpretation of these findings is im­
paired by the presence of many confounding factors and the use of a correlational
design. However, such results encourage follow-up research using longitudinal
methods and clear measures of the frequency and content of nonexpert
information.

Implications
Laypersons. People should be careful, when giving or receiving comparison
information, to avoid placing too much emphasis on the subject’s ability or
inability to perform normal functions. Although the origins of this role inter­
ference bias are open to speculation, it seems clear that there is no necessary
relationship between the seriousness of medical problems and the extent to which
they inhibit routine behaviors (e.g., the “innocuous” first signs of head and
neck cancer). Similar caution should be exercised against the tendency to use
generalization as a guide for action because superficially similar cases may differ
in subtle but critical ways. Patients in serious or unpleasant conditions may
benefit from knowing that their inability to obtain useful comparison information
from lay consultants does not necessarily reflect on the poor quality of their
relationships or on the hopelessness of their case; rather it is a common problem
caused by ambivalent feelings on the part of the consultants. In turn, the consul­
tants themselves would do well to realize that their reluctance to express their
true opinions freely comes at a time when patients are most in need of discussion
and clarification and that the patient’s inability to have a meaningful exchange of
opinions can be more stressful than anything the consultants might have to say.
Health Care Professionals. Lay consultation has the potential to reinforce
and supplement the professional’s concerns and goals beneficially. It would

152

SANDERS

therefore be wise not to discourage the receipt of lay opinions automatically, but
instead to determine the content of such opinions first to see if they are or can be
helpful. Second, if it is known that some generalizations are particularly mislead­
ing (e.g., if treating a broken arm like a broken toe would be dangerous), special
care should be taken to advise clients against such reasoning. Third, the tendency
of lay consultants to discourage action if the subject is able to function in normal
work and social roles requires special vigilance in administering preventative or
recovery programs under these conditions. Finally, patients who are in serious
condition and under the professional's direct care may be frustrated in their
customary attempts to clarify their condition via lay consultation, so it is es­
pecially important for professionals to address and resolve uncertainties in these
stages of illness.

IMPLICATIONS OF LAY CONSULTATION
FOR HEALTH CARE MODIFICATION
Thus far, we have been exploring the issue of nonexpert medical information as a
world unto itself, isolated from other pressures and concerns inherent in health
care behavior. In this concluding section, attention is focused on some examples
of how lay consultation might affect the success of deliberate attempts to im­
prove people’s health through prediction or modification of their behavior.
A good starting point for this discussion is provided by the Health Belief
Model (HBM). As was mentioned in the preceding section, the HBM describes
an interrelated set of beliefs about an individual’s need for professional care
together with the costs and benefits associated with such care. This model was
formulated in order to facilitate predictions about the likelihood that a person will
participate in preventive programs and/or adhere to professionals’ suggestions.
In turn, good predictive power would allow professionals to concentrate and
expand their influence on those targets whose beliefs are likely to interfere with
their health. Although the HBM has often successfully predicted relevant behav­
ior, the overall associations are rather weak (correlations of less than. 14 are
typical), and there have been almost as many complete failures as successes
(e.g., Haynes, Taylor, Snow, & Sackett, 1979, Table 5). Furthermore, in most
cases of successful “prediction” the correlational methods have left open the
possibility that the behavior caused the attitudes, not vice versa. Although there
are many possible sources of the HBM’s weakness (e.g., the generally unreliable
casual link between attitudes and behavior, cf. Wicker, 1969), the influence of
lay consultation is a likely contributor. The idea here is that health beliefs may
predict relevant behavior, but those beliefs are likely to change as a result of
nonexpert comparison information. That is, as the subject progresses through an
illness experience, uncertainties may be resolved by lay consultation in such a
way that the subject’s original health beliefs are altered. Any attempt, then, to

5.

SOCIAL COMPARISON AND ILLNESS

153

use the HBM as a predictive device should determine that the attitudes used to
make the prediction are still held by the subject when the relevant behavior is
measured. An illustration of this principle is provided by Taylor's study, de­
scribed by Becker, Maiman, Kirscht, Haefner, Drachman, and Taylor (1979).
He found that when beliefs about the seriousness of hypertension and the safety
of combative drugs were measured prior to being diagnosed as hypertensive,
these beliefs failed to predict pill-taking compliance. However, the same atti­
tudes were successful predictors if they were measured 6 months after diagnosis.
This clearly suggests that the experience of illness results in a modification of
health beliefs. Lay consultants, in turn, are a probable source of such
modification.
A second approach to controlling health behavior that should be affected by
nonexpert information is the attempt to induce rational decisions by providing
objective medical information. The highly publicized seven warning signs of
cancer represent one such attempt to offer reliable information as a basis for
health behavior. To the extent such information is seen as being an objective
description (i.e., a true statement of reality), this approach should theoretically
eliminate the influence of lay consultation. Festinger’s theory of social compari­
son (1954) proposed that people would not use comparisons with others to clarify
their uncertainties if an objective basis for evaluation was available (Hypothesis
Il and Corollary II B). This position implies that if people were given an objec­
tive basis for health care decisions, such as whether to see a doctor or whether to
continue treatment, lay consultants would have relatively little input. However,
the existence of substantial interference with the persuasive impact of objective
information is indicated by the frequently observed failure of this approach to
affect compliance with remedial or preventive regimens (e.g., Haynes et al.,
1979, Table 5; Schmidt, 1977). That is, given clear and abundant information
about the nature of their problems and the costs and benefits of compliance,
patients are more likely than not to ignore or discount this objective knowledge.
A possible explanation is that, despite Festinger’s propositions, lay consultation
continues to be influential when contrasted with objective information, and per­
haps the former is even more influential than the latter.
As a preliminary exploration of this possibility, 1 had subjects role-play the
development of symptoms and then gave them both objective and social com­
parison information relevant to the need to see a doctor (Sanders, in press). It
was found that if the objective information suggested that a doctor should be
consulted, the effect of comparison opinions to the contrary (i.e., not to go) was
completely eliminated, as hypothesized by Festinger. On the other hand, if the
objective information suggested there was no need for alarm, the effect of con­
trary comparison opinions (i.e., to see a doctor) remained at full strength. For
whatever reasons, subjects were much more willing to believe that an objective
test could "prove” that they were ill than that they were healthy, relying in the
latter case on the opinions of nonexperts. In general terms, these results suggest

154

SANDERS

that objective information does not automatically rule out the use and impact of
lay consultation. Research into the conditions under which objective information
is successful in overriding social comparison information should help to pinpoint
areas where health education programs will be most effective.
One final example of the interaction of lay consultation with health modifica­
tion efforts involves the use of social support groups to ease the burdens of
chronic illness and to hasten recovery from acute episodes (cf. Kaplan, Cassel, &
Gore, 1977, for background on the social support concept). The basic approach
here is to enlist the involvement of family, friends, or other patients in the
subject’s problems and coping efforts. It is hoped that these support groups can
offer numerous benefits to the subject, such as bringing disturbing fears into the
open and dispelling or minimizing them, offering sympathy and encouragement,
performing chores that are stressful or that interfere with treatment requirements,
and serving as calm and effective models that generally set a good example for
the subject to follow. Despite all these potential benefits, however, the one
extensive attempt to improve health via support groups has yielded rather nega­
tive results (Caplan, Robinson, French, Caldwell, & Shinn, 1976). These inves­
tigators divided patients receiving hypertension medication into three groups:
Control, in which normal therapist/patient relationships were unmodified; Lec­
ture, in which patients attended four 1-hour presentations on the nature of high
blood pressure and its treatment; and Social Support, in which the lectures were
supplemented by the joint participation of family and friends of each patient and
a group-dynamics expert was present to supervise various discussions and role­
playing exercises designed to encourage the exchange of socioemotional support.
It was found that both the Lecture and Social Support groups surpassed the
Control group in both the motivation to adhere to regimens and in the actual
adherence, as well as in subjects’ satisfaction with efforts being made on their
behalf. The surprising result was that the Social Support treatment not only failed
to improve upon the gains made by the Lecture treatment, but it was actually
somewhat, and on occasion significantly, less effective. For example, subjects
felt that others’ concern was less helpful, that they received less tangible support,
and that their medical information was less adequate if they were in a Social
Support group than if they just heard the lectures. Thus, the attempt to involve
others actively in the patient’s problems only served to disrupt the positive effect
of objective information mildly. Several reasons for the failure of social support
to be truly supportive are discussed by Wortman and Dunkel-Schetter (1979). All
of these reasons basically specify ways in which unwanted and/or disturbing
comparison information can be supplied by lay consultants. It seems clear that
increasing social support will also increase the frequency and impact of nonex­
pert opinions. As discussed in an earlier section on the possible influences of
such opinions, it is quite possible, though not necessary, for these opinions to
counter or even reverse the beneficial aspects of social support. Therefore, it is
important to determine what kind of comparison information is likely to result

5.

