Life difficulties, coping, and the use of medical services

RITA S. GALLIN

LIFE D I F F I C U L T I E S , C OP ING, AND THE USE OF M E D I C A L

S E R V I C E S

ABSTRACT. A retrospective study of 124 "healthy" females was designed to explore the components of high use of medical services. Analysis of data from medical records and responses to survey and in-depth interview questions showed that poor, less educated, separated or divorced women were likely to feel that their social resources were only nominally effective in mediating between them and the pressures of life difficulties. It was foui,,d that such women used health services for vague, unorganized symptoms more frequently than women whose situations were less burdened.

Over two decades ago, Densen and his colleagues (1959) reported that (1) a

group of high utilizers accounted for a significant segment of the medical care provided to all persons enrolled in a prepaid health care plan in New York; and

(2) the members of this group were more likely to remain at the same utilization

level from year to year than might be expected if one year's experience was

independent of the previous year's. The results of their study, they suggested,

gave ample justification for inquiring into this phenomenon. Nevertheless,

despite the voluminous literature on utilization that has appeared since the late

fifties, little still is known about frequent users of health care services.

A search of the work available - including several summaries of the literature

(Aday and Eichhorn 1972; Anderson 1963; Kasl and Cobb 1966; McKinlay

1972; Stoeckle et al. 1963) - suggests that most researchers have been pre-

occupied with underutilization of services, perhaps revealing the traditional

concerns of planners and administrators of services. Yet, existing studies, some

undertaken to account for differences in health care behavior, suggest several

explanations that might be used to elucidate the phenomenon of high utilization,

particularly high utilization of medical services by females (Andersen and

Anderson 1967; Nathanson 1975).

These explanations have been broadly classified as macro-functional, micro-

structural, and socio-psychological (Gibson 1971). The macro-functional approach views the functional needs of the larger society as the major determinant

of both the structure of the health care system and the health behavior of individuals. This explanation, exemplified by the works of Parsons (1951), Shuval (1970), and the Marxist-feminists (see Fee 1975: 124-131) posits that certain functional requisites of the social (and, for the Marxists, capitalistic economic) structure of society are provided, in part, by the medical system and the actors within that system.

For example, Parsons (1958) suggests that strains impinging on the isolated

Culture, Medicine and Psychiatry 4 (1980) 249-269. 0165-005X/80/0043-0249 $02.10. Copyright © 1980 by D. Reidel Publishing Co., Dordreeht, Holland, and Boston, U.S.A.

250 RITA S. GALLIN

nuclear family in America generate distinctive patterns of illness behavior. That is, when individuals fred it difficult to fulfdl social roles, illness can provide "semi-institutionalized respite" from their demanding responsibilities. Thus, the high use of services by women might, in part, reflect an attempt to adopt the sick role by a "wife-mother" reacting "to her exclusion from the life open to a man" (Parsons and Fox 1958:237) or a working-mother responding to the strains of performing both integrative and functional roles.

Shuval (1970), in a similar vein, explains differential health care use among members of a prepayment medical insurance system in Israel on the basis of latent functions that the medical system performs for the society. That is, because Israeli society has a functional need to acculturate and integrate its immigrants, the cathartic element of the physician's role acts as a potential mechanism to handle problems of recent arrivals, such as their need for re- assurance, support, and advice. The high use of medical services by some women, then, might be viewed as an attempt to seek solutions to life problems by individuals dealing with challenging, unmanageable situations.

Finally, within the macro-functional paradigm, Marxist-feminists account for the health behavior of females by a capitalist society's imperative of production for profit. That is, since women are not as crucial to the production process, their illnesses are taken less seriously than those of men, often considered psychic in origin, and not infrequently treated with tranquillizers. This orientation, then, suggests that the high use of services by some women might be a function of an intensified pattern of visits to the physician as the individual 1) seeks help for ailments that the provider devalues; and/or 2) responds to the iatrogenic effects of the placebo prescribed.

The second classification of explanation, the micro-structural, considers health care behavior to be largely determined by the present structure of the medical system and has been used most frequently to explain underutilization by the poor. For example, the organization of medical services has been shown to present geographic, f'mancial and/or temporal barriers to use by the disadvantaged (Anderson 1963; Bergner and Yerby 1968; Kane et al. 1976). In addition, the conduct of services - e.g., impersonal, fragmented, authoritarian and biased - has been found to alienate the poor and to discourage them from seeking necessary care (Abrams and Snyder 1968; Berkanovic and Reeder 1974; Osofsky 1968).

Yet, this latter finding, an explanation of low use of services, can provide potential insights into high use of services by females. For example, radical- feminists (see Fee 1975:119-124; Ruzek 1978:77-84 and 103-142) consider the medical system a replica of the patriarchal family and the set of psychological and cultural structures associated with it, i.e., the physician-father is active, instrumental and authoritative while the patient-child is passive and dependent.

