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Self-care and mastery among primary health care patients
Pergamon
0277-9536(93)E0103-L
RESEARCH SELF-CARE
Sot. Sci. Med. Vol. 39, No. 5, pp. 733-741, 1994 Copyright Q 1994 ElsevierScienceLtd Printedin Great Britain.All rightsreserved 0277-9536/94 $7.00 + 0.00
NOTE
AND MASTERY AMONG HEALTH CARE PATIENTS
PRIMARY
RAIJA-LEENA PUNAM~~KI’ and HANNA ASCHAN~
‘Department SF-00014,
of Psychology, Applied Division, University of Helsinki, P.O. Box 4, Helsinki, Finland and ‘Department of Nursing, University of Turku, Turku, Finland
Abstract-In
this paper the content of everyday mastery is described, and related background variables are analyzed. Health maintenance, self-care practices, coping resources and feelings of helplessness, as indicators of daily mastery, were studied among a group of 142 Finnish primary care patients using a two-week diary method. The main themes related to health maintenance, self-care, and coping resources were found to be: meaningfulness of life, social relations and togetherness, activities, recreation and enjoyment, discipline and good health, and treatment of symptoms and diseases. The most frequent causes of feelings of helplessness were: diseases and symptoms, discrepancies between demands and capabilities, and negative psychological and emotional states. When writing about mastery, women mentioned philosophy and faith, social relations and togetherness, as well as food and dieting more often than men. Women recorded more helplessness due to discrepancies between demands and capabilities and to negative
psychological and emotional states, whereas men recorded more helplessness due to global, political, and societal conditions. Older people recorded philosophy and faith and lay care more frequently as sources of mastery more than younger people. Helplessness due to the discrepancies between demands and capabilities was more evident among older people. Key
words-self-care,
health maintenance, coping resources, helplessness, health diary
In research on health care the use of medical criteria has been criticized, with priority given instead to patients’ own definitions of self-care. In support of this view, alternative theoretical models combining social, psychological and medical perspectives have been suggested [3-51. The essence of self-care lies in patients’ ability to exercise control and responsibility over their own health and illnesses. The healing power of self-help and lay-care is due to their providing the social support and feelings of control which have been found, in turn, to be important factors in recovery from illness [6-l 11. Kickbush and her colleagues [3,4] have criticized the view that self-care and mastery consist solely of individual ways of dealing with health problems. Rather they emphasize self-care as a collective phenomenon, since it is not possible to understand the conditions for mastery of health without knowing about the meanings that people give to self-care and health maintenance practices. Hence, they argue, self-care can be best understood through the study of the history and lifestyle of the community. Further research has focused on the nature and effectiveness of self-care practices. Dean [ 121 presented a literature review on the nature of self-care responses to illness and their effectiveness. The most common self-care practices were found to be drug-taking, rest, and lay consultations. According to a Danish study
INTRODUCTION
Among primary health care patients, the most frequent illnesses, such as muscular-skeletal strains, cardiovascular diseases and mental health problems, are typically those for which medical treatment alone is insufficient. Their etiology and recovery from them are affected by both biomedical and psychological and social factors. Patients’ involvement in the healing process, the adoption of daily self-care practices, and the development of control over illness are essential factors determining successful recovery. The aim of this study is to increase knowledge about the content and conditions of self-care and mastery among Finnish health-care patients. Research has shown that only about one-third of people with medical symptoms seek medical advice, irrespective of the particular primary health care system. The majority of people’s symptoms and illnesses are treated through lay consultations and self-care [1,2]. The perspectives of lay persons and specialists on the role and meaning of self-care differ, however. The lay concept of self-care involves psychosocial and everyday dimensions of health, while specialists tend to see self-care as supplementary to medical care. Research on self-care has also mostly tended to use medical criteria to define the concept and to assess the effectiveness of self care. 733
134
RAIJA-LEENAPUNAM~KIand HANNA ASCHAN
(N = 1462) self-care responses to such common medical problems as the flu, muscular-skeletal strain, exema. depression and chest pain included conscious disregard of the symptoms, drug-taking, rest, massage. and, finally, the seeking of medical help [13]. Elo and Myllykangas [I41 studied self-care practices in a response to everyday symptoms among a Finnish random sample of middle-aged urban dwellers (N = 214), using the diary method. The results showed that, on 56% of the recorded days, the respondents had some symptoms, and on a third of them, they employed some sort of self-care practice. The most common practices (30%) were drug taking (e.g. painkillers) and lay consultations. Only 2% of the symptom days led to consulting a doctor. The factors increasing self-care practices included: a medical diagnosis of the illness. the use of lay consultations, the perceived seriousness of the symptoms, and psychological disorders. Aukee [I 51 studied the self-care practices of Finnish women (N = 290) using diaries and interviews as research methods. Self-care practices were documented as responses to common symptoms. The most common self-care for a headache was drug-taking, while social support was sought to alleviate depression. Other common self-care practices among the women were sports and exercise, reading, discussions with others, handicrafts, as well as self-indulgences (such as eating sweets), deliberate laziness. and solitude. Self-care in treatment of symptoms and illnesses has been judged to be effective by medical criteria. Research has shown about two-thirds of lay practices to have been evaluated as effective by general practitioners [16, 171. Research has further focused on the genesis. conditions, and functions of self-care groups. It is obvious that self-care groups evolve in order to provide the healing power of social support and feelings of control when official health care is experienced as unsuitable or insufficient. One of the main catalysts for the development of self-care groups has been the failure of a highly technical and authoritarian healthcare system to involve patients in the control of their own treatment. Additionally, the simultaneous increase in lay knowledge regarding illnesses has also contributed. Hence, self-care provides an alternative to an official health care which produces feelings of personal helplessness regarding one’s own body and illnesses [6, 18-221. There is a great discrepancy between the theoretical concerns of self-care research and the available empirical data. First, even if research were to demonstrate that the most important health resources are found in people themselves, the concept of self-care is mostly defined from a medical perspective, and is only regarded as supplementary or secondary alternative to professional medical care. Orem [23], for instance, defines self-care as daily activity for maintaining and promoting the health and well-being of oneself and significant others. This kind of definition
lacks an analysis of the more varied purposes of self-care in everyday life, as well as the aims of and the motives for self-care within a social context. Research has also mainly focused on self-care practices as responses to specific symptoms and illnesses. This approach reflects a very narrow concept of health: that of lack of illness. It ignores the fact that treating symptoms always entails contextualizing and making sense of the underlying problem [21]. Historical and cultural issues, as well as personal experiences, may also be important influences on the motives for and the significance of self-care. In conclusion, these studies have not treated self-care as a set of resources or a means of mastery for health, but rather as only a response to symptoms. The aim of this study is to respond to some of these theoretical concerns. In this study self-care is conceptualized in terms of the concepts and issues brought up and defined by the patients themselves. The context of everyday life is preserved through the use of the diary for data gathering. Self-care is understood here in broader terms as the practical means and resources for attaining mastery over daily life. Different types of mastery over daily life are conceptualized through analyzing health maintenance, self-care practices, and the balance between helplessness and coping resources in the context of daily life. The following questions guided the analysis of the content of the responses. What do people daily consider, plan. and actually do in order to maintain and care for their health? What sort of everyday things do they regard as coping resources? What evokes feelings of helplessness? Finally the relationships between mastery and age. sex and place of residence are considered.
