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Everyday illness behavior: A situational approach to health status deviations
Soc. Sci. & Med.. Vol. 13A. pp. 397 to 404 Pergamon Press Ltd 1979. Printed in Great Britain
EVERYDAY ILLNESS BEHAVIOR: A S I T U A T I O N A L A P P R O A C H TO HEALTH STATUS D E V I A T I O N S ANGELO A. ALONZO Department of Sociology, The Ohio State University, Columbus, Ohio 43210, U.S.A. Abstract--Individuals who seek medical care clearly represent only the tip of the illness iceberg. To explain how individuals cope with medically unreported health status deviations, a situational conception of everyday illness behavior is proposed. The primary assumption of this conceptualization is that illness and pathology may not be reported because persons are able to contain signs and symptoms of illness within socially defined situations. Several factors influence this process, namely: (a) commitment to and engrossment in situations; (b) tolerance quotient and idiosyncrasy credit given by others; (el power relationships among participants: (d) coping resources of the situations; (e) symptom meaning; (f) the presence of normal processes and chronic diseases; and (g) age and sex as circumstances. Definitions of illness emerge when there is a cumulative decline in the individual's ability to contain sign and symptoms over a significant proportion of his "situation set". How illness emerges and is contained within daily social situations in the absence of medical care is a significant issue in the development of health care policy.
defined situations against the total background of daily life and relations with others E13, 17, 18] and that it is within these defined situations that the individual, social structure, culture and biology intersect. To understand this intersection requires a social psychological perspective wherein the individual is viewed as a social psychological actor who attempts to interpret, to evaluate and to cope with body state deviations by initially mobilizing situational resources. In considering the relationship between signs and symptoms of illness and/or injury, and social situations, the focal issue is whether or not the individual can handle or manage health status deviations and remain within the situation and whether socially defined situations can be ongoing while one (or more) of its participants are symptomatic. For our purposes, the interaction between body state deviation and the social situation will be termed the process of containment. That is, we shall see if the body state deviations can be contained within social situations while retaining definitional and participatory integrity. It will be argued that everyday, typical signs and symptoms of illness and injury will not reach medical attention if individuals can contain them in their daily situational settings. Such signs and symptoms are of the type reported in studies of illness and self-medication behavior [4, 19, 20]. Examples of the most frequently reported types are: cough, cold, and flu sy.mptoms; aches, stiffness, swelling, or pains in joints or muscles; headache; indigestion and stomach ache; breathlessness and wheeziness; rashes, itches or other skin troubles; diarrhea; faintness or dizziness; backache; OBJECTIVES burns, bruises, cuts or other accidental trauma; feeling and appearing fatigued; "female complaints"; The purpose of this paper is to develop a conceptual understanding of signs and symptoms of illness hemorrhoids; nausea; chest pain and discomfort; ear and, to a lesser extent, injury which do not receive and hearing trouble; teeth, gums, and jaw pain and medical attention, but yet may be socially and mediproblems; fever; and eye trouble. Any one of these cally significant and consequential. This conceptual signs and/or symptoms can potentially be an indiapproach rests primarily on the assumption that the cator of a more serious pathological condition or an process of illness definition emerges within socially insidious chronic disease. 397 INTRODUCTION
Generally it is agreed that objective pathology of disease is neither a necessary nor a sufficient condition to prompt the seeking of medical care [,,1]. In fact, seekers of medical care represent only the "tip of the iceberg" in terms of existing illness and pathology [2-6]. Even though illness may be more prevalent than health--setting aside issues of definition--there also is little information as to how presumably healthy individuals perceive or cope with signs and symptoms of health deviation aside from ignoring or tolerating them [-7], engaging in self-care and selftreatment activities [4, 8], or accepting them as a part of divine purpose [9]. In essence, these observations suggest that illness or some health status deviation is an everyday, typical experience. An emphasis on medical consultation as an indicator of illness, resulting largely from a dependence on the Parsonian sick role conception [10], has tended to limit and narrow our perspective of how individuals define and cope with illness or a health status deviation as an everyday experience [11-13]. A broader approach begins with the assumption that illness definition is a selective, interpretative and evaluative process [7, 9, 14-17] and seeks to specify the analytic level at which the process can be most effectively described and explained. That is, it addresses the question: can sign and symptom attentiveness, interpretation and evaluation best be understood at the cultural, structural, psychological, social psychological or biological level?
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The initial impetus for a situational approach to illness derives from two comprehensive studies of ill- . ness behavior surrounding acute episodes of coronary heart disease, where it was repeatedly observed that factors having the greatest impact on the duration of time from acute symptom onset to definitive medical care were not background or demographic lactors, but situational variables such as location and time of acute illness onset, medications available, number and relationship of lay others present, and the defined occasion at onset [21]. For example, one individual was stricken in the midst of a bowling game and could not "let down" his fellow teammates; another was in the midst of a large birthday party given in his honor and could not "disappoint" the guests. In both instances, these individuals continued their activities, despite signs and symptoms of chest pain, shortness of breath and perspiration, until a time considered more appropriate to take leave of the occasion. Defined situations can promote or discourage the acceptability of defining one's self as ill, unless, of course, the biophysical nature of the illness intervenes and removes an individual from participation in the situation. BACKGROUND
Surprisingly, a situational orientation has considerable implicit support, if not explicit development [-13, 14, 17, 22-26). In various studies the terms situational factors, variables, constraints and enablements have been used as specifying or modifying elements in illness defining and care seeking behavior. For example, Petroni [27] defines family size and income as situational variables; Ludwig and Gibson [28] use experience with welfare, lack of faith in the medical care system, and an unfavorable life as situational variables; Zola [29] uses the concept of the "situation of poverty" as a cause of illness; Lipowski [30] vaguely defines situation as the constellation of intraand inter-personal factors; McKinlay [3] uses situation to represent differences in role expectation between professional and manual workers; and Kirscht et al. [31] focus on resources and psychological dispositions which constrain behavior as features of the situational matrix. Though there is considerable diversity in what is included under the rubic of situation, inspiration and support for situational conceptions frequently derive from an interactionist perspective [32-34]. Within an interactionist framework, the individual is not conceived of as evaluating signs and symptoms according to any intrinsic meaning. Instead, paraphrasing Stone and Farberman [33, p. 149] in their discussion of words and situations, signs and symptoms of illness must be interpreted in terms of transactive situat i o n s - a s situated conduct--for it is in concerted situational responses that signs and symptoms are given meaning. To develop the situational approach to illness and the notion of containment, we will consider first the nature of signs and symptoms or what it is that must be contained. Next, attention will be given to the socially defined situation, or container, and to the concept of side-involvement--both of which together are the essential elements in sign and symptom con-
tainment. Then, a typology of situations will be considered to show how situations may vary in their ability to contain signs and symptoms. Finally, we will look at factors which promote or lessen one's ability to contain signs and symptoms within socially defined situations. BIOPHYSICAL REALITY