THE USE OF MEDICAL SERVICES 251

As a result, these theorists posit, women patients who deviate flom enacting

their traditional sex role are at risk to have their complaints labeled as emotional,

rather than organic. The high use of medical services by some women, then,

might be a function of the conduct of services which generates an intensified

pattern of visits to the physician similar to that suggested above.

The third explanatory approach, the social-psychological, focuses on the per-

sonal characteristics of the actors themselves to explain the differential use of

services. For example, social scientists have long recognized that the ascription

of sex status provides a complex of culturally defined behaviors that are relevant

to action (Bierstedt 1963; Davis 1962). Thus, since illness is considered a femi-

nine characteristic to be shunned by men (Barker 1953; Chesler 1972; Mechanic

1965), women may be more likely to report illness and to seek medical care than men. That is, it is more culturally acceptable for them to be expressive

about their difficulties (Phillips and Segal 1969).

Furthermore, it has long been recognized that the experience of stress in-

creases the likelihood that an individual will seek professional medical care

(Kulka et al. 1979;McKinlay and Dutton 1974;Mechanic 1963, 1974; Mechanic

and Volkhart 1961; Stoeckle et al. 1963; Tessler et al. 1976; Zola 1973). Thus, since it has been suggested that constitutional frailty (Weissman and Klerman

1977), learned helplessness (Kaplan 1977), and ineffective coping (Pearlin and Schooler 1978) magnify the impact of stress on women, females may be more

likely to use medical services to deal with life-strains than males (see also Kessler 1979). That is, their high use of medical services is a response to higher levels of stress.

In short, three major perspectives have attempted to explain differences in

utilization behavior of some groups vis-fi-vis others. Each has the potential to explain the differential use of services among women. But, such explanations are

based on the assumption that the illness behavior of women is a response to or

reflection of their s i tua t ion as w o m e n . The purpose of this paper is to report on

a study which raises some questions about this assumption. The study, an

exploration of the way in which the life circumstances of female patients affect

their use of medical services, argues that high utilization is a response to or a

reflection of inadequate social resources under difficult life circumstances.

RATIONALE

The rationale of the research may be briefly stated. The medical institution has latent functions that open up the possibility for the individual to turn to the

physician for support and advice (Shuval 1970). Individuals who find it difficult to cope with environmental stress are likely to be more sensitive to symptoms

and to seek medical care for minor complaints (Balint 1957; Mechanic 1963,

252 RITA S. GALLIN

1974; Stoeckle et al. 1964). The use of services by such people may be seen as

"an attempt to make an unstable, challenging situation more manageable"

(Mechanic 1972:119), as well as an attempt to find a cure for physical ailments.

The social resources available to individuals can mediate responses to difficult

life situations by "buffering" or "cushioning" them from their consequences

(Cobb 1976; Gore 1978; Henry and Stevens 1977;Kaplan et al. t977; Lin et al. 1979; Rahe and Arthur 1978). Such resources are represented by family, friends,

or neighbors who serve as a potential source of emotional sustenance and tangible

assistance in times of need (Caplan 1974). The social support provided by these

significant others reduces the likelihood of stress and the experience of illness

(Dean and Lin 1977; Lin et al. 1979; Rabldn and Struening 1976). Accordingly,

it was premised that when the resources necessary to deal with social and economic pressures were unavailable or inadequate, the individual would engage in

alternative coping responses in an attempt to deal with emotional burdens and

life problems. More specifically, it was thought that women whose social re-

sources failed to mediate effectively between them and the consequences of

deleterious life situations would frequently use medical services.

RESEARCH METHODS

The study was conducted with female patients, 20 to 40 years of age, at an ambulatory health care center located in a mid-western, industrial city. The

center is affiliated with an acute care hospital and staffed by physicians in train- ing as family practitioners.

Women, 20 to 40 years of age, were selected as study subjects for both prag-

matic and theoretical reasons. First, these lower and upper age limits eliminated

the possible intervention of parental influence and health problems associated

with menopause or chronic, degenerative diseases on the use of services. Second,

the members of this age group should tend to visit the physician less than the old

and the very young who use more services because of a high prevalance of chronic

and" acute conditions, respectively. Third, excluding utilization of services

associated with pregnancy and childbirth, females should tend to visit a physician

less than men since they have lower morbidity rates for most causes of death (Andersen et al. 1972). Fourth, the majority of the patient population at the center is female and too few male subjects were available for inclusion. Finally,

even if an adequate pool of males had been available, their inclusion would have accounted only for differences in utilization behavior of one sex vis-fi-vis the other. The findings would not have specified why differences in use occur

among females, a group which frequently uses medical services despite its "bio- logical advantage" (Nathanson 1975).

The medical records of the subjects were abstracted for a six-month period


prior to the study using a standardized form. A separate form was completed

for each visit and information such as the following was abstracted: symptoms;

physical findings; diagnoses; laboratory procedures and/or x-rays planned and performed; results of diagnostic procedures; and dispositions, i.e., requests for follow-up visits.