SOCIAL COMPARISON AND ILLNESS

155

from the introduction of social support. For example, in the particular situation
studied by Caplan et al. (1976), hypertension did not significantly interfere with

normal functions. As discussed earlier, lay consultants are biased in the direction
of recommending inaction in the absence of role interference. Thus, most par
tients may have been told by their social support groups that preventive efforts
were not necessary, resulting in the failure of social support to improve ad­
herence despite the groups’ potential benefits.
These three examples should suffice to illustrate the general point that the
operation of the lay conferral system can often interact with and impair the
effectiveness of attempts to predict or modify health behavior. As further re­
search clarifies the frequency, impact, and content of comparison information in
various situations, it should be possible to design health care programs that either
neutralize the influence of lay consultation or that use its influence to their own
advantage.

SUMMARY
It is very common for people to seek and heed the opinions of nonexperts in
clarifying uncertainties and taking actions relevant to health and illness. Al­
though it is surprising that uninformed medical advice would be sought or of­
fered, this practice has a solid basis in people’s experiences, attitudes, and goals.
Despite the overall frequency and impact of lay consultation, numerous sources
of variation in its magnitude can be identified. The lay conferral system is
likewise variable in terms of the types of influence it can exert as the subject
moves from health to illness and back again to health. General sources of the
content of nonexpert opinions can be specified, together with certain biases that
help shape these opinions, but little is known about the relative or absolute
frequency of specific types of information. Nonetheless, it seems clear that lay
opinions can be beneficial despite their lack of expertise, and this may be the
case more often than not. Finally, it is important for designers of health care
modification programs to anticipate how lay consultation will interact with their
efforts and, when possible, to incorporate it into their procedures.

REFERENCES
Amarasingham, L. R. Social and cultural perspectives on medication refusal. American Journal of
Psychiatry, 1980. 137, 353-358.
Antonovsky, A. A model to explain visits to the doctor: With special reference to the case of Israel.
Journal of Health and Social Behavior. 1972, 13. 446-454.
Apple, D. How laymen define illness. Journal of Health and Human Behavior, 1960, 1, 219-228.
Becker, M. H. (Ed.). The health belief model and personal health behavior. Health Education
Monographs. 1974, 2. 324-473.

156

SANDERS

Becker, M. H.. Maiman, L. A., Kirscht, J. P.» Haefner, D. P., Drachman, R. H., & Taylor, D.
W. Patient perceptions and compliance: Recent studies of the health belief model. In R. Haynes,
D. Taylor, & D. Sackett, (Eds.), Compliance in health care. Baltimore, Md.: Johns Hopkins
University Press. 1979.
Campbell, J. D.- Attribution of illness: Another double standard. Journal of Health and Social
Behavior, 1975, 16, 114-126.
Caplan, R. D., Robinson, E. A., French, J. P., Caldwell, J. R., & Shinn, M. Adhering to medical
regimens: Pilot experiments in patient education and social support. Ann Arbor, Mich.: Institute
for Social Research, 1976.
Carver, C. S., & Glass, D. C. The self-consciousness scale: A discriminant validity study. Journal
of Personality Assessment, 1976. 40. 169-172.
Cobwin, D., & Pope, L. R. Socioeconomic status and preventive health behavior. Journal ofHealth
and Social Behavior, 1974, 15, 67-78.
Davis, M. S., & Eichom, R. L. Compliance with medical regimens: A panel study. Journal of
Health and Human Behavior, 1963, 4. 240-249.
Elder, R. Social class and illness behavior in response to symptoms of a common chronic disease,
osteorarthritis. Unpublished doctoral dissertation, Yale University, 1968.
Festinger, L. A theory of social comparison processes. Human Relations. 1954, /, 117-140.
Fillenbaum. G. G. Social context and self assessments of health among the elderly. Journal of
Health and Social Behavior, 1979, 20, 45-51.
Friedman, M., & Rosenman, R. H. Type A behavior and your heart. Greenwich, Conn.: Fawcett,
1974.
Friedson, E. Patients' view of medical practice. New York: Russell Sage Foundation, 1961.
Geertsen, R., Klauber. M. R.. Rindflesh, M., Kane, R., & Gray, R. A re-examination of Suchman’s views on social factors in health care utilization. Journal of Health and Social Behavior,
1975, 16. 226-231.
Goethals, G. R., Darley, J. M. Social comparison theory: An attributional approach. In J. Suls, &
R. Miller (Eds.), Social comparison processes: Theoretical and empirical perspectives. Wash­
ington, D.C.: Hemisphere. 1977.
Hartley, E. L. Determinants of health beliefs and behavior. American Journal of Public Health,
1961.5/, 1541-1547.
Harwood, A. The hot-cold theory of disease: Implications for treatment of Puerto Rican patients.
Journal of the American Medical Association, 1971, 2/6. 1153-1158.
Haynes, R. B.. Taylor, D. W., Snow, J. C., & Sackett, D. L. Annotated and indexed bibliography
on compliance with therapeutic and preventive regimens. In R. Haynes, D. W. Taylor, & D. L.
Sackett (Eds.), Compliance in health care. Baltimore, Md.; Johns Hopkins University Press,
1979.
Heinzelmann, F., & Bagley, R. Responses to physical activity programs and their effects on health
behavior. Public Health Reports. 1970. 85. 905-911.
Hessler. R. M.. Kubish, P., Kong-Ming, N. P., Ellison, D. L., & Taylor, F. H. Demographic
context, social interaction and perceived health status: Excedrin headache # 1. Journal of Health
and Social Behavior, 1971, 12, 191-199.
Jourard, S. M. The transparent self. Princeton, N.J.: Van Nostrand Reinhold, 1964.
Kaplan, B. H., Cassel, J. C., & Gore, S. Social support and health. Medical Care, 1977,15, 47-64.
Miller. M. H. Seeking advice for cancer symptoms. American Journal of Public Health, 1973, 63,
955-961.
Mullen, B., & Suls, S. ' ’Know thyself'': Stressful life changes and the ameliorative effect ofprivate
self-consciousness. Unpublished manuscript. SUNY/Albany, 1980.
Osterweis, M., Bush, P., & Zuckerman, A. Family context as a predictor of individual medicine
use. Social Science and Medicine: Medical Psychology and Medical Sociology, 1979, 13A,
287-291.

5.

