Why People Use Health Services

The principal aims of this paper are (1) to increase professional health workers' knowledge of selected research findings and theory so that they may better understand why and under what conditions people take action to prevent, detect and diagnose disease; and (2) to increase awareness among qualified behavioral scientists about the kinds of behavioral research opportunities and needs that exist in public health. A matter of personal philosophy of the author is that the goal of understanding and predicting behavior should appropriately precede the goal of attempting to persuade people to modify their health practices, even though behavior can sometimes be changed in a planned way without clear understanding of its original causes. Efforts to modify behavior will ultimately be more successful if they grow out of an understanding of causal processes. Accordingly, primary attention will here be given to an effort to understand why people behave as they do. Only then will brief consideration be given to problems of how to persuade people to use health services. Kasl and Cobb recently provided a classification of various behaviors in the health area that provides a useful framework for considering the focus and limitations of the present paper.1 They define health behavior as “any activity undertaken by a person who believes himself to be healthy, for the purpose of preventing disease or detecting disease in an asymptomatic stage.” Illness behavior is defined as “any activity undertaken by a person who feels ill, for the purpose of defining the state of his health and of discovering suitable remedy.” Finally, sick-role behavior “is the activity undertaken by those who consider themselves ill for the purpose of getting well.” In terms of these distinctions, the present paper emphasizes research on the determinants of health behavior and to a lesser extent, research on illness behavior. No attempt will be made to treat the voluminous literature on sick-role behavior for two reasons. First, the public health worker is more centrally concerned with behavior relative to prevention, early detection and diagnosis of illness than he is with behavior in response to diagnosed illness. Second, the author's research experience is largely confined to studies of health behavior, as defined by Kasl and Cobb. Another limitation that should be made explicit is that virtually all material to be presented has been drawn from studies of various subgroups of the population of the United States. No attention will be given to the contributions accruing from studies of other cultures. Consideration may first be given to the relationship between studies of how health services are used and an understanding of why health services are used. Do studies of how people use services explain why people use health services? In approaching an answer to this question, a careful distinction should be drawn between studies of utilization whose findings are intended to have immediate application, and studies of utilization which are intended to serve as means to still other research ends. In the first case, information is sought to serve as a basis for formulating and implementing public policy in the health area. Utilization data obtained for such purposes have proved invaluable in the health field.2-4 However, studies of the use of services may also be undertaken as means to achieve the broader aim of increased understanding of why services are used. In this sense, utilization studies are intended to generate hypotheses about why services are used. Such utilization studies have generally failed to accomplish their purpose. Little can be learned from these studies about why people use or fail to use certain services. Evidence in support of this conclusion has been drawn from studies of high and low users of free medical examinations,5 detection tests for cervical cancer,6 polio immunization,7 dental services,8, 9 physicians' services,3, 10 hospital services11 and from studies of the characteristics of those who do and those who do not delay in seeking diagnosis and treatment of cancer.1, 12 Analyzing the major findings of studies on the patterns of use of preventive and detection services permits certain summary generalizations about the association of personal characteristics with the use of services. In general, such services are used most by younger or middle aged people, by females, by those who are relatively better educated and have higher income (though perhaps not the very highest levels of education and income). Striking differences may nearly always be found in acceptance rates between whites and non-whites, with whites generally showing higher acceptance rates, although occasional exceptions occur. A review of the previously cited data on utilization of diagnostic and treatment services provided by the physician, the dentist and the hospital, suggests a pattern quite similar to that obtained in connection with preventive and detection services. In general, more females than males visit the physician and the dentist and incur hospitalization, even when hospitalization for pregnancy is excluded. Higher socioeconomic groupings (defined in terms of educational and income level) are also more likely to obtain medical, dental and hospital services, although the associations between income and utilization are becoming less marked.2, 3 With reference to race, whites show much higher utilization rates than non-whites in all three utilization categories (physician visits, dental visits and hospitalization). The nature of the association between age and utilization of treatment services is generally different from that found between age and seeking preventive and detection services, probably reflecting the effect of objective medical and dental need. With respect to characteristics of those who delay in seeking diagnosis and treatment of cancer, similar patterns emerge. In general, persons who delay are