METHOD
Subjects Data was obtained from patients in six Finnish primary health-care centres located in different parts of the country. In each centre, 50 patients were randomly sampled from all those who consulted a doctor or nurse in December 1991 and January 1992. The sampling procedure in each health care centre was the following: if the number of visiting patients was, for instance, 5000. every 100th was chosen for the study. Initially there was a total of 258 patients interviewed. This sample was checked to make sure that the common illnesses of Finnish health-care patients were represented. A focused interview was conducted on the patients’ explanations of health and illness, their social networks, and their experiences of the health-care services. At the end the interviewees were given a semi-structured diary to fill in for 2 weeks [24,25]. They were instructed to record daily their activities, intentions, and thoughts they related to health maintenance, self-care. coping resources and causes of feelings of helplessness. Since we were particularly
Research Note Table 1. Age and sex of the sample Women
All
Men
Age
N
%
N
%
>30 31-40 41-50 51a >60
14 13 14 I5 17
IO 9.3 10 10.7 12.1
6 11 14 14 22
4.3 1.9 10 10 15.7
All
13
52.1
67
47.9
% 14.3 17.2 20 20.7 21.8 100
interested in the patients’ own definitions of mastery, the interviewers therefore emphasized that there were no right or wrong answers, but that the patient’s personal understanding of these issues was of main interest. Of the 258 interviewed patients, 142 returned the completed diary (55%). No attempt was made to obtain more diaries. The group of 142 who completed the diaries and the 85* who did not return the diaries were compared in order to check the distributions of sex, age and place of residence. This showed that those who returned and those who did not return the diaries were similar in sex (x * = 0.79, df = 1, P = NS) and in urban or rural residency (x * = 0.12, df = 1, P = NS). The group that returned the diary was, however, older than those who did not (t (227) = 6.62, P = 0.01). The sample was distributed across all adult age ranges with a mean age of 48.7 + 15.8, The proportions of men (48%) and women (52%) were almost equal (Table 1). The majority (73.5%) of the subjects lived in the countryside, while a quarter (26.5%) lived in towns. Data-analysis The
diaries were analyzed using qualitative methods of content analysis. This analysis consisted of three stages: (1) Both researchers read the data repeatedly and performed a primary classification of the answers. For this analysis, it was felt important that the original text formed the basis of the classifications. A saturation principle was applied here, i.e. the search for new dimensions was completed when no new or different categories emerged. (2) The primary categories were further analyzed and grouped together, using the theoretical criteria for the motive or goal of self-care and health maintenance, and the domain of people’s coping resources and helplessness. (3) All the diary entries were coded on the basis of these primary dimensions. This was done in order to determine the frequencies for each category and to study their relationships to the demographic factors. *Of the original sample 31 cases were dismissed dw to missing information. tThe diary instructions for health maintenance were: every day, record issues (activities, intentions, thoughts) that in your own opinion are related to health maintenance. The instructions for self-care were: every day, record what you do in order to care for your health and the health of those close to you.
135
Reliability of the classification was achieved in two ways. First, the primary search for and identification of categories was done independently by the two researchers. The primary categories were then negotiated. Coding reliability was checked by two judges who simultaneously classified the entries in 40 of the diaries. The percentage of agreement indicates the proportion of responses that both judges coded as belonging in the same category. For instance, both judges coded 205 causes of feelings of helplessness from 40 of the diaries, and of these they coded 14 of the responses into differing categories. The agreement percentage of 93% reveals that 191 of the 205 responses were coded into the same category. The following two-judge reliabilities were attained: Health maintenance 90%, self-care 88%, coping resources 80% and sources of helplessness 93%. One characteristic of the diaries was the diversity of responses: on a daily basis, people recorded many different kinds of self-care practices and multiple sources of helplessness. In order to preserve this diversity in the analysis, Korhonen’s [26] Multiresponsesprogramme was applied. This makes it possible statistically to document the occurrence of all the different responses covering a given theme. The programme then creates dichotomous variables for each response, thus taking into account all the responses. The response categories were constructed using qualitative content analysis, and the relations between indicators of mastery and demographic factors were assessed by cross tables with ,y* statistics and analyses of variance.