Then, a survey questionnaire was administered to the subjects. It dealt with their perceptions and experiences, the social hardships they had encountered, their social support systems, and their definition of the physician role. The respondents included 124 patientsJ Finally, in order to provide insights into the data collected through the survey questionnaire, 25 respondents were selected for in-depth interviews. These women were chosen on the basis of an expressed interest in the study (as documented during the survey interview) and willingness to share their experiences. The in-depth interview format was standardized, but flexible, and dealt with such topics as the individual's situation, coping strategies, difficulties, and worries.

The specific variables used in this paper include: 1) life circumstances; 2) social resources; 3) perception of health; 4) perceived medical needs; and 5) number of visits to the center for diagnosis and treatment. 2

A characterization of a person's life circumstances should contain both an objective and subjective dimension. Marital status, income, and level of education constitute objective characteristics that affect an individual's life chances. Similarly, the presence of stressful situations can impose in a very real way hardships on the individual. All of these objective phenomenon were considered in

the study. The individual's perception of the quality of her life, i.e., her sense of well-being about her situation, in contrast, is a subjective description of her circumstances. This subjective dimension was operationalized in a series of ques-

tions that asked the respondent her perception of the general state of her life, her family and money situations, and difficulty in living on her income.

The second variable, social resources, was represented by kin and friends who serve as a potential source of emotional and functional support in time of need. The term emotional support was used to refer to any behavior that makes an individual feel better or improves her spirits. Serving as an emotional outlet so that difficulties can be acknowledged and feelings expressed, listening and helping to

identify and objectify a problem, or sustaining and validating another's self-image are a few, among several possibilities, such support may take. The term functional support was used to refer to any tangible assistance provided for the individual such as "extra supplies of money, materials, tools, skills and cognitive guidance to improve . . . [her] handling o f . . . [her] situation" (Caplan 1974: 6).

The social resources of the individual were operationalized in a series of questions that first asked the respondent about the telephone and personal contact she had had with relatives and friends during the month preceding the interview.

254 RITA S. GALLIN

Then, she was asked 1) whether she received emotional support such as friend- liness, attention, encouragement, and understanding from kin and friends; 2) whether she received functional support such as financial assistance, help with child care and personal problems, and aid when there was an illness in the family from significant others; and 3) if such support had been received, who had provided it. If a respondent mentioned kin and/or friends, she was classified as receiving support from these categories of people .3

The third and fourth variables, perception of health and perceived medical needs, represent the characteristics of the women as patients. Perception of health is, by definition, a subjective concept. This was operationalized by asking respondents how they would describe their general health. Medical needs, however, may be a subjective or an objective concept. In this study the concept was measured subjectively by accepting the symptoms presented at physician visits as a measure of the individual's perception of her medical needs. 4

First, the symptoms presented by patients during the six-month period were classified by number of different symptoms, by number of different parts of the body in which they were located, and by type of complaint, s The number of

different symptoms and number of different parts of the body in which they were located were simply counts of distinct entries in the medical record. The type of complaints presented by the patient was operationalized using a typo-

logy developed by Zola (1966, 1973). In this typology, two types of complaints are distinguished. One type represents a rather specific organic dysfunctioning and reflects the way in which the patient restricts his or her difficulties, e.g., difficulty in heating, sees spots, has tics, etc. The second type represents a more global malfunctioning and reflects the way in which the patient emphasizes the more diffuse nature of his or her complaints, e.g., aches, feels tired, nauseous, nervous, etc. 6 All symptoms were coded, classified according to Zola's typology,

and operationalized as number of symptoms of specific dysfunction and number of symptoms of diffuse anomalies.

Next, number of different symptoms and number of different parts of the body in which they were located were adjusted for variations in the number of visits among patients in order to account for the fact that those who had sought care more frequently had had more opportunities to report symptoms. In addition, type of complaint was adjusted to determine the proportion of a patient's symptoms that were of specific dysfunction and of diffuse anomalies.

Then, since the correlation between the various symptom classifications was so high, a reliability coefficient was computed. ~ The results of this computation yielded an alpha of .89 and, accordingly, an index representing this configura- tion of multiple, vague symptoms located in diffuse body systems was calculated and assigned to each patient. This index is referred to as "symptoms of distress" and was used in all analyses. 8


The fifth variable, number of visits to the center for diagnosis and treatment,

was simply a count of the number of face-to-face contacts between patient and provider during the six-month observation period, i.e., the actual use of medical

services. Number of visits ranged from one to ten. In short, a retrospective study of young, "healthy" females was designed to

explore the extent to which observed patterns of utilization of medical services could be accounted for by variations in patients' environments. The retrospective design of the study has definite weaknesses, which are worthy of note. First, the design assumes that patterns of use of medical services are relatively consistent over time. Second, it assumes that the objective circumstances of patients' lives also remain relatively consistent over time. Preferably, the design should have been prospective. But, the findings of Densen et al. (1959) lend support to the first assumption that patients have a tendency to repeat past utilization patterns in the future. In addition, the findings of several researchers lend support to the second assumption that the life situations of individuals tend to remain fairly immutable over time (Berle 1958; Brandwein et al. 1974; Fine 1974). Thus, while the design has weaknesses which should be corrected in future research, it represents an attempt to examine a subject that has received little systematic attention.