SOCIAL COMPARISON AND ILLNESS

157

Parsons, T. Definitions of health and illness in light of American values and social structure. In E.
G. Jaco, (Ed.), Patients, physicians and illness. New York: Free Press, 1958.
Rotter, J. B. Generalized expectancies for internal versus external control of reinforcement. Psycho­
logical Monographs. 1966, 80, (Whole no. 609).
Sanders, G. S. Social comparison with similar others as an influence on health care decisions.
Unpublished manuscript. SUNY/Albany, 1980.
Sanders, G. S. The interactive effect of social comparison and objective information on the decision
to see a doctor. Journal of Applied Social Psychology, in press.
Sanders, J. B., & Kardinal, C. G. Adaptive coping mechanisms in adult acute leukemia patients in
remission. Journal of the American Medical Association, 1977, 238, 952-954.
Scheier, M. F. The effects of public and private self-consciousness on the public expression of
personal beliefs. Journal of Personality and Social Psychology. 1980, 39, 514-521.
Schmidt, D. D. Patient compliance: The effect of the doctor as a therapeutic agent. Journal of
Family Practice. 1977, 4, 853-856.
Skipper, J., Tagliacozzo, D. M., & Mauksch, H. D. Some possible consequences of limited com­
munication between patients and hospital functionaries. Journal of Health and Social Behavior,
1967, 8. 33-44.
Suchman, E. A. Stages of illness and medical care. Journal of Health and Social Behavior.
10. 105-114.
Suls, J., & Miller, R. (Eds.). Social comparison processes: Theoretical and empirical perspectives.
Washington, D.C.: Hemisphere. 1977.
Tcsser, A., & Rosen, S. The reluctance to transmit bad news. In L. Berkowitz (Ed.), Advances in
experimental social psychology (Vol. 8). New York: Academic Press, 1975.
Twaddle, A. C. Health decisions and sick role variations: An exploration. Journal of Health and
Social Behavior. 1969. 10. 105-114.
Wallston, B. S., Wallston, K. A., Kaplan, G., & Maides, S. Development and validation of the
health related locus of control (HLC) scale. Journal of Consulting and Clinical Psychology.
1976, 44. 580-585.
Wicker, A. W. Attitudes versus actions: The relationship of verbal and overt behavioral responses to
attitude objects. Journal of Social Issues. 1969, 25, 41-78.
Wortman, C. B., & Dunkel-Schetter, C. Interpersonal relationships and cancer A theoretical analy­
sis. Journal of Social Issues, 1979, 35, 120-154.
Zola, I. Pathways to the doctor: From person to patient. Social Science and Medicine, 1973, 7,
677-689.

! ___ ^“7
What determines behaviour:
back to theory

Martine Collumbien

Objectives
o Understand multiple levels of
influence on behaviour
o Learn more on individual,
interpersonal and community level
theories of behaviour change
o Understand some key
concepts/constructs and their
practical application in health
interventions

3

f

A

Ecological perspective
individual

Change people

reciprocal causation
interpersonal
between individuals
and their environments

Change environment

community

Individual-oriented theories / models
Stages of change

Health belief model

' Individual's
readiness to
change towards
more healthy
behaviour

focus

Persons' perception
of the threat of a
health problem and
the appraisal of
recommended
behaviour to
prevent or manage
problem

4

Key concepts in stages of change
Key Concept Definition____________________
Pre­
contemplation
Contemplation

unaware of the problem, has not thought
about change

Decision/
Determination
Action

making a plan to change - preparing

Maintenance

I continue desired actions, repeating

thinking about change

implement a specific action plan

1 recommended steps

Application of key concepts in stages of
change
Key Concept Application
Pre­
contemplation
Contemplation

increase awareness of need for change,
personalise information on risks and benefits

Decision/
Determination
Action

assist in developing concrete action plans,
setting appropriate goals

Maintenance

assist in coping, reminders, finding
alternatives, avoiding relapses

motivate and encourage to make specific
plans

assist with feedback, problem solving, social
support, reinforcement

Key concepts in health belief model
Key Concept 1 Definition ________________
perceived
susceptibility
perceived
severity
readiness \
perceived
to act
benefits
perceived
< barriers
cues to action

self-efficacy

chances of getting a condition (eg.
STI)__________________________
opinion of how serious an STI and
its sequelae are_________________
opinion on how effective condoms
are to reduce risk getting STI_____
opinion of psychological/tangible
cost of using condom
strategies to activate 'readiness'
confidence in one's ability to act

Application of key concepts in HBM
Key Concept

Application of concepts

perceived
susceptibility
perceived
severity
perceived
benefits
perceived
barriers
cues to action

personalise risk based on person's
features/ behaviour, heighten suscept...

self-efficacy

provide training In performing action

specify consequences of risk and the
condition
define action to take: how, where, when
- clarify positive effects

identify and reduce through
reassurance, incentives, assistance
provide how to information, promote
awareness, reminders

6

Interpersonal level: Social Learning
Theory (social cognitive theory)
human behaviour is explained in terms of
a three-way, dynamic, reciprocal theory
in which personal factors, environmental
influences and behaviour continually

focus

interact
addresses
psychosocial factors that influence behaviour
» strategies to promote behaviour change

o

Key concepts in social learning\ieory
\
\
Key Concept Definition
Reciprocal
determinism
Behavioural
capability
Expectations

change is bidirectional - results from \
interaction
\

Self-efficacy

confidence in at>H|ty to take and persist in
action
\

knowledge and skill to influence behaviour^
beliefs abouL|lkely results of action

Observational beliefs based on obsen/lng other like self
learning______ and/or visible results \
Reinforcement responses to a person's behaviour that
increase or Increase chance'qf recurrence

7

8

Key concepts in community organisation
Key
Concept

Definition

Empowerment

process of gaining mastery and power over
oneself/ one's community, to produce change

Community
competence
Participation
and relevance
Issue
selection
Critical
consciousness

community's ability to engage in effective
problem solving

learners should be active participants and
work "start where the people are"
identifying winnable, simple, specific
concerns as focus for action
developing understanding of root causes of
problems

Applications otkey concepts in
community organisation
Key Concept

Application

Empowerment

give individuals and communities tools and
responsibility for making decisions that affect
them

Community
competence
Participation
and relevance

work with community to identify problems;
create consensus and reach goals

Issue
selection

assist community in examining how they can
communicate the concerns, and whether
success is likely

Critical
consciousness

guide consideration of health concerns in broad
perspective of social problems

help community set goals within the context of
pre-existing goals and encourage active
participation

-

Key concepts in organisational change
Key Concept

Definition

Problem definition
(awareness stage)
Initiation of action
(adoption stage)

problems recognised and analysed;
solutions sought and evaluated

Implementation of
change
Institutionalisation
of change

innovation is implemented, reactions
occur, role changes occur

policy and directive formulated;
resources for beginning change
allocated

policy or programme becomes
entrenched in the organisation; new
goals and values are internalised

Application of key concepts in
organisational change
Key Concept

Application

Problem definition
(awareness stage)

involve management and other
personnel In awareness-raising
activities

Initiation of action
(adoption stage)

provide process consultation to inform
decision makers and Implemented of
what adoption involves

Implementation of
change
Institutionalisation
of change

provide training, technical assistance
and problem-solving aid
Identify high-level champion, work to
overcome obstacles to
institutionalisation and create
structures for integration

io

Key concepts in Diffusion of
Innovations
Characteristics of innovations can improve the
chances they will get adopted and diffused

A
m
■ 4

Key
Concept

Definition

Relative
advantage

degree to which innovation is better (more
convenient, prestigious, satisfying) than the
practice it replaces

Compatibility

how consistent is innovation with values, past
experiences and needs of the potential adopters

Complexity

how difficult is innovation to understand or use

Triability

extent to which the innovation can be
experimented with before a commitment to
adopt is required

Observability

extent to which innovation provides tangible
and visible results

Application of key concepts in Diffusion
of Innovations
-------------------------------------------------------Key Concept Application
Relative
advantage

point out unique benefits: convenience, time
saving, prestige

Compatibility

tailor innovation for the intended audience's
values, norms and situations

Complexity

create idea/product to be uncomplicated, easy
to use and understand

Triability

provide opportunities to try: free samples,
money back guarantee

Observability

assure visibility of result: feedback or publicity

Communication channel: two-step flow of communications in
which opinion leaders mediate the impact of the mass-media
and emphasize value of social networks and interpersonal
channels for adoption decision

11

How to use theory and constructs
o Look at the focus of what the theory
addresses
o Choose determinants/constructs/
key concepts that are relevant to
your context
o Look at the practical application for
influencing that determinant
through your intervention strategies

How to use theory and constructs
o Do not limit yourself to one theory!
o Pick and choose according to your BDI
model and your constraints
o Your NGO may not be able to change all
the concepts/ determinants in one theory,
and not all constructs are going to be
equally relevant
o Strategists at state level - see that all
important barriers to behaviour change
are identified and addressed by
coordinating different interventions