RESULTS
Health Maintenance, Se[f-care and Coping Resources
Content analysis involving health maintenance and self-care showed that they consisted of similar actions, plans, and thoughts. It was therefore concluded that no differences exist in lay definitions for the concepts of maintenance and self-care.7 Coping resources were also, to a great extent, of the same nature as health maintenance and self-care. The following example of one day’s diary entries for a 33-year old woman depicts this. Her response concerning health maintenance was: “My plans: I’m going to jog in the forest. I’ll start a diet in order to lose weight”. Her response concerning self-care was: “I’ve been jogging in the forest, about 3 kilometres. I’ve started a diet.” And for coping resources she records: “I went jogging with our dog. The countryside is beautiful and quiet. It makes me serene and happy. I was in a radiant mood.” Table 2 shows the contents and frequencies of health maintenance, self-care, and coping resources in the sample. The percentages indicate the number of people who recorded that particular category of mastery at least once in the 2-week period.
736
RAIJA-LEENAPLJNAMAKI and HANNA ASXAN Table 2. Frequencies
and percentages of categories of mastery’
Health maintenance (N = 115) Meaningfulness of /i/e Philosophy and faith Nature Social r&lions and togetherness Activities Work and achievements Hobbies and activities Recreation and pleasure Leisure and relaxation Enjoyment and pleasure Discipline and good health Sports and exercise Food and diet Avoiding risks Sauna and hygiene Hea/ing of symptoms Official health care
Lay care ‘Differences
Coping resources (N = 140)
Self-care (N = 139)
Al
V”
N
a/”
N
35
30.4
25
18.0
9 38
7.8 33.0
12 40
8.6 28.8
28 54 55 74 82
20.0 38.6 39.3 52.9 58.9
43
37.4
34
24.5
68
48.6
27
23.5
25
18.0
62
44.3
55
47.8
41
29.5
I2 70
8.6 (Creativity) 50.0 (Recreation)
IO
8.7
IO
7.2
75 52
65.2 45.2
88 43
63.3 30.9
I8
15.6
16.5 25.2
I9 29
in sample sizes across variables
reflect missing
I4
IO.I
36
25.9
I4 69
IO.1 49.6
data. For instance,
only
I I5
%
II
completed
(Religiousness) (Philosophy) (Family) (Other social relationships)
7.9
diaries on health maintenance.
The primary content analysis of the diaries revealed 13 categories of health maintenance and self-care. These categories were grouped according to the goals served by self-care and health maintenance: (1) Meaningfulness of life, (2) Social relations and togetherness, (3) Activities, (4) Recreation and enjoyment, (5) Discipline and good health, and (6) Treatment of symptoms and diseases. When the domain of coping resources was used as a criterion, similar categories emerged. Examples of responses classified in each category are presented below.
I remember my mother often used to say: ‘There is always a good feeling to be found’.
(I) The meaningfiilness of life
(2) Social relations and togetherness
The daily recordings concerning health maintenance, self-care, and coping resources contained aphorisms and reasonings which were interpreted as seeking and safeguarding the meaning and purposefulness of life. Nature as a healing agent combined the search both for belonging, as well as for a broader meaning of life. Philosophy, faith, and inventories of life. In the diary entries which revealed a philosophy of life, the subjects estimated the course of their life, the sufficiency of their own resources, as well as their ability to cope. The ‘blessing’ of some moments of everyday existence and the maintenance of some comforting rituals were also interpreted as search for meaningfulness of life. As well, religiousness and the relationship to God were interpreted as important coping resources. Examples included:
Seeking and maintaining social support and feelings of belonging are important sources of healing in people’s everyday lives. Feelings of togetherness with family, grandchildren, relatives, friends, and colleagues were frequently described in one-third of the diaries. It is important to note that not only receiving social support, but also providing it, were recorded as means of health maintenance and self-care.
I listen to religious music and the morning a half-hour’s
service, and keep
silence.
I’m like a cat. Who would lift its tail, if not the cat itself? in life.
You need imagination
I enjoy the small things in life. I generally experience joy just from little things. It’s typical of me to feel alienated in the midst of very dramatic events, even if they are positive.
Nature. The responses referring to nature included remarks on the change of seasons, the beauty of the landscape, and to the sun as a healing agent. There were also observations of plants and animals, and the subjects’ own involvement with natural phenomena. I love plants, they heal me. I wait for spring, so that I can go out into the fresh air and admire nature and observe the development of plants.
We had a picnic together, therapy for a person. I discussed
death
the whole family.
and the after-life
I read aloud to a blind person. a good mood.
It is the best
with my cousins.
Helping
I discussed my worries with my mother a little bit easier.
someone
put me in
and this made things
(3) Activities Work and hobbies were frequently mentioned as means for health maintenance and self-care. The responses revealed an active motivation to change conditions to achieve important goals, and to see the results of effort. The connections between activity, good mood, and health were often explicitly reported.
Research Note Work and achievement. Though working at a job was reported as a source of satisfaction and joy, it was usually described only briefly. In contrast, work at home or at a summer cottage was discussed more extensively. The satisfaction
of achieving
short-term
work
objectives.
It was wonderful to work for many hours with my plants in the fresh air without any hurry and then to sit on a tree stump, and to listen to the spring-time voices in the forest. Friday is both my working day and my therapy day. I tested myself a test to see if I could finish cleaning the house and also bake some coffee cake and pastries. I did it!