As Clausen [35] notes, insufficient attention has been devoted to the way in which individuals come to label their own bodily states. To an extent, we have used an absolutist approach to disease and assumed that meaning resides in the disease itself, rather than in the situation where it arises [13, 17, 36]. Illness, like any situationally defined object or "fact", does not speak for itself but rather emerges from the interaction of biophysical sensations and the processes of social selection, interpretation and evaluation [9, 14, 16, 17, 37, 38]. Laing [39] suggests that these bodily sensations tell us that we are embodied or confirm, as Berger and Luckman [40] argue, that we are a body and we have a body and that the balance between the two is constantly redressed. (I will forego the issues of mind-body dualism implied here and refer the reader to Burnham [41] for the current status of this continuing debate.) While we constantly interact with our environment and experience ourselves, we receive a multitude of bodily sensations which must be interpreted and evaluated. Becker [42], borrowing from Bartlett's theory of memory, suggests that these sensations are given meaning by being compared to previously stored experiences. With Garfinkel's notion of social "background expectancies" [43] in mind, it can be suggested that we each develop "bodily background expectancies" which are conditioned by illness experiences, sociocultural milieu, and most importantly, current situational contingencies. Our body and our expectancies of it, both impose and dispose themselves to our action. The construction of action, in the Meadian sense [44], with unencumbered bodily compliance generally has been interpreted as health, while interference with normal activity has been interpreted as illness [7, 13, 18, 45-47]. However, as noted previously, individuals experience more symptoms than are ever acknowledged as medically treatable problems. Thus incapacitation may be too gross an indicator, applying primarily to those seeking medical care and implying that these individuals have limited commitment to everyday social situations and became engrossed instead with troublesome bodily sensations. The chronically ill may bring signs and symptoms to situations; professional athletic situations may produce signs and symptoms; unanticipated situational demands may produce sensitivity to bodily status to determine if these demands can be met; and situations may be defined as therapeutic where signs and symptoms are the main focus of attention. Sign and symptom transformation from a biological facticity [40] to a social facticity should not be viewed as leading to social incapacitation; rather, it should be considered in terms of containment. Given the typical nature of signs and symptoms and their potential to interfere with normal activity, how do individuals manage to fulfil normal social
A situational approach to health status deviations roles and obligations? In answer to this question, let us turn to features of social situations which are conducive to the containment of signs and symptoms. SOCIAL SITUATIONS
Socially defined situations and occasions are necessary conditions of human conduct [33]. Gonos argues that situations "represent a potential world that answers all questions about what it is that shall be taken by participants as real, and how it is that they should be involved in this reality" [48, p. 860]. Goffman [49] suggests that people strive to be involved in situations for they are a little social system, a little social reality that individuals come to sustain wherein subjectively meaningful (and, as Gonos [48] suggests, mundane) transactions occur and much of our social life is given organization. Holzner adds that "society appears as a multitude of timed and spaced situations which define the living environments of individuals who are, also, distributed in space and time" [32, p. 80]. Whether situational reality is conceived as problematic [50] or taken for granted [43], individuals are continually constructing and confronting emergent, engrossing and negotiable situations which are meaningfully and normatively bounded. The normative dimension presents itself to us as rules or a grammar whereby situational elements [51] are typically assembled, arranged, manipulated and controlled 1-33]. I N V O L V E M E N T AND SIDE-INVOLVEMENTS
Goffman's [49] treatment of situational behavior, places considerable emphasis on the rules of involvement and how individuals negotiate and juggle situational claims and obligations. For Goffman, involvement refers to the "capacity of an individual to give, or withold from giving, his concerted attention to some activity'~ (49, p.43). He also speaks of involvement contours, wherein involvement may vary over the course of the occasion, but what actually varies over time is the "tightness" or "looseness" of the situation, with, of course, some situations being inher= ently defined as loose or tight. A tight situation is one where there are many onerous situational obligations, while a loose situation is relatively free of such situational constraints [49]. By being involved, the individual demonstrates that he is in play, alive to, oriented in and open to what the situation may. bring. Goffman further recognizes that we are always faced with the biophysiological fact of our existence and that there will always be a desire, in even the most circumspect of situations, to "shift slightly, scratch, yawn, cough, and engage in other side-involvements affording 'creature release'" [50, p. 204]. Having a side-involvement means giving one's attention to objects subordinate to the dominant focus of a situation. The range of signs or symptoms of "the animal", as Goffman terms them, may range from these creature releases to more flagrant violations of situational decorum; for example, • belching, flatulence or incontinence. He terms this range of side-involvements "auto-involvements", In a second type of side-involvement, referred to as
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"aways", the individual gives attention to other "worlds" in which he alone participates; these aways are exemplified by reverie, woolgathering, or daydreaming [49]. Both types of side-involvement represent "insufficient situational presence" and are of concern to others, relative to the looseness or tightness and involvement contour of the situation. CONTAINMENT
Signs and symptoms as part of bodily background expectancies (e.g. normal processes or chronic disease), illness, or situational participation may be viewed as side involvements and may be contained if they can be kept from becoming the dominant involvement for the individual and others in the situation. Containment measures, such as suppressing signs and symptoms, disattending them, concealing or shielding them, or openly attending them [50], must be integrated into the involvement-contour and role demands and obligations of the situation. Containment involves maintaining proper situational involvement while keeping bodily derelictions at the level of a side-involvement, either as an "auto-involvement" or as an "away". Individuals enter situations with bodily background expectancies, but situations, themselves, it may be argued, have bodily performance and impact expectancies which are a part of the constitutive features of each situation. Bodily performance expectancies indicate what physical or mental capacities, skills, reserves or conditions are expected of participants. Impact expectancies refer to the consequences of bodily interaction with situational objects and environment. A picnic volleyball game requires certain capacities of participants and also offers the possibility of physical pain and discomfort as a consequence of bodily collisions, excessive fatigue, and high temperatures. Situations can be thought of in terms of their capacity to contain and their potential to produ.ce signs and symptoms either during or after participation. SITUATION TYPES
It is possible to provide a limited and tentative typology of situations on the basis of their potential for producing and containing signs and symptoms. The first type (Type I) encompasses most daily situations where participation is not expected to produce signs and symptoms, setting aside the latent and unforseen affects of stress, unknown toxic substances, and radiation. Body state deviations in these situations are containable as side-involvements within the involvement contour of the situation. Examples of this type include attending school, commuting, family dining, dating, and reading. A second type of situation (Type II) produces or has the potential to produce signs and symptoms of illness and/or injury currently or in the future. Here there is an expectancy that participation will have an impact on one's body state, and because it is anticipated or likely, there are generally resources for and/or training in prevention and containment. Some primary examples are: professional and amateur athletics, high risk occupational settings and periods of
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excessive demands in daily situations, i.e. final exam role set [54], a "situation set" wherein role sets are periods, periods of increased work, or possibly rites played out and contained. In other words, each status of passage or other initiation rituals. Because illness and role set is attached to a situation set within which and/or injury may be anticipated, there is a greater each individual of a given status is likely to be found range and severity of signs and symptoms that are and expected to particiPate. Thus definitions of illness or injury, requiring special self or medical care, containable than in the first situation type described. A third type of situhtion (Type III) suggests that etnerge as an individual and/or others perceive more social life is not so tight and encompassing that indi- and more situations to be incapable of containing signs and symptoms. The primary issue raised is that viduals are not able to take or are not accorded moments and periods of "free time" or "breaks in illness is not a dichotomous state, but that it results the action" for the purpose of tending to bodily needs from a cumulative process in which an individual and derelictions. They can generally "take leave" [49] and/or others evaiuate the degree of containment over of situations for the purpose of coping with incipient the range of situations associated with his situation or established illness, normal processes (e.g. fatigue, set. menstruation), and chronic diseases. These periods Unless he is the object of heroic medical intervenmay be breaks in everyday situations or transitional tion where the circumstances of care precludes everysituations between situations, such as taking an day role enactment [55], the individual may still aspirin, resting briefly, tending to bandages and dress- retain vestiges of his role set and, therefore, situation ings or stretching a cramped muscle while going • set. If Type III situations increase in number and between meetings. These activities are more extensive duration, Type I and II situational participations may than auto-involvements because for a brief period of become more difficult, indicating that signs and symptime, they are the dominant involvement, and they toms cannot be situationally contained. But the unmay also be less specific than the range of containability of signs and symptoms does not occur side-involvements allowable in the second type of uniformly or simmultaneously across the entire situsituation. Associated with each type of situation is ation set. The individual may not consider himself a range of containable derelictions; for example, stu- ill enough to miss work but too ill to attend a dinner dents during exam periods may be allowed psychotro- party or vice versa. Although one may argue that pic drugs for anxiety and