older, of low educational status and, at least in some studies, males.12 Although most studies of utilization do not throw light on why people use health services, one area of research can be identified in which quite sophisticated efforts have been made to understand health and illness behavior as a function of personal characteristics; an area described by Kasl and Cobb as “variables affecting the perception of symptoms.” Several other workers attempt to link personal and subcultural variables to the individual's likelihood of perceiving an event as a symptom or to his mode of responding to a symptom. For instance, Koos found a social class gradient in terms of the likelihood of interpreting a particular sign as a symptom.13 Stoeckle, Zola, and Davidson studied the effects of ethnic values upon the specific decision to seek medical attention and on the differential interpretation of objectively similar symptoms.14, 15 Freidson illustrated the different processes through which members of different social groups move in obtaining diagnosis (lay and professional) and in seeking care.16 Suchman attempted an interesting and promising approach which links demographic factors to social structure, both of these to medical orientation and in turn to health and medical care.17 Studies of the kinds performed by Koos, Stoeckle, Zola, Freidson and Suchman are far superior in their ability to explain than are the more traditional analyses of relationships between demographic factors and the utilization of services. This superiority lies in the proposed linking mechanisms between personal characteristics and behavior. These studies also demonstrate that health decision making is a process in which the individual moves through a series of stages or phases. Interactions with persons or events at each of these stages influence the individual's decisions and subsequent behavior. Yet, even these sophisticated studies limit their focus to illness behavior; that is, to behavior undertaken in response to symptoms. The findings are, thus, of unknown relevance to the situation confronting the person who must decide whether to seek preventive or detection services before the appearance of events that he interprets as symptoms. Suchman explicitly notes the failure of his concepts of social structure and health orientation to account for preventive health actions.17 Stimulating the development of a preventive orientation in the public is the heart of most educational programs in public health. Within the past decade several theoretical papers and empirical research reports have appeared which deal with a particular model for explaining health behavior in individuals who believe themselves to be free of symptoms or illness.18-26 A comprehensive description and critique of the model28 will be provided, as well as a presentation of research evidence that tends both to support it and to contradict it. An analysis will be made of the questions that remain unanswered and of the kinds of research that will be needed to answer these questions. The model does not attempt to provide a comprehensive explanation of all health action. Rather, what is attempted is the specification of several variables that appear to contribute significantly to an understanding of behavior in the health area. Considerable detail will be provided although the model is far from having been proven valid and useful. This is justified on the grounds that the model seems to provide a most promising framework for explaining large segments of behavior relevant to health and for unifying what, at the moment, are unrelated findings from several investigations. Possibly, though the attempt will not be made in this paper, the model, formulated essentially to explain health behavior (in the sense used by Kasl and Cobb1) can ultimately be applied as well to explaining illness behavior and sick-role behavior. Before turning to a presentation of the model itself, a few words about some of its general characteristics are in order. The major variables in the model are drawn and adapted from general social-psychological theory, notably the work of Lewin.27 The variables deal with the subjective world of the behaving individual and not with the objective world of the physician or the physicist. The two, no doubt, are correlated, but the correlation is far from perfect. The focus in the application of the model is to link current subjective states of the individual with current health behavior. A truism in social psychology is that motivation is required for perception and action. Thus, people who are unconcerned with a particular aspect of their health are not likely to perceive any material that bears on that aspect of their health. Even if, through accidental circumstances, they do perceive such material, they will fail to learn, accept or use the information. Not only is such concern or motivation a necessary condition for action; motives also determine the particular ways in which the environment will be perceived. That a motivated person perceives selectively in accordance with his motives has been verified in many laboratory studies29 as well as in field settings.30 The proposed model to explain health behavior grows out of such evidence. Specifically, it includes two classes of variables: 1. the psychological state of readiness to take specific action and, 2. the extent to which a particular course of action is believed, on the whole, to be beneficial in reducing the threat. Two principal dimensions define whether a state of readiness to act exists. They include the degree to which an individual feels vulnerable or susceptible to a particular health condition and the extent to which he feels that contracting that condition would have serious consequences in his case. Readiness to act is defined in terms of the individual's points of view about susceptibility and seriousness rather than the professional's view of reality. But the model does not require that