Hobbies and recreational activities. A wide variety of hobbies and recreational activities was recorded in the diaries. There were entries such as: I went fishing. In a few days the rally will start. Then I’ll get some exercise; I’ll wash the tyres of the cars, and fill the tanks with petrol for the next race.’ (4) Recreation and enjoyment
Leisure and relaxation. Some of the responses involving recreation and rest reflected the goals of ongoing self-care and the conscious release of tension and stress. The goal of attaining a balance between work and leisure was often explicitly expressed. The ways of relaxing were almost as numerous as the people studied. They included travelling, reading newspapers, sleeping, going to exhibitions, going to restaurants with dancing, window shopping, spending time alone, and engaging in creative activities. Today I went shopping by myself. It was a luxury to be alone and to be able to go around and shop wherever I liked. Just time for myself, without anyone rushing me or putting pressure on me. An important feature of my holidays is the spontaneous rather than organized aspect of them; I don’t like planning anything in too much detail, I’d rather decide things on a day-to-day basis; I want as much contrast as possible to the 8 to 4 o’clock, 5 days a week job which I have the rest of the year.
Enjoyment and pleasure. In these responses, pleasure was the explicit motive and aim. The sources of enjoyment included the arts, good food, good company, and varying rituals for satisfying the body and soul. Another day gone and it’s time for the sauna. We warmed ourselves up in the smoke sauna, again and again, and enjoyed
some beer.
Making
love.
*All hobbies related to sport and exercise were coded in the category ‘Exercise and sports’ which, in turn, belongs to the main category ‘Discipline and good health’, Watching sports was, however, included in the category of hobbies, because it was interpreted as a form of active social participation.
137
(5) Discipline and good health The majority of the people studied strove to achieve and maintain good health through organized sports, exercise, and diet. In addition, avoiding risk behaviours and attending to personal hygiene fell into this category. Sports and exercise. Two-thirds of the subjects mentioned sport and exercise as their means to healthmaintenance and self-care. This category included many types of sports and exercise, such as jogging, slalom and cross-country skiing, weight-lifting, tennis, squash, volley ball, cycling, swimming, archery, gymnastics, aerobics as well as simply membership in fitness clubs. Sometimes these activities were characterized as things one ‘should-do’. If only I could get my act together and do more walking. If I could cycle to work three times a week, I would improve my fitness. Today, when I’m not working exercises.
in the fields, I’ll do some
Food and diet. The descriptions of diet and references to healthy eating habits also tended to have the tone of ‘shoulds’. Typical diets involved the inclusion of vegetables, berries, and fruit into meals. Regular eating hours, consuming a variety of foods, and the preparation of food at home were also mentioned. The different Finnish food cultures were present in the descriptions, such as the eating of reindeer and elk meat, as well as the preparation of blood soup. I proposed to my wife that we should order to purify products. I should traditions surprised.
our bodies of dangerous
fast sometimes in and foreign waste
have the courage to change our daily food and try some new menues, we might be positively
Avoiding risks. Here, the subjects examined their daily activities from the perspective of their health consequences. Regular routines and reasonable, or even zero, consumption of alcohol and tobacco were mentioned in reference to health maintenance and self-care. Consciousness of other risk-avoidance measures, such as using car seats for children and having ergonomically well-designed working conditions, were also included in this category. I say to myself, never smoke or drink do, do so with restraint.
alcohol.
And if you
I’ve been considering the healthiness of coffee drinking after discussing it with my colleagues during the coffee break at the office.
Sauna and hygiene. In a quarter of the diaries the taking of saunas was mentioned as a self-care practice. Some of these entries clearly referred to enjoyment and recreation, leading to both bodily and spiritual benefits. However, the answers included in this category reflected the hygienic rather than the ‘purification’ aspects of the sauna.
RAIJA-LEENAPUNAM~~KI and HANNA ASCHAN
738 I am going cleanliness.
to the sauna
with my spouse
to ensure
our
I keep an eye on both the cleanliness of the environment and of my own body. (6)
Treatment of symptoms and diseases
The treatment of symptoms and diseases included both the use of official health services and lay care. Both were employed for specific purposes. Although both professional help and lay care were used for treating pain and illness and to solve medical problems, lay care was also used for pleasure and health maintenance. UfJicial health care. Official health care is presented in the diaries in terms of consultations with doctors and the obtaining of laboratory tests.
Table 3 shows the contents and frequencies of causes of feelings of helplessness. The percentages indicate the number of people who recorded that particular source of helplessness at least once in the 2-week period. (I)
The global, political and societal circumstances
News of violence, starvation, and national or global difficulties caused feelings of helplessness. The responses revealed frustration due to the inability to help
other
people’s
despair
News about war, starvation,
and
injustice.
and homelessness
I must admit that I feel hatred European Community. Again I don’t have any influence government
among others.
and even fear towards on the activities
the
over the
Walking and wandering about the countryside, dieting, and trying not to get tense. I made an appointment with a doctor and I was seen immediately. He sent me for an X-ray; apparently I have another gastric ulcer. LUJ care. Half of the subjects used lay care practices for self-care. while one-third used them for health maintenance. Lay care has three aspects: the taking of medications, the use of non-medical remedies and cures, and treatment by ‘traditional healing’. Medications included various vitamins, non-prescription drugs, and painkillers. Remedies and cures included massage, fasting. breathing exercises, stretching, and the use of respirators, electric cushions. and cold bandages. I massaged 1 warmed
my wife’s aching my aching
back
neck.
using an electric
cushion.
In the forest, a big ant hill was bristling with life. 1 took a birch twig, moistened it in my mouth and let the ants urinate on it. OK, let’s taste it. I’m sure it’s healthy.