associated symptoms, but ~secondary gain deriving from illness should be may not be able to contain signs and symptoms of avoided by our expecting consistent behavior in terms hepatitis. As an individual attempts to "sneak" or of what he wishes to avoid or wishes to do, Parsons' extend these types of situations or periods, he may [10] view that the sick role seeks to control secondary begin moving toward an illness state, or the fourth gain is again too narrow a view. Let us assume intype of situation. stead that individuals prefer to remain in situations In this fourth type (Type IV), termed diagnostic, where containability is feasible. It may well be that illness, health training, or therapeutic situations, loose, less demanding situations are easier to particibodily problems are given dominant situational atten- pate in and appear to others as more "fun"; therefore, tion, In these situations illnesses, normal processes participation is less acceptable. With the exception (e.g. child birth), and chronic diseases are managed of the impaired role [56] among the chronie~tlly ill, or coped with and acknowledged as being uncontain- being ill or injured is an ambiguous position because able in the course of everyday typical situations. Ac- of the variability of containment that each individual tivities may range from self-imposed home convales- may find in his situation set. In an attempt to specify cence for flu, to heroic intervention within an emer- further the process of containment, certain analytic gency medical setting. An important activity within factors or variables and their interrelationship at this these medical situations is health training where tech- preliminary stage of conceptualization need to be niques and strategies of containment or qf "passing" considered. [52] are learned and practiced. La Maze training, breathing techniques for emphysema patients, manF A C T O R S IN C O N T A I N M E N T agement of medical regimens and recognition and prevention of medical crises are examples. The priFirst, whether bodily sensations intrude themselves mary focus of attention in medical situations is the upon our consciousness or result from our actual parapplication of medical resources to contain signs and ticipation in situations, the attention given to these symptoms of illness and injury within parameters of sensations is affected by an individual's and/or others" normal social and biologic functioning. Here death engrossment in and commitment to the situation. may represent the final problem of containment Engrossment refers to the level of attention given to where the issue shifts from sustaining situational re- the dominant focus of the situation to the exclusion ality to sustaining life within the body, given biologic of side-involvements and extraneous features in and incapacities or damage. out of the situation. Soldiers in the heat of battle, Situational containment of signs and symptoms is it is reported, may sustain potentially painful injuries generally accomplished within the first three situation that do not trouble them until after they are safely types. In considering the transition to the fourth type, back at camp [50]. Heart attack patients may someor sick role status [53], individuals are generally con- times attempt to become intensely involved in their ceived of as having only a single role with which to work or leisure activity to disattend evolving coronconcern themselves when making this decision. A ary symptoms [21]. To the extent that signs and major consideration, in attempting to understand why symptoms require one's attention and lessen one's most illness goes unreported, but not unattended, is ability to become engrossed, containment is that individuals possess, in addition to a status and diminished or compromised. Also at issue is whether
A situational approach to health status deviations the involvement contour of the situation offers a focus of attention sufficient to engross the individual despite his condition. Commitment, using Becker's [57] conception, refers to attachment to situational interest, projects or goals within a particular situation and/or over a range of situations to the exclusion of other potential situational attachments. Situations, moreover, provide commitment as they may be part of the individual's identity, and his participation represents personal attachment [49]. As noted above, individuals have situation sets and are frequently known not only by the company they keep, but also by the situations in which they are found and by their commitment to interpersonal relationships found therein. Thus attentiveness to and the meaning of signs and symptoms is evaluated and given significance in light of situational engrossment and commitment. Yet it is also possible to suggest some circularity, as does Twaddle [58], when discussing the conditions of sick role release. Engrossment and commitment may depend on sign and symptom severity while evaluations of severity are dependent on the engrossmerit and commitment one can maintain. While there is no simple way out of this interaction, obviously, overwhelming incapacitation, i.e. unconsciousness, may preclude participation. On the other hand and consistent with the prevalence of unreported illness, some situations are so engrossing and so much a part of an individual's identity that he is oblivious to signs and symptoms and/or feels so obligated and committed to a particular situation that continued participation and containment are believed essential and appropriate. Second, whether or not an individual is engrossed or committed, the meaning and evaluation of his participation derives from his and others' assessment of his role enactment [59,60] i.e. "...gross skeletal movements, the performance of verbal and motoric gestures, posture and gait, styles of speech and accent, the wearing of certain forms of dress and costume, the use of material objects, the wearing of emblems or ornamentation...etc." [55]. Others, as status definers [60] in the situation, are either made aware of health status changes or observe their behavioral manifestations in role enactment. Containability is influenced by others' actual assessment and response and by an individual's conception of others' assessment of his behavior. Others become arbiters of situational goals, performance norms and constitutive propriety to which an individual must appeal if. he wishes to be excused or remain in the situation. Situations may contain compromised involvement and role enactment to the extent that "tolerance quotients" [61], "idiosyncracy credits" [62], and "benefit of the doubt" [33] are provided to an individual. These conceptions imply flexibility with regard to situational derelictions, but more importantly, they address the constitutive nature of situational reality, that is, they indicate how much dereliction in involvement a situation may contain before its definition is altered or collapsed. Again, the tightness or looseness and involvement contour of the situation greatly influence how tolerant others are of compromised role enactraent. But each individual is also provided with a certain degree of idiosyncracy credit which he has
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accumulated by appropriate situational involvement and role enactment in the past. If, however, the individ u a l has not accumulated such credit or has exhausted it, he may be asked to leave the situation, the situation may move from his presence, or it may collapse if he does not take leave of it. Third, and very much related to the above issues, Mechanic [63] and Scheff [64] suggest that the position and power of an individual is important in attempting to define him as either physically or mentally ill. I,lere the question is, who has the constitutive power to define, change, or terminate situational definitions, e.g. in a classroom situation, who has the power to begin or end class? Obviously there is a differential distribution of constitutive and sustaining power in situations. Some individuals with little power may be asked to leave situations if they become symptomatic; others may be asked to remain despite signs and symptoms. While studying acute coronary episodes, it was observed that family members usurped control of the illness situation and summoned emergency medical services more easily for an older, widowed woman living with her children than for a male head of the household [21]. Power further allows an individual to alter his own idiosyncracy credit as well as to act in behalf of less powerful, symptomatic persons. Containment then, must be considered in terms of the relative power relations between the symptomatic individual and others in the situation. Fourth, even though an individual is able to provide excuses [65] or disclaimers F66], rely on an idiosyncracy credit, or use power, propriety remains an issue. Given one's condition, should an individual attempt to remain in the situation? Is he giving proper deference to the occasion by remaining despite compromised performance, potential for contagion or cost and danger to others? Airline pilots and persons directly responsible for the safety of others should be aware of their incapacities [67]. If a work group is dependent on piece work for its wages, compromised performance is not desirable [59], especially if healthy substitutes are available. In this and similar contexts idiosyncracy credit may be consumed quickly. There is a fine line between altruistic commitment and containment and an affront to situational propriety and common sense in the face of signs and symptoms, especially if continued participation has morbid and mortal consequences. Fifth, for containment to be sustained, situational resources are required to cope with and manage signs and symptoms. Coping in this context implies the mobilization of resources to affect a change in the course of signs and symptoms or to change environmental causes. Resources can be broadly" defined to include anything that the individual and others, when involved, perceive as aiding in coping. Resources can range from asking solneone to speak more softly when one has a severe headache to asking another to bandage a laceration. In this context, asking for idiosyncracy credit--whether by virtue of power or pleading--is a resource just as being able to "take it easy" to reduce symptoms or conserve energy in one situation to perform more adequately in another is a resource. Thus, power, itself, may be a situational resource.