individuals be continuously or consciously aware of the relevant beliefs. Evidence from studies to be discussed subsequently suggests that the beliefs that define readiness have both cognitive (i.e., intellectual) elements and emotional elements. The author's opinion is that the underlying emotional aspects have greater value in accounting for behavior than do the cognitive elements. Perceived Susceptibility Individuals vary widely in the acceptance of personal susceptibility to a condition. At one extreme is the individual who, during interview, may deny any possibility of his contracting a given condition. In a more moderate position is the person who may admit to the “statistical” possibility of its occurrence but to whom this possibility has little reality and who does not really believe it will happen to him. Finally, a person may express a feeling that he is in real danger of contracting the condition. In short, as it has been measured, susceptibility refers to the subjective risks of contracting a condition. Perceived Seriousness Convictions concerning the seriousness of a given health problem may also vary from person to person. The degree of seriousness may be judged both by the degree of emotional arousal created by the thought of a disease as well as by the kinds of difficulties the individual believes a given health condition will create for him.31 A person may, of course, see a health problem in terms of its medical or clinical consequence. He would thus be concerned with such questions as whether a disease could lead to his death, or reduce his physical or mental functioning for long periods of time, or disable him permanently. However, the perceived seriousness of a condition may, for a given individual, include such broader and more complex implications as the effects of the disease on his job, on his family life and on his social relations. Thus a person may not believe that tuberculosis is medically serious, but may nevertheless believe that its occurrence would be serious if it created important psychological and economic tensions within his family. Perceived Benefits of Taking Action and Barriers to Taking Action The acceptance of one's susceptibility to a disease that is also believed to be serious provides a force leading to action, but it does not define the particular course of action that is likely to be taken. The direction that the action will take is influenced by beliefs regarding the relative effectiveness of known available alternatives in reducing the disease threat to which the individual feels subjected. His behavior will thus depend on how beneficial he thinks the various alternatives would be in his case. Of course, he must have available to him at least one action that is subjectively possible. An alternative is likely to be seen as beneficial if it relates subjectively to the reduction of one's susceptibility to or seriousness of an illness. Again, the person's belief about the availability and effectiveness of various courses of action, and not the objective facts about the effectiveness of action, determines what course he will take. In turn, his beliefs in this area are doubtless influenced by the norms and pressures of his social groups. An individual may believe that a given action will be effective in reducing the threat of disease, but at the same time see that action itself as being inconvenient, expensive, unpleasant, painful or upsetting. These negative aspects of health action arouse conflicting motives of avoidance. Several resolutions of the conflict are possible. If the readiness to act is high and the negative aspects are seen as relatively weak, the action in question is likely to be taken. If, on the other hand, the readiness to act is low while the potential negative aspects are seen as strong, they function as barriers to prevent action. Where the readiness to act is great and the barriers to action are also great, the conflict is more difficult to resolve. The individual is highly oriented toward acting to reduce the likelihood or impact of the perceived health danger. He is equally highly motivated to avoid action since he sees it as highly unpleasant or even painful. Sometimes, alternative actions of nearly equal efficacy may be available. For example, the person who feels threatened by tuberculosis but fears the potential hazards of x-rays may choose to obtain a tuberculin test for initial screening. But what can he do if the situation does not provide such alternative means to resolve his conflicts? Experimental evidence obtained outside the health area suggests that one of two reactions occur. First, the person may attempt to remove himself psychologically from the conflict situation by engaging in activities which do not really reduce the threat. Vacillating (without decision) between choices may be an example. Consider the individual who feels threatened by lung cancer who believes quitting cigarette smoking will reduce the risk but for whom smoking serves important needs. He may constantly commit himself to give up smoking soon and thereby relieve, if only momentarily, the pressure imposed by the discrepancy between the barriers and the perceived benefits. A second possible reaction is a marked increase in fear or anxiety.32 If the anxiety or fear become strong enough, the individual may be rendered incapable of thinking objectively and behaving rationally about the problem. Even if he is subsequently offered a more effective means of handling the situation, he may not accept it simply because he can no longer think constructively about the matter. Cues to Action The variables which constitute readiness to act, that is, perceived susceptibility and severity as well as the variables that define perceived benefits and barriers to taking action, have all been subjected to research which will be reviewed in subsequent sections. However, one additional variable is believed to be necessary to complete the model but it has not been subjected