Sources of’ Helplessness The analysis of the diaries revealed nine causes of everyday helplessness: (1) global, political and societal circumstances, (2) the circumstances of the subject’s own life, (3) human relationships, (4) the discrepancy between demands and capabilities, (5) diseases and symptoms, (6) psychological and emotional states, (7) death, (8) everyday hassles, and, then, (9) other. Table
3. Frequencies
and percentages (N = 140)
of sources
Source of helplessness
N
Global and political
and .socirtal situation of the suhjc~ct’s ~MTI liw.\
Circumstance
Loss of vigor Poverty
and unemployment
Human
relurionships
Longing and worry Difficulties m relations Discrepancy
hetn~em
demond.~
Work and its demands and symptoms
Psychological
and emotional
Death Ewryday Other
hassle.\
%
8
5.7
7 15
5.0 10.7
30 26
21.4 18.6
44 41
31.4 29.3
and capabilities
Willpower and abilities Diseases
of helplessness
state
64
45.7
36
25.7
7
5.0
14
10.0
29
20.7
Environmental risks and pollution were a source of feelings of helplessness within the subjects’ own society. These feelings sprung from a sense of alienation and impotence in relationship to their everyday lives. I couldn’t sleep when I started to think about the fluoride solution that the dentist had spread on my teeth. I wondered how many other dissolvents and chemicals had gotten into my body. The factory visitor noticed the smell of gas. I must have become accustomed to it. Now I realize that, now and then, you need to open the doors. The dirty air and lack of oxygen in my workplace are a source of helplessness.
(2) The circumstances of the subjects’ own lives Helplessness due to the subjects’ own life circumstances was varied and very personal in nature. It concerned aging, loss of physical and mental vigour, poverty, unemployment, loneliness, and alienation. Every day I feel helpless. I am only 53 years of age and I feel that there are still lots of things that would be nice to do, but I have to leave a lot undone. I simply cannot do any more. I fear the future
and unemployment.
(3) Human relationships Human relationships were sources of helplessness in two distinct ways: missing, and worrying about loved-ones and, then, having relationship difficulties at home and work. Missing and worrying about loved-ones. As children, respondents were concerned about the well-being of their parents, while, as parents, they worried about the future and happiness of their children. The subjects also expressed great concern for the spouses and parents that they lived with, as well as for the raising of children. Parents of grown-up children worried about their children’s problems with finances, alcohol, studies, work, and marriage. Long distances, living abroad, as well as earlier deaths led to the missing of loved-ones.
Today, mother would have had her 80th birthday, but she died 20 years ago. I still miss her. A moment her grave, incurable longing.
of sorrow
by
Research Note
739
My children live far away, I can’t sleep. My youngest child may still hate me and that is difficult to bear. He never visits me.
I have the feeling that I’m inferior and not good for anything, both in my own and in other people’s eyes. I feel that nobody cares for me.
D@cult human relationships. Human relationships both at home and work caused many feelings of helplessness. Not being accepted as a member of a working group or suffering because of one’s own behaviour are examples in this category.
(7) Death
I suffer from loneliness, I don’t think any of my children care whether I live or die. Continuous difficulties with one person in particular work, and whatever I do, the conflict continues. (4)
Work and its demands. Work and activity were very important in this Finnish sample as resources for coping, health maintenance, and self-care. However, work was also a cause of helplessness. The subjects mentioned a variety of well-known work stressors: on the one hand, work overload, unfinished tasks, and constant time pressure; on the other hand, monotony, and boredom. Strain, tiredness, insecurity, and a lack of knowledge and expertise also made people feel helpless. Furthermore, poor work organization, unclear or overwhelming responsibilities, and inadequate communications were also mentioned. For me, it’s difficult to work with the computer. There are lots of things I don’t understand and afterwards I feel ashamed. I had to perform in the meeting. In my opinion it was a complete failure. Will-power and abilities. Feelings of incompetence, frailty, and ineffectiveness in relationship to aspirations were mentioned as sources of helplessness. The discrepancies had implications for life-styles, happiness, and ambitions. The negative thing which depresses me is my dependence on smoking: I should really try+ne day soon---to do something about stopping. I found myself eating too much again, even after I had decided to go on a diet. (5) Diseases and symptoms The most common symptoms experienced as sources of helplessness were pain, insomnia, dizziness, stress, and fatigue. The attitudes of other people and the public health authorities towards one’s illness also contributed to the feeling of helplessness. thought I’d die.
I can’t figure out how much sleep I need in order not to be constantly tired and feel lack of energy day and night. (6)
Psychological and emotional states
Depression, grief, loss and anxiety were the sources of feelings of helplessness in this category. I feel helpless morning,
because
generally in the night I’m alone.
Deep in my soul, there is an immense
and sadness.
early
of a lack of control with helplessness.
over death
was
I witnessed a car accident. A small boy died and I could do nothing. I saw that, again, acquaintances have died. They are the same age as I am, some of them are even younger.