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Aside from modification in performance standards, prescribed and proprietary medications can also be consumed to relieve and/or conceal signs and symptoms. Consumption or application of these medications are examples of side-involvements, as are selfmanipulation activities, oriented toward testing capacities-activities such as seeing what movements make symptoms worse, changing posture or stance, and reducing an activity's duration, intensity and/or type. Efforts at containment can be prolonged by what may be termed, the "'effect interval" of coping activities. During this time individuals and others wait to observe the effectiveness of resources expected to contain signs and symptoms. Appearances of coping behayior which can be kept a.t the level of a sideinvolvement or within transient Type III situations, facilitates tolerance and provides signs of effort to remain involved and committed to the situation. However, as noted above, remaining in a situation beyond the point of propriety or potential harm to others is inappropriate. Thus, the failure or success of coping resources may directly affect one's ability to contain health status deviations within situational boundaries. Sixth, for individuals with chronic diseases and those experiencing normal processes, i.e. maturing, growing ol.der, or being pregnant, the process of containment focuses on the avoidance of situations where signs and symptoms and/or incapacities could be potentially uncontainable. As Goffman notes, an individual tends to avoid situations where the necessary commitment is beyond his capacity or "the occasion would be too much for him" [49, p. 206]. Other situations where these conditions might be exacerbated are also avoided, or negotiated participation is arranged, so that tolerance quotients are raised or performance norms lowered [67]. The chronically ill place themselves or are placed in "containing" situation sets as are individuals experiencing normal processes. In either case, some individuals are excluded from situational participation, e.g. pilots with coronary heart disease are made to retire or pregnant women are restricted from flying toward the end of the last trimester; the decision of containment is made for them. In addition, Type IV therapeutic situations may be typical for some chronically ill who are expected to prepare for otherwise "normal" situational participation, e.g. periods of hemodiaylsis for the chronic renal failure patient. A lack of containment for the chronically ill and some individuals with normal process problems may indicate a greater health status deviation than tbr presumably "normal" individuals given their already containment selected situation set. Seventh, although individuals generally attempt to normalize [7] and contain signs and symptoms and their meaning and consequences arise within a situational matrix, it must be argued that the meaning and significance of certain signs and symptoms exist independent of specific situations. This situation is especially true for illnesses which are prevalent at a particular time or which have precipitant manifestations and have received considerable public education; for example, signs and symptoms of myocardial infarction or specific types of flu. While flu symptoms may be contained and tolerated because of their gen-
eral prevalence, those of myocardial infarction have meaning and significance beyond the immediate situation in terms of morbidity and mortality. Yet, as was noted earlier, situational definitions can constrain an individual from responding to morbid and potentially mortal illness episodes. There are instances when situational reality is collapsed by signs and symptoms, or containment is not a viable alternative to a therapeutic definition of the situation. In a sense these instances represent the influence of biological intrusion beyond that expected from our bodily background expectancies. Eighth, aside from the issue of power and implicit assumptions regarding differential containment as affected by age and chronic disease, social structure explicitly influences containment by the impact of sex as a circumstance. As Stone [68] argues, females are trapped, ensnared or fated by virtue of the meaning attached to gender. Goffman [49] observes that the behavior and performance surrounding women is more tightly defined than it is for men. Females, whether by virtue of their biologic endowment, their tightly defined role behavior, or the nature of the situations in which they find themselves, tend to report more episodes of illness and compromised role performance than do males. [69, 70]. Defining females tightly and providing them with roles where commitment may be low [69] provides greater opportunity to assume illness status. Females may not be expected to contain symptoms to the degree males are expected to. In situations where commitment and involvement are greater, where females have younger rather than older children in the home, they are less inclined to assume the sick role [71]. Women are allowed to take leave readily rather than attempt to contain signs and symptoms. CONCLUSIONS
This preliminary inquiry into the interrelationship between everyday typical signs and symptoms of illness or injury and socially defined situations essentially describes everyday illness behavior (EIB) wherein the principle social process in containment. In the present context, EIB applies to the continuum of body state deviations, ranging from incipient awareness of body presence and sensations to acute illnesses, but not including illnesses if a decision to seek medical care is made because the signs and symptoms of illness or injury cannot be contained. The majority of illnesses, injuries, and health status deviations fall somewhere along this continuum and are containable within everyday social situations. Health and illness definitions within an EIB perspecti{,e are variable and emerge from a cumulative assessment of an individual's situation set, bodily background expectancies, and degree of achieved containability. In contrast to considerations of the social control functions inherent in Parsons' sick role--for example, the control of secondary gain, EIB focuses more specifically on the positive aspects of successful containment and compromised role performance. A basic assumption is that individuals desire to remain involved in dally social situations. In addition, it may be reasonable to assume that far greater social control is exerted over health deviations within everyday situ-
A situational approach to health status deviations ations than within the sick role, judging by the pervasive nattu'e of unreported illness. These varied and diffuse mechanisms of control require further articulation and specification as this preliminary conceptualization has attempted. At a broader societal level, discovery of the processes leading to containment in everyday social situations provides a glimpse of self-care and self-treatment strategies that appear to be effective. The implications of these strategies extend to issues of health care delivery and utilization; health care costs; and health care policy. Of course, the consequences of containment may lead, in some instances, to increased morbidity and mortality as with acute coronary episodes or neoplastic diseases. However, as Illich [72] argues, the benefits of what here has been termed containment probably far outweigh the potentials for social, cultural and/or clinical iatrogeneses resulting from contacts with health care practitioners. If health is a day-by-day and everyday activity [73], the concept of EIB suggests that broader issues of health policy should be informed by how the majority of individuals successfully contain health status deviations. At this preliminary point in conceptual development, any empirical exploration of EIB should use an inductive, in vivo methodological strategy to assess actual individual experience with arid response to signs and symNoms of illness and injury. While one can appreciate the control and analytic measurement afforded by in vitro research strategies, they fail, as Robinson [18] and Dingwall [17] argue, to view the behavior surrounding illness within a meaningful social context. The grounded theory approach suggested by Glaser and Strauss [74] with its inductive bias would allow further specification and development of the coocept of containment and would clarify the eight contributory factors suggested above. There is a need to ask how individuals actually manage health status deviations in everyday typical social situations, not how they think they would manage them. By using this approach we may begin to understand the lower part of the illness iceberg. Acknowledgement--I would like to express my appreciation to Paul Luken for his comments on earlier drafts of this paper.
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6. Hinkle L. E. Jr and Wolff H. G. Health and the social environment: experimental investigations. In Explorations in Social Psychiatry (Edited by Clausen J. A. and Wilson R. N.) p. 105. Basic Books, New York. 1957. 7. Mechanic D. Medical.Sociology, The Free Press, New York, 1968. 8, Levin L. S., Katz A. H. and Hoist E. Self-Care: Lay Initiatives in Health, Prodist, New York, 1976. 9. Zhorowski M. People in Pain, Jossey-Bass Inc., San Francisco, 1969. 10. Parsons T. The Social System, The Free Press, Glencoe, Illinois, 1951. 11. Gold M. A crisis of identity: the case of medical sociology, J. H l ~ soc. Behav. 18, 160, 1977. 12. Segall A. The sick role concept: understanding illness behavior. J. Hlth soc. Behav. 17, 162, 1976. 13. Herzlich D. Health and Illness, Academic Press Inc., London, 1973. 14. Zola I. K. In the name of health and illness: On some socio-political consequences of medical influence. Soc. Sci. Med. 9, 83, 1975. 15. Koos E. L. The Health of Regionville, Columbia University Press, New York, 1954. 16. Friedson E. Profession of Medicine, Dodd, Mead & Company, New York, 1970. 17. Dingwall R. Aspects of Illness, Martin Robertson, London, 1976. 18. Robinson D. The Process of Becomin9 Ill, Routledge & Kegan Paul, London, 1971. 19. Knapp D. A. and Knapp D. E. Decision-making and self-medication: Preliminary findings. Am. J. Hosp. Pharm. 29, I010, 1972. 20. World Health Organization, Health Care: An International Study, Oxford University Press, London, 1976. 21. Alonzo A. A. Illness behavior during acute episodes of coronary heart disease. Doctoral Dissertation, University of California, Berkeley, 1973. 22. Wadsworth M. E. J. Illness behaviour and studies of communications between doctors and patients. J. Psychosom. Res. 20, 317, 1976. 23. Tagliacozzo D. M. and Ima K. Knowledge of illness as a predictor of patient behaviour. J. chron. Dis. 22, 765, 1970. 24. Berkanovic E. Lay Conceptions of the Sock Role. Social Forces 51, 53, 1972. 25. McKinlay J. B. Some approaches and problems in the study of the use of services--An overview. J. Hlth soc. Behav. 13, 115, 1972. 26. Dubos R. Man Adapting, Yale University Press, Ncw Haven, 1965. 27. Petroni F. Preferred right to the sick role and illness behavior. Soc. Sci. Med. 5, 645, 1971. 28. Ludwig E. G. and Gibson G. Self perception of sickness and the seeking o f medical care. J. HIth soc. Behav. 10, 125, 1969. 29. Zola I. K. Illness behavior of the working class: implications and recommendations. In Blue Collar World (Edited by Stostak A. B. and Gomberg W.) p. 350. Prentice-Hall Inc., Englewood Cliffs, New Jersey, 1964. 30. Lipowski Z. J. Physical illness, the individual and the coping process. Psych. Med. 1, 91, 1970. 31. Kirscht J. P., Becker M. H. and Eveland J. P. Psychological and social factors as predictors of medical behavior. Med. Care 14, 422, 1976. 32. Holzner B. Reality Construction in Society Schenkman Publishing Company Inc., Cambridge, Massachusetts. 1968. 33. Stone G. P. and Farberman H. A. Social Psycholo.qy Through Symbolic Interaction, Ginn-Blaisdell. Waltham, Massachusetts, 1970. 34. McHugh P. Definin O the Situation. Bobbs-Merrill. Indianapolis, 1968.