to careful study. A factor that serves as a cue or a trigger to trip off appropriate action appears to be necessary. The level of readiness (susceptibility and severity) provides the energy or force to act and the perception of benefits (less barriers) provides a preferred path of action. However, the combination of these could reach quite considerable levels of intensity without resulting in overt action unless some instigating event occurred to set the process in motion. In the health area, such events or cues may be internal (e.g., perception of bodily states) or external (e.g., interpersonal interactions, the impact of media of communication, knowledge that some one else has become affected or receiving a postcard from the dentist). The required intensity of a cue that is sufficient to trigger behavior presumably varies with differences in the level of readiness. With relatively low psychological readiness (i.e., little acceptance of susceptibility to or severity of a disease) rather intense stimuli will be needed to trigger a response. On the other hand, with relatively high levels of readiness even slight stimuli may be adequate. For example, other things being equal, the person who barely accepts his susceptibility to tuberculosis will be unlikely to check upon his health until he experiences rather intense symptoms (e.g., spitting blood). On the other hand, the person who readily accepts his constant susceptibility to the disease may be spurred into action by the mere sight of a mobile x-ray unit or a relevant poster. Unfortunately, the settings for most of the research on the model have precluded obtaining an adequate measure of the role of cues. Since the kinds of cues that have been hypothesized may be quite fleeting and of little intrinsic significance (e.g., a casual view of a poster urging chest x-ray), they may easily be forgotten with the passage of time. An interview taken months or years later could not adequately identify the cues. Freidson has described the difficulties in attempting to assess interpersonal influences as cues.33 Furthermore, respondents who have taken a recommended action in the past will probably be more likely to remember preceding events as relevant than will respondents who were exposed to the same events but never took the action. These problems make testing the role of cues most difficult in any retrospective setting. A prospective design, perhaps a panel study, will probably be required to assess properly how various stimuli serve as cues to trigger action in an individual who is psychologically ready to act. Although many investigations have identified explanatory variables which are similar to one or another variable contained in the model, only seven major projects have been undertaken whose design was largely or entirely determined by the behavioral model. Of these, four were retrospective studies18-21 while three were prospective studies.22-24 The retrospective research projects have in common the crucial characteristic that data about respondents' beliefs and behavior are gathered during the same interview and the beliefs are assumed to have existed in a point in time prior to the behavior. That assumption is a questionable one at best and will be considered after a review of the retrospective research. One other problem in the interpretation of the studies should be noted. With the exception of the Hochbaum study18 and the National Study of Health Attitudes and Behavior,24 the research has been based on quite small samples. Sometimes sample size has been limited by financial or other insuperable obstacles. However, in some cases difficulties in categorizing responses or in obtaining responses to every necessary item have reduced samples to dangerously low proportions. The best documented of the retrospective studies were performed by Hochbaum18 and Kegeles,19 and these will be reviewed in some detail. Hochbaum studied more than 1000 adults in three cities in an attempt to identify factors underlying the decision to obtain a chest x-ray for the detection of tuberculosis. He tapped beliefs in susceptibility to tuberculosis and beliefs in the benefits of early detection. Perceived susceptibility to tuberculosis contained two elements. It included, first, the respondent's beliefs about whether tuberculosis was a real possibility in his case, and second, the extent to which he accepted the fact that one may have tuberculosis in the absence of all symptoms. Consider first the findings for the group of persons that exhibited both beliefs, that is, belief in their own susceptibility to tuberculosis and the belief that over-all benefits would accrue from early detection. In that group 82 per cent had had at least one voluntary chest x-ray during a specified period preceding the interview. On the other hand, of the group exhibiting neither of these beliefs, only 21 per cent had obtained a voluntary x-ray during the criterion period. Thus, four out of five people who exhibited both beliefs took the predicted action, while four of five people who accepted neither of the beliefs had not taken the action. Thus, Hochbaum appears to have demonstrated with considerable precision that a particular action is a function of the two interacting variables—perceived susceptibility and perceived benefits. The belief in one's susceptibility to tuberculosis appeared to be the more powerful variable studied. For the individuals who exhibited this belief without accepting the benefits of early detection, 64 per cent had obtained prior voluntary x-rays. Of the individuals accepting the benefits of early detection without accepting their susceptibility to the disease, only 29 per cent had prior voluntary x-rays. Hochbaum failed to show that perceived severity plays a role in the decision-making process. This may be due to the fact that his measures of severity proved not to be sensitive, thus precluding the possibility of obtaining definitive data. Kegeles19 dealt with the