at
The discrepancy between a’emandr and capabilities
An asthmatic attack--I
A feeling synonymous
in the
(8) Everyday hassles Everyday hassles such as worrying about how a kitten would cope alone outside a house or running a car battery down by leaving the lights on were, in a few cases, causes of feelings of helplessness. In this category also belonged technical problems with machines, repairs, and services. It is interesting that nature functioned not only as a healer and a resource, but also as a cause of helplessness. Experiences of having no control over nature and of its coldness, unfriendliness, and greyness were described. For example, descriptions of snow, storms, and frosts recalled the ‘struggle against the powers of nature’. (9) Other One-fifth of all diary entries mentioned causes of helplessness that did not fit into the above categories. These responses were often very personal and specific to a particular situation. Factors Related to Mastery and HeIplessness A one-way ANOVA was applied in order to assess the differences in everyday mastery and helplessness according to sex and place of residence. As dependent factors, a combination of variables were constructed by summing up identical or similar categories within health maintenance, self-care and coping resources. The results showed differences between women and men in philosophy and faith (P < O.lO), social relations and togetherness (P < O.OOl),and diet and food (P < O.Ol), as sources of everyday mastery, with women expressing these sources of mastery more often than men. The results of the ANOVA are summarized in Table 4. The ANOVA results for the relationship of sex and helplessness showed that the women recorded more helplessness due to a discrepancy between demands and capabilities, F (1,138) = 2.70, P < 0.10, and to psychological and emotional states, F (1,138) = 4.78, P < 0.03. The men, on the other hand, recorded more helplessness due to global, political, and societal conditions, F(l,138) = 2.80, P < 0.09. The ANOVA results for the relationship of place of residency and mastery showed that there were differences between people from different parts of Finland. This variation, however, did not follow the town-countryside or north-south dimensions that have previously been found to differentiate Finnish
740
RAIJA-LEENA
Meaningfulness l?fII/k Philosophy and faith Nature Social relalrons and rogerherne.rs Acfioities Work and achwements Hobbies and activities Recreation and pleasure Leisure and relaxation Enjoyment and pleasure Discipline and good health Sports and exercise Food and diet Avoiding risks Healing ofsymproms Official health care Lay care ‘F(l,l
PUNAM~~KI and
1.59 0.98 2.75
1.90 1.82 3.08
2.30 I.13 5.45
3.19 1.63 4.88
2.68 I.91
2.19 2.54
2.64 1.57
2.63 1.97
0.90 0.62
1.90 2.79
2.54 3.08
1.56 3.43
1.97 3.39
0.62 I .06
4.17 1.35 I.15
3.49 2.02 2.13
4.29 2.62 0.88
3.05 3.21 1.57
0.04 6.16** 0.50
0.33 I.91
0.84 2.51
0.67 2.00
1.50 2.55
2.12 0.03
2.61’ 0.22 11.90***
IO); *P < 0.10; **p < 0.01; ***p < 0.001
health behaviour [27]. Overall the six places of residence differed significantly with respect to social relations and togetherness F(5,106) = 2.09, P < 0.09, sports and exercise F(5,106) = 3.29, P < 0.008, and lay care F(5,106) = 3.50, P < 0.003 as sources of mastery. All these differences were due to the people of one town consistently recording the lowest number of sources of mastery. This town is an industrial port, and much of its population has moved there from other parts of Finland. Hence this factor may explain the result. Correlation analysis between age and sources of mastery showed that older subjects recorded philosophy and faith (r = 0.32, P < 0.001) and lay care (r = 0.21, P ~0.01) as their resources for mastery more frequently than the younger subjects. The older subjects recorded more discrepancies between demands and capabilities, especially work and its demands, as sources of feelings of helplessness than the younger ones (r = 0.30, P < 0.001). DISCUSSION
The aims of this study were two-fold. The first aim was to further understanding of the contents of everyday health maintenance, self-care, coping resources, and causes of feelings of helplessness. In addition, people experiencing everyday life both causes of helplessness as well as resources for coping, and so the second aim was to learn more about the formation of a positive balance between them and to analyze the demographic factors related to them. The subjects comprehensively described their everyday lives in diaries. They tended to understand the activities of health maintenance, and self-care and their resources for coping in similar ways. In all of these domains, the main themes involved work, activities and accomplishments, human and spiritual affiliations, the enjoyment and recreation, and the meaningfulness of life. Sources of helplessness and
HANNA ASCHAN
coping resources were not exactly of the same nature. In other words, the deprivation of certain coping resources did not necessarily mean helplessness in that area. However, good human relationships and rewarding work were experienced as resources, while bad relationships and work difficulties were experienced as sources of helplessness. This indicates the importance of these two domains for the experience of mastery of daily life. It is important to note that social affiliation did not mean only receiving social support but also giving it. Helping and bringing joy to others were recorded as self-care and health maintenance activities, while relying on others and sharing feelings were recorded as coping resources. In this study, the starting point was the patient’s own concepts and definitions of self-care, health maintenance, coping resources, and sources of helplessness. Mastery has been found to be essential in preventing illness and recovering from it [7, 281. The patient practising self-care controls the everyday means and resources that enables him or her to live a healthier life. The promotion of people’s health and mastery in primary health care setting is not possible without knowledge of the content of the patient’s own resources for health. The results of this study showed that patients utilize a variety of means for attaining this mastery. This picture of a patient challenges the view of a ‘normal consultation’ [29], in which a patient is portrayed as passive and docile, a target or object of care, and in which the patient easily becomes helpless and irresponsible regarding his/her own health. One of the reasons for the previous rather narrow picture of self-care may have been the approach and method of previous studies. Self-care has been mostly analyzed as a response to a certain illness, symptom or problem. However, the results in this study concerning the content of mastery indicate that patients exercise a diversity of health maintenance and selfcare practices. ‘Medicalization’ [30] of the everyday life is not evident from this data. It is apparent that treating symptoms is only one, but not the most frequent, self-care practice. The conceptualization of self-care and health maintenance should be more comprehensive and include social and phenomenological domains. It should also include existential and ritual methods for experiencing the meaningfulness of life, as found in philosophies of life and in affiliations with the creator, nature, and other people. It should also include everyday activities and enjoyment in life, as well as recreation as a potential source of accomplishment. REFERENCES
Hannay D. R. The ‘iceberg’ of illness and ‘trivial’ consultations. J. R. Coil. gen. Pratt. 30, 551, 1980. 2. Pill R. Health beliefs and behavior in the home. In I.