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35. Clausen J. A. The oranism and socialization. In Perand Research (Edited by Biddle B. J. and Thomas sonality (Edited by Heise D. R.) p. 24. Rand McNally E. J.) p. 195. Wiley, New York, 1966. Chicago, 1973. 56. Gordon G. Role Theory and Illness: A Sociological 36. Douglas J. D. Understanding Everyday Life, Aldine Perspective, College and University Press, New Haven, Publishing Company, Chicago, 1970, 1966. 37. Lorber J. Deviance as performance the case of illness. 57. Becker H. S. Personal changes in adult life. In Social Soc, Prob. 14, 302, 1967. Psychology Through Symbolic Interaction (Edited by 38. Zeitin I. M. Rethinking Sociology: A Critique of ConStone G. P. and Farberman H. A.) p. 583. Ginn-Blaistemporary Theory, Appleton-Century-Crofts, New dell, Waltham, Massachusetts, 1970. York, 1973. 58. Twaddle A. C. Health decisions and sick role vari39. Laing R. D. The Divided Self, Penguin Books Inc., Balations. J. HIth Soc. Behav. 10, 105, 1969. timore, 1965. 59. Goldstein B. and Dommermuth P. The sick role cycle: 40. Berger P. and Luckman T. The Social Construction An approach to medical sociology. Sociol. Soc. Res. of Reality, Doubleday, Garden City, 1966. 46, 37, 1961. 41. Burnham J. C. The mind-body problem in the early 60. Twaddle A. C. The concept of the sick role and illness twentieth century. Perspec. Biol. Med. 20, 271, 1977. behavior. Adv. Psychosom. Med. 8, 162, 1972, 42. Becker E. The Revolution in Psychiatry, The Free Press 61. Lemert E. /V~l. Social Pathology, McGraw-Hill, New of Glencoe, New York, 1964. York, 1951. 43. Garfinkel H. Studies in Ethnomethodology, Prentice- 62. Hollander E. P. Conformity, status, and idiosyncrasy Hall Inc., Englewood Cliffs, New Jersey, 1967. credit. Psychol. Rev. 65, 117, 1958. 44. Blumer H. Symbolic Interaction. Prentice-Hall, 63. Mechanic D. Medical Sociology, The Free Press, New Englewood Cliffs, New Jersey, 1969. York, 1978. 45. Apple D. How laymen define illness. J. Hlth soc. 64. ScheffT. J. Being Mentally Ill, Aldine Publishing ComBehav. !, 219, 1960. pany. Chicago, 1966. 46. Blackwell B. L. When do physicians expect their 65. Scott M. and Lyman S. Accounts. Am. Sociol. Rev. patients to come to them. Med. Care 7, 155, 33, 46, 1968. 1969. 66. Hewitt J. P. and Stokes R. Disclaimers. Am. Sociol. 47. Butler J. R. Illness and the Sick Role: An EvaluaRev. 4, 1, 1975. tion in Three Communities. Br. J. Sociol. 21, 241, 67. Haber L. D. and Smith R. T. Disability and deviance: 1970. Normative adaptations of role behavior. Am. Sociol. 48. Gonos G. "Situation" versus "Frame", the "InteracRev. 36, 87, 1971. tionist" and the "Structuralist" analYses of everyday 68. Stone G. P. Sex and age as universe of appearance. life. Am. Sociol. Rev. 42, 854, 1977. In Social Pscyhology Through Symbolic Interaction 49. Goffman E. Bevhaior in Public Places, The Free Press (Edited by Stone G. P. and Farberman H. A.) p. 227. of Glencoe, New York, 1963. Ginn-Blaisdell, Waltham, Massachusetts, 1970. 50. Goffman E. Frame Analysis, Harper & Row, Pub- 69. Nathanson C. A. Illness and the feminine role: A lishers, New York, 1974. theoretical review. Soc. Sci. Med. 9, 57, 1975. 51. Bennett D. J. and Bennett J. D. Making the Scene. 70. Verbrugge L. M. Females and illness: Recent trends In Social Psychology Through Symbolic Interaction in sex differences in the United States. J. Hhh soc. (Edited by Stone G. P. and Farberman H. A.) p. 190, Behav. 17, 387, 1976. Ginn-Blaisdell, Waltham, Massachusetts, 1970. 71. Cole S. and Lejeune R. Illness and the legitimation 52. Goffman E. Stigma, Prentice-Hall, Englewood Cliffs, of failure. Am. Sociol. Rev. 37, 347, 1972. New Jersey, 1963. 72. lllich I. Medical Nemesis, Random House, New York, 53. Twaddle A. C. The concept of health status. Soc. Sci. 1976. Med. 8, 29, 1974. 73. Belloc N. B. Relationship of health practices and mor54. Merton R. K. Social Theory and Social Structure, The tality. Preventive Med. 2. 67, 1973. Free Press of Glencoe, New York, 1957. 74. Glaser B. and Strauss A. The Discovery of Grounded 55. Sarbin T. R. Role enactment. In Role Theory: Concepts Theory, Aldine Publishing Company, Chicago. 1976.
EVERYDAY ILLNESS BEHAVIOR: A S I T U A T I O N A L A P P R O A C H TO HEALTH STATUS D E V I A T I O N S ANGELO A. ALONZO Department of Sociology, The Ohio State University, Columbus, Ohio 43210, U.S.A. Abstract--Individuals who seek medical care clearly represent only the tip of the illness iceberg. To explain how individuals cope with medically unreported health status deviations, a situational conception of everyday illness behavior is proposed. The primary assumption of this conceptualization is that illness and pathology may not be reported because persons are able to contain signs and symptoms of illness within socially defined situations. Several factors influence this process, namely: (a) commitment to and engrossment in situations; (b) tolerance quotient and idiosyncrasy credit given by others; (el power relationships among participants: (d) coping resources of the situations; (e) symptom meaning; (f) the presence of normal processes and chronic diseases; and (g) age and sex as circumstances. Definitions of illness emerge when there is a cumulative decline in the individual's ability to contain sign and symptoms over a significant proportion of his "situation set". How illness emerges and is contained within daily social situations in the absence of medical care is a significant issue in the development of health care policy.
defined situations against the total background of daily life and relations with others E13, 17, 18] and that it is within these defined situations that the individual, social structure, culture and biology intersect. To understand this intersection requires a social psychological perspective wherein the individual is viewed as a social psychological actor who attempts to interpret, to evaluate and to cope with body state deviations by initially mobilizing situational resources. In considering the relationship between signs and symptoms of illness and/or injury, and social situations, the focal issue is whether or not the individual can handle or manage health status deviations and remain within the situation and whether socially defined situations can be ongoing while one (or more) of its participants are symptomatic. For our purposes, the interaction between body state deviation and the social situation will be termed the process of containment. That is, we shall see if the body state deviations can be contained within social situations while retaining definitional and participatory integrity. It will be argued that everyday, typical signs and symptoms of illness and injury will not reach medical attention if individuals can contain them in their daily situational settings. Such signs and symptoms are of the type reported in studies of illness and self-medication behavior [4, 19, 20]. Examples of the most frequently reported types are: cough, cold, and flu sy.mptoms; aches, stiffness, swelling, or pains in joints or muscles; headache; indigestion and stomach ache; breathlessness and wheeziness; rashes, itches or other skin troubles; diarrhea; faintness or dizziness; backache; OBJECTIVES burns, bruises, cuts or other accidental trauma; feeling and appearing fatigued; "female complaints"; The purpose of this paper is to develop a conceptual understanding of signs and symptoms of illness hemorrhoids; nausea; chest pain and discomfort; ear and, to a lesser extent, injury which do not receive and hearing trouble; teeth, gums, and jaw pain and medical attention, but yet may be socially and mediproblems; fever; and eye trouble. Any one of these cally significant and consequential. This conceptual signs and/or symptoms can potentially be an indiapproach rests primarily on the assumption that the cator of a more serious pathological condition or an process of illness definition emerges within socially insidious chronic disease. 397 INTRODUCTION
Generally it is agreed that objective pathology of disease is neither a necessary nor a sufficient condition to prompt the seeking of medical care [,,1]. In fact, seekers of medical care represent only the "tip of the iceberg" in terms of existing illness and pathology [2-6]. Even though illness may be more prevalent than health--setting aside issues of definition--there also is little information as to how presumably healthy individuals perceive or cope with signs and symptoms of health deviation aside from ignoring or tolerating them [-7], engaging in self-care and selftreatment activities [4, 8], or accepting them as a part of divine purpose [9]. In essence, these observations suggest that illness or some health status deviation is an everyday, typical experience. An emphasis on medical consultation as an indicator of illness, resulting largely from a dependence on the Parsonian sick role conception [10], has tended to limit and narrow our perspective of how individuals define and cope with illness or a health status deviation as an everyday experience [11-13]. A broader approach begins with the assumption that illness definition is a selective, interpretative and evaluative process [7, 9, 14-17] and seeks to specify the analytic level at which the process can be most effectively described and explained. That is, it addresses the question: can sign and symptom attentiveness, interpretation and evaluation best be understood at the cultural, structural, psychological, social psychological or biological level?