12

Recap on how and why to use theories
o Theories as focal points for needs
assessment and problem diagnoses and
to identify points of intervention at
different levels
o Theories as reference to design
intervention strategies and messages
o They identify the assumptions behind
intervention strategies and pinpoint
intermediate steps to be assessed in
evaluation
o We cannot substitute theory for planning
and research

13

pH-I
World Conference on
Social Determinants of Health

World Health
^^Organization

RIO DE JANEIRO | BRAZIL | 19-21 OCTOBER 2011

All for Equity

Rio Political Declaration on Social Determinants of Health
Rio de Janeiro, Brazil, 21 October 2011

1.
Invited by the World Health Organization, we, Heads of Government, Ministers and government
representatives came together on the 21st day of October 2011 in Rio de Janeiro to express our
determination to achieve social and health equity through action on social determinants of health and
well-being by a comprehensive intersectoral approach.
2.
We understand that health equity is a shared responsibility and requires the engagement of all
sectors of government, of all segments of society, and of all members of the international community, in an
"all for equity" and "health for all" global action.
3.
We underscore the principles and provisions set out in the World Health Organization
Constitution and in the 1978 Declaration of Alma-Ata as well as in the 1986 Ottawa Charter and in the
series of international health promotion conferences, which reaffirmed the essential value of equity in
health and recognized that "the enjoyment of the highest attainable standard of health is one of the
fundamental rights of every human being without distinction of race, religion, political belief, economic or
social condition". We recognize that governments have a responsibility for the health of their peoples,
which can be fulfilled only by the provision of adequate health and social measures and that national
efforts need to be supported by an enabling international environment.
4.
We reaffirm that health inequities within and between countries are politically, socially and
economically unacceptable, as well as unfair and largely avoidable, and that the promotion of health
equity is essential to sustainable development and to a better quality of life and well-being for all, which in
turn can contribute to peace and security.
5.
We reiterate our determination to take action on social determinants of health as collectively
agreed by the World Health Assembly and reflected in resolution WHA62.14 ("Reducing health inequities
through action on the social determinants of health"), which notes the three overarching
recommendations of the Commission on Social Determinants of Health: to improve daily living conditions;
to tackle the inequitable distribution of power, money and resources; and to measure and understand the
problem and assess the impact of action.

2

6.
Health inequities arise from the societal conditions in which people are born, grow, live, work and
age, referred to as social determinants of health. These include early years' experiences, education,
economic status, employment and decent work, housing and environment, and effective systems of
preventing and treating ill health. We are convinced that action on these determinants, both for
vulnerable groups and the entire population, is essential to create inclusive, equitable, economically
productive and healthy societies. Positioning human health and well-being as one of the key features of
what constitutes a successful, inclusive and fair society in the 21st century is consistent with our
commitment to human rights at national and international levels.

7.
Good health requires a universal, comprehensive, equitable, effective, responsive and accessible
quality health system. But it is also dependent on the involvement of and dialogue with other sectors and
actors, as their performance has significant health impacts. Collaboration in coordinated and intersectoral
policy actions has proven to be effective. Health in All Policies, together with intersectoral cooperation
and action, is one promising approach to enhance accountability in other sectors for health, as well as the
promotion of health equity and more inclusive and productive societies. As collective goals, good health
and well-being for all should be given high priority at local, national, regional and international levels.
8.
We recognize that we need to do more to accelerate progress in addressing the unequal
distribution of health resources as well as conditions damaging to health at all levels. Based on the
experiences shared at this Conference, we express our political will to make health equity a national,
regional and global goal and to address current challenges, such as eradicating hunger and poverty,
ensuring food and nutritional security, access to safe drinking water and sanitation, employment and
decent work and social protection, protecting environments and delivering equitable economic growth,
through resolute action on social determinants of health across all sectors and at all levels. We also
acknowledge that by addressing social determinants we can contribute to the achievement of the
Millennium Development Goals.
9.
The current global economic and financial crisis urgently requires the adoption of actions to
reduce increasing health inequities and prevent worsening of living conditions and the deterioration of
universal health care and social protection systems.

10.
We acknowledge that action on social determinants of health is called for both within countries
and at the global level. We underscore that increasing the ability of global actors, through better global
governance, promotion of international cooperation and development, participation in policy-making and
monitoring progress, is essential to contribute to national and local efforts on social determinants of
health. Action on social determinants of health should be adapted to the national and sub-national
contexts of individual countries and regions to take into account different social, cultural and economic
systems. Evidence from research and experiences in implementing policies on social determinants of
health, however, shows common features of successful action. There are five key action areas critical to
addressing health inequities: [i] to adopt better governance for health and development; (ii) promote
participation in policy-making and implementation; (iii) to further reorient the health sector towards
reducing health inequities; (iv) to strengthen global governance and collaboration; and (y) to monitor
progress and increase accountability. Action on social determinants of health therefore means that we, the
representatives of Governments, will strive individually and collectively to develop and support policies,
strategies, programmes and action plans, which address social determinants of health, with the support of
the international community, that include:

11.

To adopt better governance for health and development

11.1
Acknowledging that governance to address social determinants involves transparent and
inclusive decision-making processes that give voice to all groups and sectors involved, and develop
policies that perform effectively and reach clear and measurable outcomes, build accountability, and, most
crucially, are fair in both policy development processes and results;

11.2

©

We pledge to:

World Conference on
Social Determinants of Health

Ok®

3

(i)

Work across different sectors and levels of government, including through, as
appropriate, national development strategies, taking into account their contribution to
health and health equity and recognizing the leading role of health ministries for

advocacy in this regard;
Qi)

Qii)

Develop policies that are inclusive and take account of the needs of the entire population
with specific attention to vulnerable groups and high-risk areas;

Support comprehensive programmes of research and surveys to inform policy and
action;

Qv)

Promote awareness, consideration and increased accountability of policy-makers for
impacts of all policies on health;

12.

(v)

Develop approaches, including effective partnerships, to engage other sectors in order to
identify individual and joint roles for improvements in health and reduction of health
inequities;

(vi)

Support all sectors in the development of tools and capacities to address social
determinants of health at national and international levels;

(yii)

Foster collaboration with the private sector, safeguarding against conflict of interests, to
contribute to achieving health through policies and actions on social determinants of
health;

(viii)

Implement resolution WHA62.14, which takes note of the recommendations of the final
report of the Commission on Social Determinants of Health;

Qx)

Strengthen occupational health safety and health protection and their oversight and
encourage the public and private sectors to offer healthy working conditions so as to
contribute to promoting health for all;

(x)

Promote and strengthen universal access to social services and social protection floors;

Cxi)

Give special attention to gender-related aspects as well as early child development in
public policies and social and health services;

(xii)

Promote access to affordable, safe, efficacious and quality medicines, including through
the full implementation of the WHO Global Strategy and Plan of Action on Public Health,
Innovation and Intellectual Property;

(xiii)

Strengthen international cooperation with a view to promoting health equity in all
countries through facilitating transfer on mutually agreed terms of expertise,
technologies and scientific data in the field of social determinants of health, as well as
exchange of good practices for managing intersectoral policy development.

To promote participation in policy-making and implementation

12.1
Acknowledging the importance of participatory processes in policy-making and implementation
for effective governance to act on social determinants of health;

12.2

We pledge to:

World Conference on

®

Social Determinants of Health
RIO DE JANEIRO | BRAZIL | 19-21 OCTOBER 2011

World Health
Organization

13.

(i)

Promote and enhance inclusive and transparent decision-making, implementation and
accountability for health and health governance at all levels, including through enhancing
access to information, access to justice and public participation;

(ii)

Empower the role of communities and strengthen civil society contribution to policymaking and implementation by adopting measures to enable their effective participation
for the public interest in decision-making;

(iii)

Promote inclusive and transparent governance approaches, which engage early with
affected sectors at all levels of governments, as well as support social participation and
involve civil society and the private sector, safeguarding against conflict of interests;

(ivj

Consider the particular social determinants resulting in persistent health inequities for
indigenous people, in the spirit of the United Nations Declaration on the Rights of
Indigenous Peoples, and their specific needs and promote meaningful collaboration with
them in the development and delivery of related policies and programmes;

(v)

Consider the contributions and capacities of civil society to take action in advocacy, social
mobilization and implementation on social determinants of health;

(vij

Promote health equity in all countries particularly through the exchange of good
practices regarding increased participation in policy development and implementation;

(vii)

Promote the full and effective participation of developed and developing countries in the
formulation and implementation of policies and measures to address social determinants
of health at the international level.