Health
Behaoiour:
Research
and Health
Promorion
(Edited by Anderson R., Davies J. K., Kickbush I.,
Research Note McQueen D. and Turner J.), p. 140. Oxford University Press, Oxford, 1988. 3. Kickbusch I. and Hatch S. Introduction: A reorientation of Health Care? In Self-help and Health in Europe. New Approaches in Health Care (Edited by Hatch S. and Kickbusch I.), p. 1. WHO Regional Office for Europe, Copenhagen, 1983. 4. Kickbush I. Introduction. In Health Behaviour Research and Health Promotion (Edited by Anderson R. et al.), p. 1. Oxford University Press, Oxford, 1988. Stewart M. J. Expanding theoretical conceptualizations of self-help groups. Sot. Sci. Med. 31, 1057, 1990. Levin L. S. Self-care in health potentials and pitfalls. Wld Hlth Forum 2, 177, 1981. Antonovsky A. Unraveling the Mystery of Health. How People Manage and Stay Well. Jossey-Bass, San Francisco, 1988. 8. Bergman L. and Syrne S. Social networks, host resistance and mortallity: A nine-year follow-up study of Alameda county residents. Am. J. Epidemiol. 109,289, 1979.
16. Dean K. Lay care in illness. Sot. Sci. Med. 22, 275, 1986.
17. Linn L. and Lewis C. Attitudes toward self-care among practicing physicians. Med. Care 17, 183, 1979. 18. Barath A. Self-help in Europe 1979-1989. A critical review. Hlth Prom. Int. 6, 73, 1991. 19. Katz A. H. and Bender E. I. The Strength in Us. Self-Help Groups in the Modern World. Franklin Watts, New York, 1976. 20. Katz A. and Bender E. Self-help groups in Western society: history and prospects. J. appl. behav. Sci. 12, 265, 1976.
21. Kickbusch I. Self-care in health promotion. Sot. Sci. Med. 29, 125, 1989. 22. Gaines A. D. and Hahn R. A. Among the physicians: encounter, exchange and transformation. In Physicians of Western Medicine. Anthropological Approaches to Theory and Practice (Edited by Gaines A. D. and Hahn
23.
9. Laffrey S. Development of Health Conception Scale. Rex Nuts. Hlth 9, 107, 1986.
10. Pender N. Health Promotion in Nursing Practice. Appleton-Centory-Crofts, Norwalk, CT, 1982. 11. Pill R. and Stott N. C. H. Looking after themselves: health protective behaviour among British working class women. Hlth Educ. Res 1, 111, 1986. 12. Dean K. Self-care responses to illness: a selected review. Sot. Sci. Med 15A, 673, 1981. 13. Dean K., Hoist E. and Wagner M. Self-care of common illnesses in Denmark. Med. Care 21, 1012, 1983. 14. Elo J. and Myllykangas M. Koetut oireet ja niiden johdosta suoritetut toimenpiteet. SOS. liiiik. Aikak 23, 28, 1986. (In Finnish. Perceived symptoms and action taking. J. sot. Med.) 15 Aukee R. Itsehoitokeskustelut ja itsehoito naisen arjessa. Tampereen yliopisto. Kansanterveystieteen laitos. Tampere, 1989. (In Finnish. The discussion of self-care and self-care in the everyday life of women. Univeristy of Tampere, Department of public health.)
741
24.
25. 26. 27.
28.
R. A.), p. 3. D. Reidel Publishing Company, Dordrecht, 1985. Orem D. Nursing: Concepts of Practice. McGraw-Hill, New York, 1985. Boyle J. S. Use of the Family Health Calendar and interview schedules to study health and illness. In Qualitative Research Methoo!s in Nursing (Edited by Leininger M. M.), p. 217. 1985. Verbrugge L. M. Health diaries. Med. Care 18,73, 1980. Korhonen M. Multiresponses-programme. University of Helsinki, Helsinki, 1991. Aromaa A., Heliovaara M., Impivaara O., Knekt P. and Maatela J. Minisuomi-terveystutkimus. KELA tutkimuksia AL.32, 1989. (In Finnish. Mini-Finland; Health study. SII The social insurance institution.) Abrahamson L. Y., Seligman M. E. P. and Teasdale J. D. Learned helplessness in humans: Critique and Reformulation. J. abnorm. Psychol. 37,49,
1978. 29. Waizkin H. Information giving in medical care. J. Hlth sot. Behav. 26, 81, 197’7 30. Zola I. Medicine as an institution of social control. Sot. Rev. 20, 467, 1972.