RESULTS AND DISCUSSION

The Women as Individuals and Patients

Nine out of every ten of the women in the sample were white, and almost eighty percent lived "within the city at the time they were interviewed. 9 Twenty-four

percent lived in hard core areas of poverty and unemployment (as compared to eighteen percent of the patient population at the center found to live in such areas). Approximately two-fifths were married (39 percent), two-fifths separated or divorced (39 percent), and one-fifth single (22 percent).

Being separated or divorced tended to be part of a constellation of characteristics. Those women whose marriages had been disrupted were likely to be living below poverty level (r = - .31, p < .001), and to be less educated (r = - .21, p < .02). l° More of these women, however, were employed (58 percent), than were unemployed and staying at home (42 percent). Apparently, their poor educational credentials tracked them into low-paying jobs.

Such disadvantages in social position influenced the women's perceptions of the quality of their lives. That is, women who were separated or divorced, living on inadequate incomes, and poorly educated had the least sense of well-being about their situation (see Table I). In general, they found it difficult to live on their incomes, reported that their lives were troubled, and felt that they were socially and financially deprived in comparison to their kin and friends.

256 RITA S. GALLIN

TABLE I Zero-order correlations between measures

of social position and quality of life

Social Position

Quality of Life Marital Status Income Education

General State of Life .21" - .39" - .28"*

Family Life Compared With: Kin .11 -.24** -.15 Friends .05 - . 1 9 ' -.21"

Family Money Situation Compared With: Kin .16 - .45** - .21" Friends .21" -.46** -.25**

Difficulty Living On Income: -.34** .65** .32**

*p < .02 **p < .005

Coding: Marital Status: 1 = single, 2 -= married, 3 = marriage disrupted; Income: 1 = inadequate income, 2 = marginal income, 3 = adequate income; Education: 1 = 0 to 8 years, 2 = less than high school graduate, 3 = high school graduate, 4 = some college, 5 = college graduate, 6 = graduate school; General State of Life: 1 = very smooth with little trouble, 2 = smooth with occa- sional trouble, 3 = frequently upset by troubles, 4 = most of the time upset; Comparative Family Life and Money Situation: 1 = lot better, 2 = little better, 3 = about the same, 4 = little worse, 5 = lot worse; Difficulty Living on Income: 1 = very difficult, 2 = fairly difficult, 3 = somewhat difficult, 4 = not too difficult, 5 = not difficult at all.

Disadvantages in social posi t ion also were related to the number o f stressful

events w o m e n had exper ienced during the year preceding the s tudy. Those who

repor ted exper iencing more stress events were separated or divorced (r = .30,

p < . 0 0 1 ) , living on inadequate incomes (r = - . 2 0 , p < . 0 1 ) , and less educated

(r = - . 2 1 , p < . 0 1 ) . Most o f the events such women had exper ienced ref lected

interpersonal difficulties, for example, difficulties wi th spouse, children, or in-

laws.

Tile data showed that differences in social posi t ion and perceived quali ty o f

life were correla ted with variations in the women ' s percept ions o f their heal th

and their medical needs. For example, w o m e n who lived On inadequate incomes

and had less educat ional credentials were l ikely to perceive their heal th as only

fair or poor (see Table II). Fur the rmore , a l though the data showed no statistically

significant relat ionship be tween mari tal status and percept ion o f heal th , w o m e n

whose marraiges had been disrupted were more l ikely to perceive their heal th as

THE USE OF M E D I C A L S E R V I C E S 257

TABLE II Zero-order correlations between life circumstances of the individual and characteristics of the patient

Individual Characteristics

Patient Characteristics

Perception of Health Symptoms of Distress

Social Position Marital Status .01 .18* Income - .22** - . 15 Education - . 25"* - . 10

Quality of Life General State of Life .22* .01 Family Life Compared With:

Kin .18* .22* Friends .17* .09

Family Money Situation Compared With: Kin .17 .21" Friends .11 .08

Difficulty Living on Income - . 35** - .24**

Number of Social Stressors Experienced .04 .11

*p < .05 **p < .008

Coding: Perception of Health: 1 = excellent, 2 = good, 3 = fair, 4 = poor; Sumptoms of Distress: indices range from low to high. Number of Social Stressors Experienced: indices range from low to high.

poor (45 percent) than married (34 percent) or single (21 percent) women. In addition, those with disrupted marriages were likely to present for care with more "symptoms of distress" than others.

Since such women reported a poor sense of well-being about their life circumstances, it was not surprising to find a relationship between these variables and perception of health. For example, women who felt their lives were troubled, their family life worse than that of thek kin and friends, and their income difficult to live on were likely to perceive their health as only fair or poor. More- over, in general, such women also were likely to seek medical care for many "symptoms of distress."