To further reorient the health sector towards reducing health inequities

13.1
Acknowledging that accessibility, availability, acceptability, affordability and quality of health care
and public health services are essential to the enjoyment of the highest attainable standard of health, one
of the fundamental rights of every human being, and that the health sector should firmly act to reduce
health inequities;

13.2

We pledge to:
(i)

Maintain and develop effective public health policies which address the social, economic,
environmental and behavioural determinants of health with a particular focus on
reducing health inequities;

(ii)

Strengthen health systems towards the provision of equitable universal coverage and
promote access to high quality, promotive, preventive, curative and rehabilitative health
services throughout the life-cycle, with a particular focus on comprehensive and
integrated primary health care;

(iii)

Build, strengthen and maintain public health capacity, including capacity for intersectoral

action, on social determinants of health;

(iv)

Build, strengthen and maintain health financing and risk pooling systems that prevent
people from becoming impoverished when they seek medical treatment;

me*;ha"isms for supporting and strengthening community initiatives for health
financing and risk pooling systems;

MniTfte
ng6j within the health sector, as appropriate, to provide the capacities and
tools to act to reduce health inequities including through collaborative action;

World Conference on
Social Determinants of Health

All for Equity

«IOD£„»tl«O

OCTOB„!0„

World Health
Organization

5

14.

(vii)

Integrate equity, as a priority within health systems, as well as in the design and delivery
of health services and public health programmes;

(viii)

Reach out and work across and within all levels and sectors of government by promoting
mechanisms for dialogue, problem-solving and health impact assessment with an equity
focus to identify and promote policies, programmes, practices and legislative measures
that may be instrumental for the goal pursued by this Political Declaration and to adapt
or reform those harmful to health and health equity;

(ix)

Exchange good practices and successful experiences with regard to policies, strategies
and measures to further reorient the health sector towards reducing health inequities.

To strengthen global governance and collaboration

14.1
Acknowledging the importance of international cooperation and solidarity for the equitable
benefit of all people and the important role the multilateral organizations have in articulating norms and
guidelines and identifying good practices for supporting actions on social determinants, and in facilitating
access to financial resources and technical cooperation, as well as in reviewing and, where appropriate,
strategically modifying policies and practices that have a negative impact on people's health and well­
being;

14.2

We pledge to:

(i)

Adopt coherent policy approaches that are based on the right to the enjoyment of the
highest attainable standard of health, taking into account the right to development as
referred to, inter alia, by the 1993 Vienna Declaration and Programme of Action, that will
strengthen the focus on social determinants of health, towards achieving the Millennium
Development Goals;

(ii)

Support social protection floors as defined by countries to address their specific needs
and the ongoing work on social protection within the United Nations system, including
the work of the International Labour Organization;

(iii)

Support national governments, international organizations, nongovernmental entities
and others to tackle social determinants of health as well as to strive to ensure that
efforts to advance international development goals and objectives to improve health
equity are mutually supportive;

Civ)

Accelerate the implementation by the State Parties of the WHO Framework Convention
on Tobacco Control [FCTC], recognizing the full range of measures including measures to
reduce consumption and availability, and encourage countries that have not yet done so
to consider acceding to the FCTC as we recognize that substantially reducing tobacco
consumption is an important contribution to addressing social determinants of health

(v)

Take forward the actions set out in the political declaration of the United Nations General
Assembly High-Level Meeting on the Prevention and Control Noncommunicable Diseases
at local, national and international levels - ensuring a focus on reducing health inequities;

fvi)

Support the leading role of the World Health Organization in global health governance,
and in promoting alignment in policies, plans and activities on social determinants of
health with its partner United Nations agencies, development banks and other key
international organizations, including in joint advocacy, and in facilitating access to the

fviil

Support the efforts of governments to promote capacity and establish incentives to
create a sustainable workforce in health and in other fields, especially in areas of greatest

and vice versa;

provision of financial and technical assistance to countries and regions;

need;------------------------------------------------------------------- -------------------------------------------------------------

World Conference on
Social Determinants of Health

RIO DE JANEIRO | BRAZIL | 19-21 OCTOBER 2011
AU for Equity

•

World Health
Organization

6

Cvni)

(ix)

Build capacity of national governments to address social determinants of health by
facilitating expertise and access to resources through appropriate United Nations
agencies’ support, particularly the World Health Organization;

Foster North-South and South-South cooperation in showcasing initiatives, building
capacity and facilitating the transfer of technology on mutually agreed terms for
integrated action on health inequities, in line with national priorities and needs,
including on health services and pharmaceutical production, as appropriate.

15.

To monitor progress and increase accountability

15.1
Acknowledging that monitoring of trends in health inequities and of impacts of actions to tackle
them is critical to achieving meaningful progress, that information systems should facilitate the
establishment of relationships between health outcomes and social stratification variables and that
accountability mechanisms to guide policy-making in all sectors are essential, taking into account
different national contexts;

15.2

We pledge to:

(i)

Establish, strengthen and maintain monitoring systems that provide disaggregated
data to assess inequities in health outcomes as well as in allocations and use of
resources;

(ii)

Develop and implement robust, evidence-based, reliable measures of societal well­
being, building where possible on existing indicators, standards and programmes and
across the social gradient, that go beyond economic growth;

(iii)

To promote research on the relationships between social determinants and health
equity outcomes with a particular focus on evaluation of effectiveness of interventions;

(iv)

Systematically share relevant evidence and trends among different sectors to inform

(v)

Improve access to the results of monitoring and research for all sectors in society;

(vi)

Assess the impacts of policies on health and other societal goals, and take these into

(vii)

Use intersectoral mechanisms such as a Health in All Policies approach for addressing
inequities and social determinants of health; enhance access to justice and ensure

policy and action;

account in policy-making;

accountability, which can be followed up;

(viii)

Support the leading role of the World Health Organization in its collaboration with
other United Nations agencies in strengthening the monitoring of progress in the field
of social determinants of health and in providing guidance and support to Member
States in implementing a Health in All Policies approach to tackling inequities in health;

(ix)

Support the World Health Organization on the follow-up to the recommendations of
the Commission on Information and Accountability for Women's and Children's Health;

(x)

Promote appropriate monitoring systems that take into consideration the role of all
relevant stakeholders including civil society, nongovernmental organizations as well as
the private sector, with appropriate safeguard against conflict of interests, in the

monitoring and evaluation process;

(xi)
Promote health equity in and among countries, monitoring progress at the
________ international level and increasing collective accountability in the field of social

All for Equity

World Conference on
Social Determinants of Health
RIO DE JANEIRO I BRAZIL j 19-21 OCTOBER JOI I

World Health
Organization

7

determinants of health, particularly through the exchange of good practices in this
field;
(xii)

16.

Improve universal access to and use of inclusive information technologies and
innovation in key social determinants of health.

Call for global action

16.1
We, Heads of Government, Ministers and government representatives, solemnly reaffirm our
resolve to take action on social determinants of health to create vibrant, inclusive, equitable, economically
productive and healthy societies, and to overcome national, regional and global challenges to sustainable
development We offer our solid support for these common objectives and our determination to achieve
them.

16.2
We call upon the World Health Organization, United Nations agencies and other international
organizations to advocate for, coordinate and collaborate with us in the implementation of these actions.
We recognize that global action on social determinants will need increased capacity and knowledge within
the World Health Organization and other multilateral organizations for the development and sharing of
norms, standards and good practices. Our common values and responsibilities towards humanity move us
to fulfil our pledge to act on social determinants of health. We firmly believe that doing so is not only a
moral and a human rights imperative but also indispensable to promote human well-being, peace,
prosperity and sustainable development. We call upon the international community to support developing
countries in the implementation of these actions through the exchange of best practices, the provision of
technical assistance and in facilitating access to financial resources, while reaffirming the provisions of the
United Nations Millennium Declaration as well as the Monterrey Consensus of the International
Conference on Financing for Development.
16.3
We urge those developed countries which have pledged to achieve the target of 0.7 percent of
GNP for official development assistance by 2015, and those developed countries that have not yet done so,
to make additional concrete efforts to fulfil their commitments in this regard. We also urge developing
countries to build on progress achieved in ensuring that official development assistance is used effectively
to help achieve development goals and targets.