conditions under which members of a prepaid dental care plan will come in for preventive dental check-ups or for prophylaxis in the absence of symptoms. He attempted to measure the respondent's perceived susceptibility to a variety of dental diseases, the perceived severity of these conditions, his beliefs about the benefits of preventive action and his perceptions of barriers to those actions. While the findings generally support the importance of the model variables, their general applicability is greatly limited by an unusually large loss in the sample. The study was initiated with a sample of 430, but those without teeth, those for whom information was not available to determine whether past dental visits had been made for preventive purposes or for treatment of symptoms and those whose positions could not be coded on all three belief variables were excluded. The crucial analysis could thus be made only on 77 individuals. Within the major limitations implied by the small sample size and by the likely nonrepresentativeness of the 77, Kegeles showed that with successive increases in the number of beliefs exhibited by respondents from none to all three, their frequency of making preventive dental visits also increased. The actual findings show that 1. of only three persons who were low on all three variables none made such preventive visits, 2. of 18 who were high on any one variable but low on the other two, 61 per cent made such visits, 3. of 38 persons high on two beliefs and low on one, 66 per cent made preventive visits and, finally, 4. of 18 persons who were high on all three variables, 78 per cent made preventive dental visits. Similar patterns of findings based on much larger samples were obtained in an analysis of relationships between behavior and each of a series of single variables, that is, susceptibility, severity, benefits and barriers. The findings of the two remaining retrospective studies will not be reviewed in detail but are in most respects quite similar to the two that have been reviewed.20,21 In each case evidence that supports the model has been obtained although the sample sizes were not large. In summary, while no one study provides convincing confirmation of the model variables, each has produced internally consistent findings which are in the predicted direction. Taken together they thus provide strong support for the model. As indicated, any interpretations made of the findings of the retrospective studies are based on an assumption. The hypothesis that behavior is determined by a particular constellation of beliefs can only be adequately tested where the beliefs are known to have existed prior to the behavior that they are supposed to determine. However, the retrospective projects have been undertaken in situations which necessitated identifying the beliefs and behavior at the same point in time. This approach has always been known to be quite dangerous. Work on cognitive dissonance34 supported these suspicions and suggested that the decision to accept or reject a health service may in and of itself modify the individual's perceptions in areas relevant to that health action. Obviously, what was needed was a two-phase study in which beliefs would be identified at one point in time, and behavior measured later. Such a study was undertaken in the fall of 1957, around the topic of the impact of Asian Influenza on American community life.22 As one of a series of related studies, Leventhal, et al. investigated the impact of the threat of influenza on families through the use of a design that was intended to permit a test of the model in a prospective manner. In this phase of the study, 200 randomly selected families in each of two medium size cities in the United States were interviewed twice. The first interview was intended to be made before most people had the opportunity to seek vaccination or to take any other preventive action and before much influenza-like illness had occurred in the communities. The second interview was to be made after all available evidence indicated that the epidemic had subsided. In fact, only partial success was achieved in satisfying these conditions because community vaccination programs as well as the spread of the epidemic moved much faster than had been anticipated. For these reasons the sample on which the test could be made was reduced to 86. This sample of 86 respondents had, at the time of initial interview, neither taken preventive action relative to influenza nor had they experienced influenza-like illness in themselves or in other members of their families. Twelve of the 86 scored relatively high on a combination of beliefs in their own susceptibility to influenza and the severity of the disease.35 Five of these 12 subsequently made preventive preparations relative to influenza. On the other hand, at the time of the first interview, the remaining 74 persons were unmotivated in the sense of rejecting either their own susceptibility to the disease or its severity or both. Of these, only eight, or 11 per cent, subsequently made preparations relative to influenza.36 Although the samples on whom comparable data could be obtained were very small and possibly not representative, the differences are statistically significant beyond the one per cent level of significance. Analysis of the available data thus suggests that prior beliefs are instrumental in determining subsequent action. A second prospective study was a follow-up by Kegeles23 on the study reported earlier.19 Three years after the initial collection of data on a sample of more than 400 in 1958, a mail questionnaire was sent to each person in the sample as well as to a comparable control group to obtain information about the three most recent dental visits. The objective of the follow-up was to determine whether the beliefs identified during the original study were associated with behavior during the subsequent three-year period. Kegeles found that perceptions of seriousness