It was surprising to find, however, no statistically significant relationship between the number of social stressors experienced by the women and their characteristics as patients (see also Lin et al. 1979: 109). Nevertheless, among those who had been exposed to a greater number of stressful situations, the majority reported a diminished sense of health (58 percent) and presented an above the average number of "symptoms of distress" (56 percent).

258 RITA S. GALLIN

The data showed that the women's perception of their health and medical

needs were related to each other (r --- .19, p < .03), and to their use of medical

services (see Table III). During the six-month period of observation, more visits

were made to the center by those who perceived their health as poor and re-

ported numerous "symptoms of distress" than by others in the sample. More-

over, such use of services tended to be self-initiated. That is, women who pre-

sented for care with many "symptoms of distress" made few physician-initiated

visits to the center. Similarly, those who perceived their health as poor visited

the center more often on their own, rather than on their physicians', initiative.

Thus, those women with high perceived medical needs and poor perceived health

were likely to be judged least in need of follow-up by their physiciansJ 1

TABLE III Zero-order correlations between characteristics of the patient and

use of medical services

Use of Services

Patient Characteristics

Perception of Health Symptoms of Distress

Total Number of Visits .29" .18"* Patient-Initiated Visits .27* .08 Physician-Initiated Visits .16 -. 35"

*p < .002 **p < .04

Coding: Use of Services: indices range from low to high.

Of course, the relationship between perception of health, "symptoms of dis-

tress," and the use of medical services is not surprising. Self-defined poor health

by implication suggests a concomitant self-defined need for medical care. Further-

more, if, as Cole and Lejeune (1972: 355) have suggested, " . . . people who de-

fine their health as poor are more likely to search for symptoms to justify their

taking the sick role," the frequent use of medical services for large numbers of symptoms that are difficult to document or deny appears a plausible eventuality.

Yet, this paper argues that the high use of medical services for vague, unorganized symptoms might also be viewed as an adjustment to a paucity of viable coping resources under deleterious life circumstances. That is, individuals

encountering difficulties with which they cannot cope may visit the physician

in an attempt to make their unstable, challenging situation more manageable. In order to provide support for this argument, let us explore the coping resources

the women had available to manage long-term privations or acute stress situations.


Coping Resources of the Women

All but five (4 percent) o f the women reported that they had received emotional

support from kin and/or friends during the month prior to the interview. A ma-

jority (58 percent) had received emotional support from both kin and friends,

and relatives were as likely to offer such help as friends. That is, 73 percent of

the women reported receiving support from kin and 79 percent from friends. Most of the women (97 percent) felt that the support they received was help-

ful. Responses such as the following were common in answer to the question,

"In what way did the support help?".

It gave me self-confidence so I wouldn't put myself down. If you feel good about yourself then everyone else is going to feel good about you.

It's not so much what they said. They showed concern. My problems seem so much smaller when I don't have to face them alone. It's good to get them off your chest.

Talking to someone else always makes me feel better. It's hard to explain. If you're upset or worried about something and you talk to somebody, your headache goes away and you don't feel nervous or testy anymore.

All of these quotes suggest the importance to the women of support that sustains

and validates their self-image or provides an emotional outlet. In addition, the

last quote suggests a keen awareness of the relationship between the psyche and

soma. That is, physical symptoms with an underlying socioemotional component

can be "cured" when the individual is free to acknowledge her difficulties and

express her feelings.

However, even though almost all of the women expressed satisfaction with

the support that they had received, one-fifth felt that more support would have

been helpful. Almost two-thirds of these women were living on inadequate or

marginal incomes (r = .28, p < .003 ) and were separated or divorced (r = - .17 ,

p < .05). In addition, although there was not a statistically significant relationship

between expressions of need for more emotional support and education, 42 per-

cent of those saying more support would have been helpful had less than a high

school education. (The percentages for high school graduates and those who

attended or completed college were 31 and 27 percent, respectively.)

Functional support from kin and friends was not as forthcoming as emotional

support. One-quarter of the women received no tangible assistance from signifi-

cant others. In addition, more women received help only from kin (33 percent)

than received it from both kin and friends (22 percent) or only from friends (20 percent).

Perhaps because material assistance was not so freely given, approximately

one-third of the women reported that they needed help with, for example, money matters and/or personal or family problems, lz Women who were separated or

divorced, living on inadequate or marginal incomes, and less educated were more

260 RITA S. GALLIN

likely to express a need for help than their more advantaged counterparts

(r = .25, p < .005, r --- - . 38 , p < .001, and r = - .23 , p < .01, respectively). What

this means is that a majority of women whose marriages had been disrupted (52

percent), whose incomes were low (56 percent) and whose education had ceased

before graduation from high school (63 percent) expressed a need for help with

one or more problems. 13 In short, women who were socially and economically

deprived tended to be less able to resolve problems successfully and to feel that

their social resources were only nominally effective in mediating between them

and the consequences of life difficulties.