16.4
World leaders will soon gather again here in Rio de Janeiro to consider how to meet the challenge
of sustainable development laid down twenty years ago. This Political Declaration recognizes the
important policies needed to achieve both sustainable development and health equity through acting on
social determinants.
16.5
We recommend that the social determinants approach is duly considered in the ongoing reform
process of the World Health Organization. We also recommend that the 65th World Health Assembly
adopts a resolution endorsing this Political Declaration.

World Conference on
Social Determinants of Health
RIO DE JANEIRO | BRAZIL | 19-21 OCTOBER 2011

World Health
Organization

COPASAH

grWiTrrtjfwWmr^iwn^
pH-l’gKnowledge building from grounded practice is one of the strategic goals of COPASAH to counter the hegemony of experts and
tool based accountability perspective dominating the accountability domain. The COPASAH members have a wide range of

i

resources and examples of citizen centric monitoring in the field of Health Rights. The experiences of practice and different
strategies in community based monitoring have been shared through COPASAH's different knowledge products, which

j
*

include issue papers, cases studies, newsletter and a host of audio-visual products.

Sssue Paper 1
Who are we to Csre? Exploring the Relationship between Participation, Knowledge
and Powenn Health Systems
Barbara Kaim, Zimbabwe
nW ARE Wt IU GAKfcZ
EXPLORING THE RELATIONSHIP BETWEEN
PARTICIPATION. KNOWLEDGE AND POWER
IN HEALTH SYSTEMS

In many developing countries like Zimbabwe, health systems fail to meet the needs of the

|

majority, especially of people and communities with less power. Equipped with knowledge

,

and skills to monitor health system practices and with awareness of health rights,
communities get enabled to assert their political power. With collective action, they are

I

able to address some of those failures. This issue paper focusing on health systems in

j

Zimbabwe, explores how the interaction between people's participation, knowledge and
OP£N SOOTY

power affects the functioning of health systems in favour of the people. There is a blend of

discussions on concepts and issues with descriptions of experiences and case studies from
around the globe. It attempts to discuss alternatives and approaches that can be used to

i

build a more just and equitable health system.
http://www.copasah.net/who-are-we-to-care-participation-knowledge-and-power-in-

|

health-systems-tarsc-zimbabwe.html

Issue Paper 2
How do we know we are making a Difference? Challenges before the Practitioner
of Community Monitoring Processes in Assessing Progress and Evaluating
£pacts
Abhijit Das, India
COPASAH ISSUE PAPER

Community based monitoring has emerged as a promising practice for improving
programme effectiveness, and as a key component of rights-based implementation of
health programmes in India and other parts of the globe. It has proved to be significant in

'empowering' communities and in building their capacities in engaging with service

providers, to negotiate better services for themselves. Using practical examples drawn
from the author's own practice and two examples of field level practice in India, this paper
discusses the different conceptual dimensions of community monitoring and explores the
difficulties of monitoring and assessing progress and results. It also explores a set of
mechanisms for documenting and assessing progress drawing upon contemporary
practice of evaluation. The authors propose a practical methodology for assessing
progress, drawing lessons and for establishing robust evidence based results in the field of
community based monitoring.
http://www.copasah.net/uploads/l/2/6/4/12642634/issue_paper_how_do_we_know_

we_are_making_a_difference_copasah.pdf

Issue Paper 3

Ethical Issues in Community Based Monitoring of Health Programmes: Reflections
from India
Renu Khanna, India
When community based monitoring of health systems are developed for advocacy and social
ETHICAL ISSUES IN
COMMUNITY BASEDMONITORING
OF HEALTH ROGRAMMES:
REFLECTIONS FROM INDIA

accountability mechanisms, sets of power relationships and ethical dilemmas often arise. The

issue paper from India reflects upon existing power discourses in the process of community
based monitoring and planning. It draws upon modern bioethics (in community action and
otherwise) and specifically shows how community based monitoring and planning, whilst
maintaining uniqueness, intersects with several other realms including: community
development and social action, community based research, public health interventions and
social science research. The issue paper examines various sets of relationships within the
process of community based monitoring and planning, and the associated power dynamics
and ethical issues emerging in each set of relationships.
http://www.copasah.net/ethical-issues-in-cbm-.nf-heaith-programmes-sahaj-india.html

issue Paper 4
Developing an Approach towards Seciaf fieeasmialiHily of Pmafg Sfeahhcare
Services
Anant Phadke, Abhijit More, Abhay Shukla, Arun Gadre, India
The Private Health sector forms a major component of the health care systems in developing
countries like India. In India, this sector is large, varied and unregulated, and is riddled with
several problems including substantial irrationalities in care provision, lack of protection of
patient's rights, lack of social accountability, lack of grievance redressal mechanisms and so
on. This paper discusses the need for social accountability mechanisms in the context of

current failure of self-regulation by medical professionals, and weaknesses of existing state
regulation mechanisms, leading to a perceived accountability deficit in private healthcare
services. It proposes likely steps and processes by which social accountability of private
healthcare services could be developed in India, while drawing on some efforts made towards
this in developing countries and lessons learnt from them.
http://www.copasah.net/developing-an-approach-towards-social-accountability-ofprivate-healthcare-services-sathi-india.html

CASE STUDIES
Women in the Lead: Monitoring Health Services in Bangladesh
Sarita Barpanda, Sarnia Afrin, Abhijit Das
\ There is a strong interlinkage between accountability and movement building, and this was recognised by Naripokkho, a

.g A national organisation working for reproductive and health rightsand rights of women in Bangladesh. Naripokkho initiated
2 ) movement and activism with marginalised women in Bangladesh based on questions around service accountability or
®

/ political accountability,that could prevent the needless deaths of women and provide better health services. The case

pSy study Women in the Lead: Monitoring Health Services in Bangladesh discusses the activities, outcomes and challenges
jS® faced in implementing the three pronged accountability approach of organising women from marginalised sections into
Nari Dal(groups of marginalised women at village level) training them to conduct monitoring visits in hospitals and working
with elected representatives to create a participatory and relevant review and planning mechanism.
http://www.copasah.net/uploads/l/2/6/4/12642634/womenJn_the_lead __ monitoring_health_services_in_banglade
sh_-_sarita_barpanda_samia_afrin_abhijit_das.pdf

Case Study 2
Accountability and Social Action in Health - A Case Study on Solid Waste Management in Three Local Authority
Areas of Zimbabwe
Training and Research Support Centre (TARSC) with Civic Forum on Housing (CFH)
Solid waste management has been a major public health challenge to most urban local authorities in Zimbabwe. Rapid

urbanisation in the past decade coupled with economic decline and social disruption has placed considerable strain on local
authority resources, resulting in their failure to provide adequate services to residents. To build capacity, strengthen

accountability and facilitate sustainable options at the local level on solid waste management, Training and Research Support
Centre (TARSC) and Civil Forum on Housing (CFH) in Zimbabwe used participatory research to map the situation. The
community-based researchers implemented civic education on social waste management and clean-up campaigns. As civil
society, the researchers also engaged with local authorities and the private sector on waste recycling and reuse, monitored

and raised issues with the local authority on waste disposal and used community feedback meetings to raise awareness and
provide feedback and review of actions. This case study on Accountability and Social Action in Health - in three local
authority areas of Zimbabwe shares the evidence and experience of the research, activities and the lessons learnt by TARSC
and CFH. It also maps the feedback acc review activities undertaken with communities, the private sector and service
organisations in three local authority areas or Zimbabwe and the lessons learnt byTARSCand CFH.
http://www.copasah.net/uploads/l/2/6/4/12642634/accountability_and_sociai_action_in_health_zimbabwe.pdf