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The initial impetus for a situational approach to illness derives from two comprehensive studies of ill- . ness behavior surrounding acute episodes of coronary heart disease, where it was repeatedly observed that factors having the greatest impact on the duration of time from acute symptom onset to definitive medical care were not background or demographic lactors, but situational variables such as location and time of acute illness onset, medications available, number and relationship of lay others present, and the defined occasion at onset [21]. For example, one individual was stricken in the midst of a bowling game and could not "let down" his fellow teammates; another was in the midst of a large birthday party given in his honor and could not "disappoint" the guests. In both instances, these individuals continued their activities, despite signs and symptoms of chest pain, shortness of breath and perspiration, until a time considered more appropriate to take leave of the occasion. Defined situations can promote or discourage the acceptability of defining one's self as ill, unless, of course, the biophysical nature of the illness intervenes and removes an individual from participation in the situation. BACKGROUND
Surprisingly, a situational orientation has considerable implicit support, if not explicit development [-13, 14, 17, 22-26). In various studies the terms situational factors, variables, constraints and enablements have been used as specifying or modifying elements in illness defining and care seeking behavior. For example, Petroni [27] defines family size and income as situational variables; Ludwig and Gibson [28] use experience with welfare, lack of faith in the medical care system, and an unfavorable life as situational variables; Zola [29] uses the concept of the "situation of poverty" as a cause of illness; Lipowski [30] vaguely defines situation as the constellation of intraand inter-personal factors; McKinlay [3] uses situation to represent differences in role expectation between professional and manual workers; and Kirscht et al. [31] focus on resources and psychological dispositions which constrain behavior as features of the situational matrix. Though there is considerable diversity in what is included under the rubic of situation, inspiration and support for situational conceptions frequently derive from an interactionist perspective [32-34]. Within an interactionist framework, the individual is not conceived of as evaluating signs and symptoms according to any intrinsic meaning. Instead, paraphrasing Stone and Farberman [33, p. 149] in their discussion of words and situations, signs and symptoms of illness must be interpreted in terms of transactive situat i o n s - a s situated conduct--for it is in concerted situational responses that signs and symptoms are given meaning. To develop the situational approach to illness and the notion of containment, we will consider first the nature of signs and symptoms or what it is that must be contained. Next, attention will be given to the socially defined situation, or container, and to the concept of side-involvement--both of which together are the essential elements in sign and symptom con-
tainment. Then, a typology of situations will be considered to show how situations may vary in their ability to contain signs and symptoms. Finally, we will look at factors which promote or lessen one's ability to contain signs and symptoms within socially defined situations. BIOPHYSICAL REALITY
As Clausen [35] notes, insufficient attention has been devoted to the way in which individuals come to label their own bodily states. To an extent, we have used an absolutist approach to disease and assumed that meaning resides in the disease itself, rather than in the situation where it arises [13, 17, 36]. Illness, like any situationally defined object or "fact", does not speak for itself but rather emerges from the interaction of biophysical sensations and the processes of social selection, interpretation and evaluation [9, 14, 16, 17, 37, 38]. Laing [39] suggests that these bodily sensations tell us that we are embodied or confirm, as Berger and Luckman [40] argue, that we are a body and we have a body and that the balance between the two is constantly redressed. (I will forego the issues of mind-body dualism implied here and refer the reader to Burnham [41] for the current status of this continuing debate.) While we constantly interact with our environment and experience ourselves, we receive a multitude of bodily sensations which must be interpreted and evaluated. Becker [42], borrowing from Bartlett's theory of memory, suggests that these sensations are given meaning by being compared to previously stored experiences. With Garfinkel's notion of social "background expectancies" [43] in mind, it can be suggested that we each develop "bodily background expectancies" which are conditioned by illness experiences, sociocultural milieu, and most importantly, current situational contingencies. Our body and our expectancies of it, both impose and dispose themselves to our action. The construction of action, in the Meadian sense [44], with unencumbered bodily compliance generally has been interpreted as health, while interference with normal activity has been interpreted as illness [7, 13, 18, 45-47]. However, as noted previously, individuals experience more symptoms than are ever acknowledged as medically treatable problems. Thus incapacitation may be too gross an indicator, applying primarily to those seeking medical care and implying that these individuals have limited commitment to everyday social situations and became engrossed instead with troublesome bodily sensations. The chronically ill may bring signs and symptoms to situations; professional athletic situations may produce signs and symptoms; unanticipated situational demands may produce sensitivity to bodily status to determine if these demands can be met; and situations may be defined as therapeutic where signs and symptoms are the main focus of attention. Sign and symptom transformation from a biological facticity [40] to a social facticity should not be viewed as leading to social incapacitation; rather, it should be considered in terms of containment. Given the typical nature of signs and symptoms and their potential to interfere with normal activity, how do individuals manage to fulfil normal social
A situational approach to health status deviations roles and obligations? In answer to this question, let us turn to features of social situations which are conducive to the containment of signs and symptoms. SOCIAL SITUATIONS
Socially defined situations and occasions are necessary conditions of human conduct [33]. Gonos argues that situations "represent a potential world that answers all questions about what it is that shall be taken by participants as real, and how it is that they should be involved in this reality" [48, p. 860]. Goffman [49] suggests that people strive to be involved in situations for they are a little social system, a little social reality that individuals come to sustain wherein subjectively meaningful (and, as Gonos [48] suggests, mundane) transactions occur and much of our social life is given organization. Holzner adds that "society appears as a multitude of timed and spaced situations which define the living environments of individuals who are, also, distributed in space and time" [32, p. 80]. Whether situational reality is conceived as problematic [50] or taken for granted [43], individuals are continually constructing and confronting emergent, engrossing and negotiable situations which are meaningfully and normatively bounded. The normative dimension presents itself to us as rules or a grammar whereby situational elements [51] are typically assembled, arranged, manipulated and controlled 1-33]. I N V O L V E M E N T AND SIDE-INVOLVEMENTS
Goffman's [49] treatment of situational behavior, places considerable emphasis on the rules of involvement and how individuals negotiate and juggle situational claims and obligations. For Goffman, involvement refers to the "capacity of an individual to give, or withold from giving, his concerted attention to some activity'~ (49, p.43). He also speaks of involvement contours, wherein involvement may vary over the course of the occasion, but what actually varies over time is the "tightness" or "looseness" of the situation, with, of course, some situations being inher= ently defined as loose or tight. A tight situation is one where there are many onerous situational obligations, while a loose situation is relatively free of such situational constraints [49]. By being involved, the individual demonstrates that he is in play, alive to, oriented in and open to what the situation may. bring. Goffman further recognizes that we are always faced with the biophysiological fact of our existence and that there will always be a desire, in even the most circumspect of situations, to "shift slightly, scratch, yawn, cough, and engage in other side-involvements affording 'creature release'" [50, p. 204]. Having a side-involvement means giving one's attention to objects subordinate to the dominant focus of a situation. The range of signs or symptoms of "the animal", as Goffman terms them, may range from these creature releases to more flagrant violations of situational decorum; for example, • belching, flatulence or incontinence. He terms this range of side-involvements "auto-involvements", In a second type of side-involvement, referred to as
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"aways", the individual gives attention to other "worlds" in which he alone participates; these aways are exemplified by reverie, woolgathering, or daydreaming [49]. Both types of side-involvement represent "insufficient situational presence" and are of concern to others, relative to the looseness or tightness and involvement contour of the situation. CONTAINMENT
Signs and symptoms as part of bodily background expectancies (e.g. normal processes or chronic disease), illness, or situational participation may be viewed as side involvements and may be contained if they can be kept from becoming the dominant involvement for the individual and others in the situation. Containment measures, such as suppressing signs and symptoms, disattending them, concealing or shielding them, or openly attending them [50], must be integrated into the involvement-contour and role demands and obligations of the situation. Containment involves maintaining proper situational involvement while keeping bodily derelictions at the level of a side-involvement, either as an "auto-involvement" or as an "away". Individuals enter situations with bodily background expectancies, but situations, themselves, it may be argued, have bodily performance and impact expectancies which are a part of the constitutive features of each situation. Bodily performance expectancies indicate what physical or mental capacities, skills, reserves or conditions are expected of participants. Impact expectancies refer to the consequences of bodily interaction with situational objects and environment. A picnic volleyball game requires certain capacities of participants and also offers the possibility of physical pain and discomfort as a consequence of bodily collisions, excessive fatigue, and high temperatures. Situations can be thought of in terms of their capacity to contain and their potential to produ.ce signs and symptoms either during or after participation. SITUATION TYPES
It is possible to provide a limited and tentative typology of situations on the basis of their potential for producing and containing signs and symptoms. The first type (Type I) encompasses most daily situations where participation is not expected to produce signs and symptoms, setting aside the latent and unforseen affects of stress, unknown toxic substances, and radiation. Body state deviations in these situations are containable as side-involvements within the involvement contour of the situation. Examples of this type include attending school, commuting, family dining, dating, and reading. A second type of situation (Type II) produces or has the potential to produce signs and symptoms of illness and/or injury currently or in the future. Here there is an expectancy that participation will have an impact on one's body state, and because it is anticipated or likely, there are generally resources for and/or training in prevention and containment. Some primary examples are: professional and amateur athletics, high risk occupational settings and periods of