There are several plausible explanations for the perceived inadequacy of the

support of significant others. First, kin and friends, caught up in their own lives

and concerns, may be unwilling to extend more than a modicum of material

assistance to others. Second, significant others may be unable to provide the

required assistance because of their own limited resources. For example, approxi-

mately two-thirds of the women felt that the financial situation of their kin and

friends was about the same or worse than their own (59 and 69 percent, respec-

tively). In such situations, then, the availability of help is at best equivocal and

at worst impossible. In point o f fact, kin perceived to have similar or worse

financial situations were as likely to provide tangible assistance (53 percent) as

not (47 percent), and friends felt to be in such circumstances were highly un-

likely to provide support (63 percent).

There also are several plausible explanations for the perceived inadequacy of

the emotional support of significant others. First, solidary ties with relatives may

generate, rather than ameliorate, problems. For example, one woman who was in

the process of a divorce said:

I'd like to talk about my divorce with somebody who hasn't decided so much about it. I don't have very understanding relatives.

Relatives, then, in an attempt to regulate or direct some aspect of the individual's

behavior, may create a situation in which the individual's desire to live up to

others' expectations is in competition with her wish to follow her own prefer-

ences. As a result, support, even if offered in a spirit of good-natured persuasion,

is likely to create a conflictive situation that exacerbates, rather than mitigates,

the individual's distress.

Second, relatives and friends may offer support, but, as the following excerpts

illustrate, their own lives may be so fraught with adversities, that it is only minimally effective in reducing the distress engendered by problems.

My aunt listens to me. But sometimes she has lots of problems too so she can't help me much . . . . I could use some good positive answers to my problems. I have friends and relatives who I can call but they've got so many problems themselves I feel worse when I hang up . . . . [Also], they try to sway you to think their way or they have different advice and mix you up.


Thus, third, as the above two excerpts also suggest, even though significant others may empathize with the individual and offer her understanding and succorance, their support may have only limited value in providing solutions to her problems. In other words, kin and friends may not have the expertise that is necessary for solving some porblems that might be better addressed through professional counseling.

It was found, however, the women confronted by life problems frequently had neither the financial resources to purchase nor the knowledge of how to find such professional help. For example, when the women were asked in the in- depth interviews if they would know how to find professional help to deal with personal problems, four-fifths (81 percent) indicated they did not. One women noted that:

The city doesn't have an information number to call where they tell you this or that agency. I 'd go to the doctor. I 'd start there.

In point of fact, however, the city directory does contain a listing for an in-

formation and referral service. But, the telephone number of this service is the last listed under more than 100 printed on two pages of listings for social service agencies. 14 Thus, even though helping services other than physicians' are avail-

able within the community, they may not be accessible if the individual is un-

aware of how to identify the appropriate service or to negotiate among the

various agencies that play a role in providing the help needed (see also, Mechanic 1975; Kulka et al. 1979).

Moreover, even if women "knew where to go" for help, many had "no

money for a counselor." As a consequence, they tended to define the breadth of

the physician's authority broadly and see him or her as a suitable person with whom to talk about personal problems, is Yet, even though the women felt that

socioemotional problems constituted a legitimate condition for which to seek

care, they defined their patient role in such a way that it would correspond to the physician's expectations. What this means is that they presented for care

with somatic complaints (although, of course, often a woman did not recognize life strains as the source of her physical problems). 16 The presentation of physi-

cal symptoms served to establish a legitimate relationship with the physician as the following excerpts illustrate:

I was more or less there for physical [problems] but I was getting sick from nerves. If you feel you have a problem - well most people don' t have enough money for a

psychiatrist . . . . I went through a bad marriage. The doctor helped me - she gave me suggestions. Sometimes it's mental. [It?] If you feel nervous or a real bad headache there's probably something back there causing it.

Thus, those women faced with social hardship with which they felt helpless to cope saw the physician not only as a medical expert who determines the threat of disease, but also as a person who permits the communication of feelings and

262 RITA S. GALLIN

provides guidance and advice on the management of social problems. Women wrestling with problems of low incomes and related difficulties beyond their

capacity to cope, frequently sought medical care at the center, in large part on

their own initiative. This is not to imply that their physical distress was non- bona-fide; their problems may have been induced by life difficulties rather than by a pathogen, but they were ailments that caused real pain. The women's fre-

quent use of medical services was an attempt for a cure of their physical ailments

as well as an endeavor to articulate their personal concerns and explore alterna-

tive ways to solve their problems.

CONCLUSIONS

The components of the high use of medical services, a subject heretofore neg-

lected in the social sciences, has been the major focus of this paper. The volume

and patterns of use and health status of 124 females were established from their

medical records at an ambulatory health care center. In addition, information about their life situation was collected via their responses to survey and in-depth

interview questions. Analysis of these data showed that the poor, less educated,

separated or divorced were likely 1) to feel that their social resources were only

nominally effective in mediating between them and the pressures of life-strains;

and 2) to define the breadth of the physician's authority broadly. It was found

that these women visited the health center more frequently for vague, unorganized symptoms than women whose situations were less burdened. The paper

showed that the disadvantaged women's high use of medical services was an

attempt to deal with their distress - social, psychic, and somatic - and consistent with and an adjustment to their deleterious life situations.