CassStusiyB
Claiming Entitlements: The Story of Women Leaders' Struggle for We Right to Health in Uttar Pradesh, India

Abhijit Das and Jashodhara Dasgupta
The situation of maternal health particularly in the state of Uttar Pradesh (India) is distressing. In addition to a poorly

equipped and weak health system, there are reports of corruption across the system and women's experiences as well as
small scale studies indicate that women face abusive and disrespectful behaviour from both nurses and doctors. The adverse

experiences of women as they came to hospitals for their delivery, energised Community Based Organisations (CBOs) from

different districts across the state of Uttar Pradesh to come together to deal with the situation. These CBOs along with
SAHAYOG, a state-level resource organisation, implemented a state-wide campaign, which led to theformation of the Mahila
Swasthya Adhikar Manch (MSAM). This case study Claiming Entitlements: The Story of Women Leaders' Struggle for the
Right to Health in Uttar Pradesh, India recounts how a group of women from the extremely marginalised sections of society

have become empowered and are monitoring their entitlements around health services and other services associated with
the social determinants of health. It describes the evolution of the MahilaSwasthya Adhikar Manch (Women's Health Rights
1mm), its activities and some of the results of their advocacy action with a focus on their empowerment process.
rap://www.copasah.net/uploads/l/2/6/4/12642634/claiming_entitlements.pdf

Community Based Monitoring and Planning in Maharashtra, India
Abhay Shukla, Shelley Saha, Nitin Jadhav
The National Rural Health Mission (NRHM) launched in 2005 in India articulated provisioning of universal access to
equitable, affordable and quality healthcare, especially for people residing in rural areas, women, children and poor.
With a view to increase people's participation for improving health governance and strengthen the community interface
with the public health service system NRHM outlined Community Based Monitoring of health services as an effective

strategy. The case study: Community Based Monitoring and Planning in Maharashtra, analyses the diverse experiences
of community action for accountability of health services that have emerged in the state of Maharashtra in India, after
the NRHM came into being. The focus is on drawing out lessons from organising several hundred Jan Sunwais (Public
hearings) and dozens of 'stories of change' associated with this process. The strategies discussed will be of value for

health and social activists workingfor accountability of public services in various contexts across the world.
http://www.copasah.net/uploads/l/2/6/4/12642634/community_based_monitoring_and_planning_in_maharashtra

.pdf

Case Study 5
Citizen Monitoring to Promote the Right to Health Care and Accountability
Ariel Frisancho and Maria Luisa Vasquez, Peru
In countries like Peru which is mired with inequality and poverty, health care equality cannot be achieved only with technical
interventions and increased resources allocated to health care. Transparency and accountability in health system remain a
challenge and significant and sustainable changes can be achieved if citizens are involved in the design and adjustment of

social policies and the programs that implement them, thus ensuring that their needs have been properly considered and
addressed. Citizen monitoring in health care promotes transparency and accountability which are essential for good

governance and democracy. The case-study: Citizen Monitoring to Promote the Right to Health Care and Accountability from

Peru is a demonstration of citizen engagement in building transparency and accoun table systems, which are essential for good
governance and democracy, it focuses on the key importance of strategic alliances with public and civil society actors to
strengthen the capacity of rural women's agency and to address unequal power relations. The case study highlights how
principles of the International Human Rights framework have been used at the local level in an effort to strengthen the quality

of care provided in health care services. This study exemplifies the accountability approach based on dialogue and the
promotion of good governance
http://www.copasah.net/uploads/l/2/6/4/12642634/citizen_monitoring_to_promote_the_right_to_health_care_and_acc

ountability_-_care.pdf

Community of Practitioners on
Accountability and Social Action in Health
VISION
Communities are actively engaged in promoting accountability and transforming health systems towards the
realization of social justice.

MISSION
Our mission is to nurture, strengthen and promote collective knowledge, skills and capacity of community-oriented
organisations and health activists - primarily from Africa, Asia and Latin America - working in the field of
accountability and social action in health, for promoting active citizenship to make health systems responsive.
equitable and people-centred.

Grounded Knowledge

Shared Practice

COPASAH

www.copasah.wordpress.com

COPASAH

For further information and suggestions contact:
GLOBAL SECRETARIAT & COMMUNICATION HUB

Centre for Health and Social Justice
Basement of Young Women's Hostel No. 2, Near Bank of India, Avenue 21, G Block, Saket, New Delhi-110017
Telephone: +91-11-26535203, +91-11-26511425, Fax: +91-11-2653604, Email: copasahnet@gmail.com, www.copasah.net

WHAT IS COPASAH?
A global network of

community of practitioners
(from global south) sharing a

community- centric vision and
human rights based approach

to health, health care and
human dignity

»
We are connected,
we share and learn from
each other

CENTRAL EUROPE

LATIN. AMERICA

. SOUTH ASIA

EAST SOURTHERN
AFRICA

Community
of
Practitioners
on
Accountability
and
Social Action
in
Health

SHARED PRACTICE
GROUNDED KNOWLEDGE

kAAAAAAAAAAAAAAAAAA

www.copasah.net
copasahnet@gmail.com

CENTRE ON •
LAW& SOCIAL
TRANSFORMATION

LAW 8 POLICY

Sexual & Reproductive Rights Lawfare: Global Battles
About the Project
Today, we see a growing judicialization of sexual and reproductive rights around the
world - including rights related to abortion, gender identity and sexual orientation. At

the domestic and international level, courts have emerged as central arenas in
political-moral battles to further - and limit - these rights. In this context, the Centre
on

Law

&

Social

Transformation

(LawTransform)

in

Bergen,

Norway

is

coordinating a multi-country research project titled, “Sexual& Reproductive Rights
Lawfare: Global Battles” with researchers from all around the world, including

India. The work in India will be done in collaboration with the Centre for Law and

Policy Research (CLPR) in Bengaluru. The project aims to understand the nature,
causes and, particularly, the consequences of sexual and reproductive rights lawfare,

which we define as strategies adopted by civil society actors that engage rights, law
and legal institutions in order to achieve policy reform and social change. CLPR will

undertake semi-structured interviews with select Indian organisations working in the
area of sexual and reproductive rights.

About Centre on Law and Social Transformation
LawTransform was established in 2014 with the aim to bring together scholars,
students and practitioners who share an interest in how law shapes societies, and the
use of rights and courts as tools for social change. Fellows and affiliates come from
numerous institutions in Norway and globally, and are drawn from a broad range of
academic fields, including law, political science, economics, sociology, anthropology,
philosophy, medicine and psychology. Through a number of interdisciplinary research
projects, LawTransform explores how law and legal institutions function, and how
legal strategies are used as political tools (lawfare) to advance goals such as

children’s- and migrants’ rights, health, sustainable development, peace and gender
equality - and develop new methods to study the effects. For more information see
www.lawtransform.no .

About Centre for Law and Policy Research
The Centre for Law and Policy Research, Bangalore is a not-for profit research

organisation committed to research, litigation and advocacy in the public interest.
Over the years, diverse and experience-driven strategies have enriched the meaning
and scope of public interest lawyering in India. CLPR believes that promoting and

relying on data driven, social science research and analysis which influences and
shapes constructive solutions to the myriad public policy challenges in India is of

paramount importance towards meaningful engagements with courts and the justice
system. For more information see http://clpr.org.in.

C PASAH
| ,

Community of Practitioners on
Accountability and Social Action in Health

A Global Network of
Community Practitioners
in Social Accountability (Health)
sharing a community- centric vision and
human rights based approach to health,
health care and dignity

www.copasah.net kzzzzzzzzzz
Yes, I am interested to be connected with COPASAH

Name:
Organisation/lnstitution:

Country:
Email:

GLOBAL SYMPOSIUM
Watch out for...

COPASAH Global Symposium on
CITIZENSHIP, PARTICIPATION, GOVERNANCE
AND ACCOUNTABILITY IN HEALTH

Join Us in New Delhi (India) in February/March, 2019

COPASAH strives for field building through
three Them
-<u:is that concern Citizens'

.