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excessive demands in daily situations, i.e. final exam role set [54], a "situation set" wherein role sets are periods, periods of increased work, or possibly rites played out and contained. In other words, each status of passage or other initiation rituals. Because illness and role set is attached to a situation set within which and/or injury may be anticipated, there is a greater each individual of a given status is likely to be found range and severity of signs and symptoms that are and expected to particiPate. Thus definitions of illness or injury, requiring special self or medical care, containable than in the first situation type described. A third type of situhtion (Type III) suggests that etnerge as an individual and/or others perceive more social life is not so tight and encompassing that indi- and more situations to be incapable of containing signs and symptoms. The primary issue raised is that viduals are not able to take or are not accorded moments and periods of "free time" or "breaks in illness is not a dichotomous state, but that it results the action" for the purpose of tending to bodily needs from a cumulative process in which an individual and derelictions. They can generally "take leave" [49] and/or others evaiuate the degree of containment over of situations for the purpose of coping with incipient the range of situations associated with his situation or established illness, normal processes (e.g. fatigue, set. menstruation), and chronic diseases. These periods Unless he is the object of heroic medical intervenmay be breaks in everyday situations or transitional tion where the circumstances of care precludes everysituations between situations, such as taking an day role enactment [55], the individual may still aspirin, resting briefly, tending to bandages and dress- retain vestiges of his role set and, therefore, situation ings or stretching a cramped muscle while going • set. If Type III situations increase in number and between meetings. These activities are more extensive duration, Type I and II situational participations may than auto-involvements because for a brief period of become more difficult, indicating that signs and symptime, they are the dominant involvement, and they toms cannot be situationally contained. But the unmay also be less specific than the range of containability of signs and symptoms does not occur side-involvements allowable in the second type of uniformly or simmultaneously across the entire situsituation. Associated with each type of situation is ation set. The individual may not consider himself a range of containable derelictions; for example, stu- ill enough to miss work but too ill to attend a dinner dents during exam periods may be allowed psychotro- party or vice versa. Although one may argue that pic drugs for anxiety and associated symptoms, but ~secondary gain deriving from illness should be may not be able to contain signs and symptoms of avoided by our expecting consistent behavior in terms hepatitis. As an individual attempts to "sneak" or of what he wishes to avoid or wishes to do, Parsons' extend these types of situations or periods, he may [10] view that the sick role seeks to control secondary begin moving toward an illness state, or the fourth gain is again too narrow a view. Let us assume intype of situation. stead that individuals prefer to remain in situations In this fourth type (Type IV), termed diagnostic, where containability is feasible. It may well be that illness, health training, or therapeutic situations, loose, less demanding situations are easier to particibodily problems are given dominant situational atten- pate in and appear to others as more "fun"; therefore, tion, In these situations illnesses, normal processes participation is less acceptable. With the exception (e.g. child birth), and chronic diseases are managed of the impaired role [56] among the chronie~tlly ill, or coped with and acknowledged as being uncontain- being ill or injured is an ambiguous position because able in the course of everyday typical situations. Ac- of the variability of containment that each individual tivities may range from self-imposed home convales- may find in his situation set. In an attempt to specify cence for flu, to heroic intervention within an emer- further the process of containment, certain analytic gency medical setting. An important activity within factors or variables and their interrelationship at this these medical situations is health training where tech- preliminary stage of conceptualization need to be niques and strategies of containment or qf "passing" considered. [52] are learned and practiced. La Maze training, breathing techniques for emphysema patients, manF A C T O R S IN C O N T A I N M E N T agement of medical regimens and recognition and prevention of medical crises are examples. The priFirst, whether bodily sensations intrude themselves mary focus of attention in medical situations is the upon our consciousness or result from our actual parapplication of medical resources to contain signs and ticipation in situations, the attention given to these symptoms of illness and injury within parameters of sensations is affected by an individual's and/or others" normal social and biologic functioning. Here death engrossment in and commitment to the situation. may represent the final problem of containment Engrossment refers to the level of attention given to where the issue shifts from sustaining situational re- the dominant focus of the situation to the exclusion ality to sustaining life within the body, given biologic of side-involvements and extraneous features in and incapacities or damage. out of the situation. Soldiers in the heat of battle, Situational containment of signs and symptoms is it is reported, may sustain potentially painful injuries generally accomplished within the first three situation that do not trouble them until after they are safely types. In considering the transition to the fourth type, back at camp [50]. Heart attack patients may someor sick role status [53], individuals are generally con- times attempt to become intensely involved in their ceived of as having only a single role with which to work or leisure activity to disattend evolving coronconcern themselves when making this decision. A ary symptoms [21]. To the extent that signs and major consideration, in attempting to understand why symptoms require one's attention and lessen one's most illness goes unreported, but not unattended, is ability to become engrossed, containment is that individuals possess, in addition to a status and diminished or compromised. Also at issue is whether
A situational approach to health status deviations the involvement contour of the situation offers a focus of attention sufficient to engross the individual despite his condition. Commitment, using Becker's [57] conception, refers to attachment to situational interest, projects or goals within a particular situation and/or over a range of situations to the exclusion of other potential situational attachments. Situations, moreover, provide commitment as they may be part of the individual's identity, and his participation represents personal attachment [49]. As noted above, individuals have situation sets and are frequently known not only by the company they keep, but also by the situations in which they are found and by their commitment to interpersonal relationships found therein. Thus attentiveness to and the meaning of signs and symptoms is evaluated and given significance in light of situational engrossment and commitment. Yet it is also possible to suggest some circularity, as does Twaddle [58], when discussing the conditions of sick role release. Engrossment and commitment may depend on sign and symptom severity while evaluations of severity are dependent on the engrossmerit and commitment one can maintain. While there is no simple way out of this interaction, obviously, overwhelming incapacitation, i.e. unconsciousness, may preclude participation. On the other hand and consistent with the prevalence of unreported illness, some situations are so engrossing and so much a part of an individual's identity that he is oblivious to signs and symptoms and/or feels so obligated and committed to a particular situation that continued participation and containment are believed essential and appropriate. Second, whether or not an individual is engrossed or committed, the meaning and evaluation of his participation derives from his and others' assessment of his role enactment [59,60] i.e. "...gross skeletal movements, the performance of verbal and motoric gestures, posture and gait, styles of speech and accent, the wearing of certain forms of dress and costume, the use of material objects, the wearing of emblems or ornamentation...etc." [55]. Others, as status definers [60] in the situation, are either made aware of health status changes or observe their behavioral manifestations in role enactment. Containability is influenced by others' actual assessment and response and by an individual's conception of others' assessment of his behavior. Others become arbiters of situational goals, performance norms and constitutive propriety to which an individual must appeal if. he wishes to be excused or remain in the situation. Situations may contain compromised involvement and role enactment to the extent that "tolerance quotients" [61], "idiosyncracy credits" [62], and "benefit of the doubt" [33] are provided to an individual. These conceptions imply flexibility with regard to situational derelictions, but more importantly, they address the constitutive nature of situational reality, that is, they indicate how much dereliction in involvement a situation may contain before its definition is altered or collapsed. Again, the tightness or looseness and involvement contour of the situation greatly influence how tolerant others are of compromised role enactraent. But each individual is also provided with a certain degree of idiosyncracy credit which he has
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accumulated by appropriate situational involvement and role enactment in the past. If, however, the individ u a l has not accumulated such credit or has exhausted it, he may be asked to leave the situation, the situation may move from his presence, or it may collapse if he does not take leave of it. Third, and very much related to the above issues, Mechanic [63] and Scheff [64] suggest that the position and power of an individual is important in attempting to define him as either physically or mentally ill. I,lere the question is, who has the constitutive power to define, change, or terminate situational definitions, e.g. in a classroom situation, who has the power to begin or end class? Obviously there is a differential distribution of constitutive and sustaining power in situations. Some individuals with little power may be asked to leave situations if they become symptomatic; others may be asked to remain despite signs and symptoms. While studying acute coronary episodes, it was observed that family members usurped control of the illness situation and summoned emergency medical services more easily for an older, widowed woman living with her children than for a male head of the household [21]. Power further allows an individual to alter his own idiosyncracy credit as well as to act in behalf of less powerful, symptomatic persons. Containment then, must be considered in terms of the relative power relations between the symptomatic individual and others in the situation. Fourth, even though an individual is able to provide excuses [65] or disclaimers F66], rely on an idiosyncracy credit, or use power, propriety remains an issue. Given one's condition, should an individual attempt to remain in the situation? Is he giving proper deference to the occasion by remaining despite compromised performance, potential for contagion or cost and danger to others? Airline pilots and persons directly responsible for the safety of others should be aware of their incapacities [67]. If a work group is dependent on piece work for its wages, compromised performance is not desirable [59], especially if healthy substitutes are available. In this and similar contexts idiosyncracy credit may be consumed quickly. There is a fine line between altruistic commitment and containment and an affront to situational propriety and common sense in the face of signs and symptoms, especially if continued participation has morbid and mortal consequences. Fifth, for containment to be sustained, situational resources are required to cope with and manage signs and symptoms. Coping in this context implies the mobilization of resources to affect a change in the course of signs and symptoms or to change environmental causes. Resources can be broadly" defined to include anything that the individual and others, when involved, perceive as aiding in coping. Resources can range from asking solneone to speak more softly when one has a severe headache to asking another to bandage a laceration. In this context, asking for idiosyncracy credit--whether by virtue of power or pleading--is a resource just as being able to "take it easy" to reduce symptoms or conserve energy in one situation to perform more adequately in another is a resource. Thus, power, itself, may be a situational resource.