These findings would seem to have important implications for further re-

search in sociology and anthropology since they are suggestive, rather than definitive. For example, although the findings isolated some factors which could

account for variations in utilization among females, they did not address the question of differences in the use of medical services between males and females.

Given this limitation, it is not known to what extent the findings are gender

specific, or universal. For example, it was found that women experiencing distress tended to define their problem medically. Does this response hold for men or do they define their problem from another standpoint, e.g., moral or

social? (See also Mechanic 1976: 34). If sexual differences in definitions of distress do exist, what are they and of what are they a product? It also was

found that women whose capacity to cope with life-strains was impaired frequently used medical services. Does this behavior hold for men or do they employ different coping responses to deal with economic and social pressures, e.g., alcohol or drugs? If sexual differences in coping repertoires do exist, what


are they and what are their bases? Further research is needed to account for the

variations between the sexes in the utilization of health services.

The findings of this study also would seem to have implications for future

planning of health programs and policies, particularly those directed toward a

population group such as that described in this paper. To understand these

implications let us return to the three explanatory models of health care be-

havior discussed earlier. It was seen that each accounts for the illness behavior

of individuals differently. Each also implies, as Gibson has noted (197i : 635),

" . . . different and at times, contradictory strategies for change." For example,

a social-pyschological explanation implies that illness behavior is manipulatable

by direct means through, for example, patient education programs. Similarly, a

micro-structural approach implies an interventionist strategy, but one that

effects reforms in the existing structure of the health care system rather than in

its clientele. By contrast, a macro-functional paradigm implies that changes in

illness behavior will not occur via planned intervention, but rather will come

about indirectly as a result of a restructuring of American society.

Are any of these approaches likely to provide a basis for successful systemic

change? It seems unlikely that the social-psychological approach can: how will

disadvantaged patients benefit from attempts to reduce their expectations to a

level congruent with the system's ability, or willingness, to respond? It seems

more likely that the micro-structural and macro-functional approaches can

generate useful goals. First, effecting reforms in the existing structure o f the

health care system - for example, expanding the size o f the medical profession

relative to the clientele by utilizing nurse practitioners or physician's assistants

- could create a less rejecting context in which patients were able to com-

municate their concerns and to receive the support and advice they now seek

from the physician. Second, eliminating economic, social, and political inequali-

ties could create an environment in which the disadvantaged were in a far better

position to escape from their poverty and associated difficulties. If the ultimate

goal is a healthy system, indeed a healthy society, then the two strategies are not contradictory.

Michigan State University

ACKNOWLEDGEMENTS

The project was supported by Grant Number 1 RO3 HS 02854-01 from the National Center for Health Services Research, HRA. I am indebted to C. William Given for his help and support in carrying out this research and to Elianne Riska for her useful suggestions on an earlier draft of this paper.

264 RITA S. GALLIN

NOTES

1. The population was defined as those patients who had visited the center one or more times during the six-month period of observation for a combination of routine physical examinations, acute illnesses, and/or psychosocial problems. Patients who had visited the center only once or twice during the period of observation for routinc or gyne- cological check-ups were excluded from the population. In addition, pre- or post-natal patients and chronically ill patients (i.e., patients for whom any single diagnosis was entered as a label at 60 percent or more of all visits) were excluded.

Questionnaires were administered to the subjects in their homes by female inter- viewers who ranged in age from 23 to 44 years of age. Self-administered questionnaires also were completed by the physicians at the center, but those data are not reported here. The methodology is described more fully in Gallin 1979.

2. Visits made to the center for routine physical or gynocological examinations and immunizations were excluded in all analyses.

The number of visits made to the center by subjects during the six-month observation period ranged from one to ten, with 3.4 visits the average per patient. Sixty-six patients (61.3 percent) visited the center one to three times and 48 (38.7 percent) four or more times. Of the 422 visits made, 284 (67.3 percent) were initiated by the patient and 138 (32.7 percent) initiated by the physician. Forty-nine patients (39.5 percent) initiated all of their visits and four (3.2 percent), none of their visits.

3. The measures of emotional support used in the study were developed by Caplan et ai. (1976). The measures of functional support were developed by researchers at the Insti- tute of Labor and Industrial Relations, University of Michigan for use in a study of the role of social supports in the behavioral response to job-loss.

4. An attempt was made to operationalize medical needs objectively by developing a "level of illness" index based on clinical evidence recorded in the medical chart, i.e., physical findings and results of diagnostic procedures. This attempt was not successful because the data were strongly influenced by physicians' clinical abilities as well as judgements. As Balinsky and Berger (1975: 286) have noted: "Even in the class of data referred to as clinical evidence . . , problems of diagnostic accuracy and prognosis often skew measures."

5. Symptoms were coded employing the classification system developed for use in the National Ambulatory Medical Care Survey (National Center for Health Statistics 1974). The coding of data contained in the medical records was done by a fourth-year medical student.