Health:

I.-

Get Involved in the Thematic Hubs for Consultations,
Capacity Building of Practitioners, Creating Knowledge
and Advocacy for Social Accountability

Know more: http://www.copasah.net/thematic-hubs.html

COPASAH SOCIAL ACCOUNTABILITY DIALOGUES
(CoPSADs)

COPASAH holds a series of CoPSADs to foster sharing and
mutual learning on social accountability practices through
the innovative use of communication technologies.

Participate in the CoPSADs

Know more:
http://www.copasah.net/socialaccountability-dialogue.html

Be Connected
Email: copasahnet@gmail.com

COPASAH
COPASAH Global Secretariat and Communication Hub
C/O - Centre for Health and Social Justice, New Delhi, India
Telephone: +91-11 -26535203, www.copasah.net

www.copasah.net

COPASAH Global Symposium 2019
On
Citizenship, Governance and Accountability in Health
Role of the Community in Strengthening Accountability of Health Systems for Achieving

Universal Health Care/Sustainable Development Goals

BUILDING A PRACTICE BASED SOUTHERN COUNTER NARRATIVE ON TRANSPARENCY,
ACCOUNTABILITY AND PARTICIPATION

Context -The Alma Ata Declaration of Health for All by 2000 in 1978 marked a new shared

aspiration for all citizens of the earth. It elevated health to the realm of a fundamental human
right and comprehensive primary health care was seen as an achievable goal.

Community

participation was centre-staged as one of the core principles. In the last four decades, the goal

of Alma Ata has not been met and the vision of comprehensive primary health care for all has
been corrupted by increasing privatization and high costs of care as well as techno-centric

fragmentation of care leading to high levels of inequality in health outcomes. There have been
some efforts to ensure a level of continuity in the discourses around health care for the poor

through focus on approaches like Universal Health Coverage, Universal Access to Health Care,
Social Determinants of Health, Millennium Development Goals as well as the current efforts on

the Sustainable Development Goals (SDGs). In some ways the SDGs because of their universal
and interconnected nature and emphasis on leaving no one behind allows an opportunity to

review the functioning of health systems to strengthen participation, equity and accountability.

The current Director General of WHO, Dr. Tedros Adhanom Ghebreyesus, has emphasised on

Universal Health Coverage as a human right in light of the SDG Goal 3.8 which calls for
achieving the following target by 2030: achieve universal health coverage, including financial
risk protection, access to quality essential healthcare services and access to safe, effective,
quality, and affordable essential medicines and vaccines for all.

He also emphasised that 'a

strong primary health care platform with integrated community engagement within the health
system is the backbone of universal health coverage'.
COPASAH (Community of Practitioners for Accountability and Social Action in health) was

started in 2012 by a group of practitioners, who had been using Social Accountability
approaches to strengthen the linkage between communities and the health system to provide

quality, accountable care. It is essentially a learning network with a focus on marginalized
communities where practitioners learn from each other and by distilling lessons from practice

and a bottom up process. Today COPASAH community consists of over 300 organisations and
individual members and around 730 listserv members across different regions of the world and
COPASAH is working closely with many academics sharing lessons on how to improve elements

of participation and increase equity and accountability of health systems. COPASAH members

have also been specifically exploring equity and accountability in the context of private health

care as well as for indigenous and other excluded communities.

1

Building upon the current interest on achieving universal health coverage and the need to
include the most marginalized within the ambit of health systems as an active participant,

COPASAH

proposes to organize

a

Global Symposium on

Citizenship, Governance and

Accountability in Health.
The theme of the Symposium will be Role of the Community in Strengthening Accountability of

Health Systems for Achieving Universal Health Care. The overall purpose of the Symposium
will be to provide a platform for learning, exchange and knowledge building on the issues
related to theme

by grassroots practitioners, programme managers, thematic experts,

academics as well as donors and international agencies. A unique element of the Symposium
will be its focus on community level practice and bottom up knowledge building processes.

Objectives and Outcomes-The overall objectives of the COPASAH Global Symposium are:

Showcase the 'state of the field' by providing practitioners to share their experiences of

1.

working on issues related to participation, social accountability, citizenship and governance;
and facilitate peer to peer learning.
Provide opportunities for interactions between academicians, researchers, development

2.

organisations, donors and practitioners to discuss and debate issues of common concern

and distill lessons on how participatory and social accountability practices could strengthen

health systems and reduce inequities in health outcomes towards achievement of desired
outcomes SDGs, UHC and Health for All.
Synthesise bottom up grounded knowledge from the discussion among participants from

3.

different stakeholder groups and share the same widely.
The Key Outcomes that are envisaged are:

1.

Synthesis

of

new

learning

from

discussions

between

practitioners,

managers,

researchers and other stakeholders around participation, accountability and health

equity. These lessons are potentially very important for achievement of SDGs related to
health.

2.

Sharpening of practitioner skills and development of new tools through mutual sharing

and learning
3.

Networking and relationship building between practitioners of different regions and

between practitioners and other stakeholders like programme managers, researchers

etc.

4.

Developing written as well as audio-visual learning resources for the field through

documentation of all key sessions and their subsequent synthesis

5.

Establish the importance of participation, social accountability and bottom up learning

for securing health equity and strengthening health systems to achieve Universal Health
Care and the SDGs and the role of COPASAH and a resource network for the same.
Themes and Structure - The overall contents of the Symposium will cover a set of broad
themes. These will include

•

Community

Participation

in

Governance

and

Accountability for

Health

systems

strengthening

2

•

Leaving No One Behind -Improving access to quality health services for Indigenous

Communities and other marginalized Ethnic Groups
•

Revisiting Reproductive

•

Setting the framework and agenda for demanding accountability of the private medical

Health - Completing the unfinished agenda of securing

reproductive health and rights for all.
and health care sector
•

Forging Alliances between the Community and the Health Workforce

The overall structure of the Symposium will be such that it allow for sharing and interaction

between participants on common issues of concern. At the same time there will be
opportunities to learn from the experiences of key practitioners and thinkers in the field. In

order to keep a focus on practice and practitioners the Symposium will facilitate conversations

between delegates by providing formal and translation services in more than one language. The
format of the Symposium will be such that there are a minimum of speeches or one way

communication. Some of the formats that will be used to stimulate interactions will be as
follows:

1.

Expert's conversation with a Host with audience participation

2.

Film show/ AV demonstration followed by discussions

3.

Facilitated Round Table discussions

4.

Curated Poster presentation - Gallery walk with discussion

5.’ Skills exchange workshops

6.

Cultural engagements

Some of the sessions will be organizer designed in that the participants and the format will be

designed by the organisers. Other sessions will be participant designed in which abstracts or
presentation ideas will be sought from applicants who wish to attend the Symposium. These

abstracts may be submitted as videos or visual presentation of ones work, with focus on the key

lesson or experience that the participant would like to share.
Besides these formal sessions there will be spaces and opportunities for informal conversation

between participants/delegates. There will also be an exhibition space where participating

organisations can showcase their work and approaches to the delegates.
On the day of the Opening Session, which is going to be held in the evening, there will be

opportunity for participating organisations to organize self-organised satellite sessions during

the day for which space will be provided at the venue by the organisers for a small fee to cover
the costs.

PARTICIPANTS - The symposium is expected to bring together 400 delegates which includes at
least 200 community based practitioners working on health equity and social accountability and

an equal number of participants from human rights/accountabiiity organisations, researchers/
academics working on accountability, health systems and health equity as well as those working

on health related public policy, media as well as donor organisations. The participants will be
from different regions where COPASAH has its membership eg. South Asia, Western, Eastern

3

and Southern Africa, Eastern Europe and Latin America as well as other regions like East and
South East Asia. We expect a number of researcher and research centres based in Universities

in the Global

North as well as other Global Organisations working on

participation,

transparency and accountability to join us. Among the 400 participants we expect to provide

travel support to the practitioners from the Global South.
Participation in the Global Symposium will be either through invitation or application. Key
practitioners and experts will be invited to participate in the Symposium and invited to

contribute to specific sessions. Participants who wish to participate will apply with the specifics

of their interest and contribution through the conference website. The organisers will review
the application and invite the delegate. Travel support will be provided at the discretion of the

organisers.

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