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Aside from modification in performance standards, prescribed and proprietary medications can also be consumed to relieve and/or conceal signs and symptoms. Consumption or application of these medications are examples of side-involvements, as are selfmanipulation activities, oriented toward testing capacities-activities such as seeing what movements make symptoms worse, changing posture or stance, and reducing an activity's duration, intensity and/or type. Efforts at containment can be prolonged by what may be termed, the "'effect interval" of coping activities. During this time individuals and others wait to observe the effectiveness of resources expected to contain signs and symptoms. Appearances of coping behayior which can be kept a.t the level of a sideinvolvement or within transient Type III situations, facilitates tolerance and provides signs of effort to remain involved and committed to the situation. However, as noted above, remaining in a situation beyond the point of propriety or potential harm to others is inappropriate. Thus, the failure or success of coping resources may directly affect one's ability to contain health status deviations within situational boundaries. Sixth, for individuals with chronic diseases and those experiencing normal processes, i.e. maturing, growing ol.der, or being pregnant, the process of containment focuses on the avoidance of situations where signs and symptoms and/or incapacities could be potentially uncontainable. As Goffman notes, an individual tends to avoid situations where the necessary commitment is beyond his capacity or "the occasion would be too much for him" [49, p. 206]. Other situations where these conditions might be exacerbated are also avoided, or negotiated participation is arranged, so that tolerance quotients are raised or performance norms lowered [67]. The chronically ill place themselves or are placed in "containing" situation sets as are individuals experiencing normal processes. In either case, some individuals are excluded from situational participation, e.g. pilots with coronary heart disease are made to retire or pregnant women are restricted from flying toward the end of the last trimester; the decision of containment is made for them. In addition, Type IV therapeutic situations may be typical for some chronically ill who are expected to prepare for otherwise "normal" situational participation, e.g. periods of hemodiaylsis for the chronic renal failure patient. A lack of containment for the chronically ill and some individuals with normal process problems may indicate a greater health status deviation than tbr presumably "normal" individuals given their already containment selected situation set. Seventh, although individuals generally attempt to normalize [7] and contain signs and symptoms and their meaning and consequences arise within a situational matrix, it must be argued that the meaning and significance of certain signs and symptoms exist independent of specific situations. This situation is especially true for illnesses which are prevalent at a particular time or which have precipitant manifestations and have received considerable public education; for example, signs and symptoms of myocardial infarction or specific types of flu. While flu symptoms may be contained and tolerated because of their gen-
eral prevalence, those of myocardial infarction have meaning and significance beyond the immediate situation in terms of morbidity and mortality. Yet, as was noted earlier, situational definitions can constrain an individual from responding to morbid and potentially mortal illness episodes. There are instances when situational reality is collapsed by signs and symptoms, or containment is not a viable alternative to a therapeutic definition of the situation. In a sense these instances represent the influence of biological intrusion beyond that expected from our bodily background expectancies. Eighth, aside from the issue of power and implicit assumptions regarding differential containment as affected by age and chronic disease, social structure explicitly influences containment by the impact of sex as a circumstance. As Stone [68] argues, females are trapped, ensnared or fated by virtue of the meaning attached to gender. Goffman [49] observes that the behavior and performance surrounding women is more tightly defined than it is for men. Females, whether by virtue of their biologic endowment, their tightly defined role behavior, or the nature of the situations in which they find themselves, tend to report more episodes of illness and compromised role performance than do males. [69, 70]. Defining females tightly and providing them with roles where commitment may be low [69] provides greater opportunity to assume illness status. Females may not be expected to contain symptoms to the degree males are expected to. In situations where commitment and involvement are greater, where females have younger rather than older children in the home, they are less inclined to assume the sick role [71]. Women are allowed to take leave readily rather than attempt to contain signs and symptoms. CONCLUSIONS
This preliminary inquiry into the interrelationship between everyday typical signs and symptoms of illness or injury and socially defined situations essentially describes everyday illness behavior (EIB) wherein the principle social process in containment. In the present context, EIB applies to the continuum of body state deviations, ranging from incipient awareness of body presence and sensations to acute illnesses, but not including illnesses if a decision to seek medical care is made because the signs and symptoms of illness or injury cannot be contained. The majority of illnesses, injuries, and health status deviations fall somewhere along this continuum and are containable within everyday social situations. Health and illness definitions within an EIB perspecti{,e are variable and emerge from a cumulative assessment of an individual's situation set, bodily background expectancies, and degree of achieved containability. In contrast to considerations of the social control functions inherent in Parsons' sick role--for example, the control of secondary gain, EIB focuses more specifically on the positive aspects of successful containment and compromised role performance. A basic assumption is that individuals desire to remain involved in dally social situations. In addition, it may be reasonable to assume that far greater social control is exerted over health deviations within everyday situ-
A situational approach to health status deviations ations than within the sick role, judging by the pervasive nattu'e of unreported illness. These varied and diffuse mechanisms of control require further articulation and specification as this preliminary conceptualization has attempted. At a broader societal level, discovery of the processes leading to containment in everyday social situations provides a glimpse of self-care and self-treatment strategies that appear to be effective. The implications of these strategies extend to issues of health care delivery and utilization; health care costs; and health care policy. Of course, the consequences of containment may lead, in some instances, to increased morbidity and mortality as with acute coronary episodes or neoplastic diseases. However, as Illich [72] argues, the benefits of what here has been termed containment probably far outweigh the potentials for social, cultural and/or clinical iatrogeneses resulting from contacts with health care practitioners. If health is a day-by-day and everyday activity [73], the concept of EIB suggests that broader issues of health policy should be informed by how the majority of individuals successfully contain health status deviations. At this preliminary point in conceptual development, any empirical exploration of EIB should use an inductive, in vivo methodological strategy to assess actual individual experience with arid response to signs and symNoms of illness and injury. While one can appreciate the control and analytic measurement afforded by in vitro research strategies, they fail, as Robinson [18] and Dingwall [17] argue, to view the behavior surrounding illness within a meaningful social context. The grounded theory approach suggested by Glaser and Strauss [74] with its inductive bias would allow further specification and development of the coocept of containment and would clarify the eight contributory factors suggested above. There is a need to ask how individuals actually manage health status deviations in everyday typical social situations, not how they think they would manage them. By using this approach we may begin to understand the lower part of the illness iceberg. Acknowledgement--I would like to express my appreciation to Paul Luken for his comments on earlier drafts of this paper.
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