6. I am indebted to Professor Zola for providing me with the nine categories of malfunctioning by which he classified presenting complaints.

7, It was found that patients who presented a large proportion of "symptoms of diffuse anomalies" also were likely to present: 1) a large average number of different symptoms (r = .64, p < .001); and 2) symptoms located in a large average number of different parts of the body (r = .63, p < .001).

8. The indices of "symptoms of distress" ranged from 0.8 to 12.0, with 3.8 the average index per patient. One patient (0.8 percent) presented 0.8 "symptoms of distress" and one patient (0.8 percent) presented 12.0 "symptoms of distress." Approximately two- Fifths (41.9 percent) of the patients presented four or more "symptoms of distress" during the six-month observation period.

9. Race was not included as a variable in any of the analyses because of the small number of blacks in the sample, i.e., 14 women (11 percent). Fewer of the blacks were separated or divorced (28.6 percent vs. 39 percent for whites) but more were living on inadequate incomes (35.7 percent vs. 23.9 percent for whites). The distribution of blacks across education levels, however, was more even than it was for whites. Half of


the blacks had at least a high school education and half a college education. The percentages for whites were 74.5 and 25.5 percent, respectively.

Because the proportion of blacks in the sample was low, the proportion of lower- and lower-middle income respondents high, and the sample restricted to females 20 to 40 years of age, the extent to which the findings might be generalized is open to question. The findings, then, must be taken as suggestive of leads for further research and their generalizability left to future research.

10. Pearson product-moment correlations are used throughout the analyses presented in this paper. They provide a single number which summarizes the strength and the direc- tion of the linear relationship between two variables. The technique assumes bivariate normal distribution, linearity and a set of interval-level variables. Several authors state, however, that the Pearson correlations can be used with "imperfect data" that do not meet these assumptions (Asher 1976:26 ; Harris 1975: 7).

11. In a similar vein, women with high self-perceived medical needs and a poor perception of their health were likely to be assigned diagnoses that either could not be supported by physical findings or were psychological labels, e.g., depression (r = .22, p < .03, and r = .19, p. < .03, respectively). See Gallin 1980 for a discussion of the influence of physicians' decisions on the use of medical services.

12. Need for help with problems was a variable derived from questions that asked about the content of the respondent's social resources. For example, if a respondent indicated that she did not receive help with an activity, she was asked whether she could use help with it. A positive response was assigned a score of one, and a negative response, zero. The scores were added and an index assigned to each respondent which ranged from zero to six.

This variable, however, has an inherent weakness. That is, it is based on the assumption that those who received assistance with specified activities were satisfied with the amount or kind of help they received and did not feel a need for any additional assistance. This, of course, may not be a valid assumption and remains an empirical question.

13. The percentages for those expressing a need for help with problems among the single and married were 22 and 27 percent, respectively; among those living on adequate incomes, 29 percent; and among those who had graduated from high school or attended college, 26 percent.

14. A content analysis of these listings revealed the following distributions: agencies dealing with specific health problems, e.g., cancer, diabetes, cerebral palsy, etc. (26 percent); agencies offering fertility services and/or abortion (9 percent); agencies offering financial or legal advice (8 percent); agencies dealing with problems of mental health (6 percent); and agencies sponsored by church or ethnic groups (8 percent), neighborhood coalitions (6 percent), and local government (5 percent). It was impossible to establish the type of service offered by or sponsor of 29 percent of the organizations listed.

The telephone book also contained categorial listings for thirty-three marriage and family counselors, twenty psychologists, and seven social workers.

15 Eighty-eight percent of the women interviewed in-depth believed that the physician should be responsible for socioemotional as well as physical problems. Among these women, 60 percent felt that the physician should accept this responsibility him- or herself, rather than refer patients to other professionals.

In the survey questionnaire, 56 percent of the respondents said that they felt the physician was a suitable person to talk with about personal problems. (Thirty-one percent responded that he was not suitable and thirteen percent were not certain or qualified a positive answer with remarks such as " . . . if you feel comfortable with him.") Sixty percent of the survey sample, moreover, indicated that they had talked with their doctor about personal problems.

266 RITA S. G A L L I N

16. Only four (1 percent) out of the 422 visits made during the six-month observation period were solely for socioemotional problems. However, data in the medical records indicated that life problems were discussed at an additional 53 visits (13 percent). The most frequently discussed problems recorded were marital problems (23 percent), followed by economic problems (18 percent), and parent-child conflicts (15 percent).

It is possible, of course, that life difficulties were discussed at some of the other visits but not entered in the medical record. For example, the medical student who coded the medical record abstract believed that one explanation for the large number of entries of "all findings normal" in the medical records might be the orientation of the physician. According to him: "Most physicians keep their assessment of the patient's psychosocial debility in their minds, not in the medical chart. As a consequence, they reschedule visits, enter a benign organic diagnosis and 'normal' in the chart, and use the visit as a counseling session." It should be remembered, however, that those burdened with difficult life situations tended to have more self-initiated, than physician-initiated, visits to the center.

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