0277-9536(93)E0103-L
RESEARCH SELF-CARE
Sot. Sci. Med. Vol. 39, No. 5, pp. 733-741, 1994 Copyright Q 1994 ElsevierScienceLtd Printedin Great Britain.All rightsreserved 0277-9536/94 $7.00 + 0.00
NOTE
AND MASTERY AMONG HEALTH CARE PATIENTS
PRIMARY
RAIJA-LEENA PUNAM~~KI’ and HANNA ASCHAN~
‘Department SF-00014,
of Psychology, Applied Division, University of Helsinki, P.O. Box 4, Helsinki, Finland and ‘Department of Nursing, University of Turku, Turku, Finland
Abstract-In
this paper the content of everyday mastery is described, and related background variables are analyzed. Health maintenance, self-care practices, coping resources and feelings of helplessness, as indicators of daily mastery, were studied among a group of 142 Finnish primary care patients using a two-week diary method. The main themes related to health maintenance, self-care, and coping resources were found to be: meaningfulness of life, social relations and togetherness, activities, recreation and enjoyment, discipline and good health, and treatment of symptoms and diseases. The most frequent causes of feelings of helplessness were: diseases and symptoms, discrepancies between demands and capabilities, and negative psychological and emotional states. When writing about mastery, women mentioned philosophy and faith, social relations and togetherness, as well as food and dieting more often than men. Women recorded more helplessness due to discrepancies between demands and capabilities and to negative
psychological and emotional states, whereas men recorded more helplessness due to global, political, and societal conditions. Older people recorded philosophy and faith and lay care more frequently as sources of mastery more than younger people. Helplessness due to the discrepancies between demands and capabilities was more evident among older people. Key
words-self-care,
health maintenance, coping resources, helplessness, health diary
In research on health care the use of medical criteria has been criticized, with priority given instead to patients’ own definitions of self-care. In support of this view, alternative theoretical models combining social, psychological and medical perspectives have been suggested [3-51. The essence of self-care lies in patients’ ability to exercise control and responsibility over their own health and illnesses. The healing power of self-help and lay-care is due to their providing the social support and feelings of control which have been found, in turn, to be important factors in recovery from illness [6-l 11. Kickbush and her colleagues [3,4] have criticized the view that self-care and mastery consist solely of individual ways of dealing with health problems. Rather they emphasize self-care as a collective phenomenon, since it is not possible to understand the conditions for mastery of health without knowing about the meanings that people give to self-care and health maintenance practices. Hence, they argue, self-care can be best understood through the study of the history and lifestyle of the community. Further research has focused on the nature and effectiveness of self-care practices. Dean [ 121 presented a literature review on the nature of self-care responses to illness and their effectiveness. The most common self-care practices were found to be drug-taking, rest, and lay consultations. According to a Danish study
INTRODUCTION
Among primary health care patients, the most frequent illnesses, such as muscular-skeletal strains, cardiovascular diseases and mental health problems, are typically those for which medical treatment alone is insufficient. Their etiology and recovery from them are affected by both biomedical and psychological and social factors. Patients’ involvement in the healing process, the adoption of daily self-care practices, and the development of control over illness are essential factors determining successful recovery. The aim of this study is to increase knowledge about the content and conditions of self-care and mastery among Finnish health-care patients. Research has shown that only about one-third of people with medical symptoms seek medical advice, irrespective of the particular primary health care system. The majority of people’s symptoms and illnesses are treated through lay consultations and self-care [1,2]. The perspectives of lay persons and specialists on the role and meaning of self-care differ, however. The lay concept of self-care involves psychosocial and everyday dimensions of health, while specialists tend to see self-care as supplementary to medical care. Research on self-care has also mostly tended to use medical criteria to define the concept and to assess the effectiveness of self care. 733
134
RAIJA-LEENAPUNAM~KIand HANNA ASCHAN
(N = 1462) self-care responses to such common medical problems as the flu, muscular-skeletal strain, exema. depression and chest pain included conscious disregard of the symptoms, drug-taking, rest, massage. and, finally, the seeking of medical help [13]. Elo and Myllykangas [I41 studied self-care practices in a response to everyday symptoms among a Finnish random sample of middle-aged urban dwellers (N = 214), using the diary method. The results showed that, on 56% of the recorded days, the respondents had some symptoms, and on a third of them, they employed some sort of self-care practice. The most common practices (30%) were drug taking (e.g. painkillers) and lay consultations. Only 2% of the symptom days led to consulting a doctor. The factors increasing self-care practices included: a medical diagnosis of the illness. the use of lay consultations, the perceived seriousness of the symptoms, and psychological disorders. Aukee [I 51 studied the self-care practices of Finnish women (N = 290) using diaries and interviews as research methods. Self-care practices were documented as responses to common symptoms. The most common self-care for a headache was drug-taking, while social support was sought to alleviate depression. Other common self-care practices among the women were sports and exercise, reading, discussions with others, handicrafts, as well as self-indulgences (such as eating sweets), deliberate laziness. and solitude. Self-care in treatment of symptoms and illnesses has been judged to be effective by medical criteria. Research has shown about two-thirds of lay practices to have been evaluated as effective by general practitioners [16, 171. Research has further focused on the genesis. conditions, and functions of self-care groups. It is obvious that self-care groups evolve in order to provide the healing power of social support and feelings of control when official health care is experienced as unsuitable or insufficient. One of the main catalysts for the development of self-care groups has been the failure of a highly technical and authoritarian healthcare system to involve patients in the control of their own treatment. Additionally, the simultaneous increase in lay knowledge regarding illnesses has also contributed. Hence, self-care provides an alternative to an official health care which produces feelings of personal helplessness regarding one’s own body and illnesses [6, 18-221. There is a great discrepancy between the theoretical concerns of self-care research and the available empirical data. First, even if research were to demonstrate that the most important health resources are found in people themselves, the concept of self-care is mostly defined from a medical perspective, and is only regarded as supplementary or secondary alternative to professional medical care. Orem [23], for instance, defines self-care as daily activity for maintaining and promoting the health and well-being of oneself and significant others. This kind of definition
lacks an analysis of the more varied purposes of self-care in everyday life, as well as the aims of and the motives for self-care within a social context. Research has also mainly focused on self-care practices as responses to specific symptoms and illnesses. This approach reflects a very narrow concept of health: that of lack of illness. It ignores the fact that treating symptoms always entails contextualizing and making sense of the underlying problem [21]. Historical and cultural issues, as well as personal experiences, may also be important influences on the motives for and the significance of self-care. In conclusion, these studies have not treated self-care as a set of resources or a means of mastery for health, but rather as only a response to symptoms. The aim of this study is to respond to some of these theoretical concerns. In this study self-care is conceptualized in terms of the concepts and issues brought up and defined by the patients themselves. The context of everyday life is preserved through the use of the diary for data gathering. Self-care is understood here in broader terms as the practical means and resources for attaining mastery over daily life. Different types of mastery over daily life are conceptualized through analyzing health maintenance, self-care practices, and the balance between helplessness and coping resources in the context of daily life. The following questions guided the analysis of the content of the responses. What do people daily consider, plan. and actually do in order to maintain and care for their health? What sort of everyday things do they regard as coping resources? What evokes feelings of helplessness? Finally the relationships between mastery and age. sex and place of residence are considered.
METHOD
Subjects Data was obtained from patients in six Finnish primary health-care centres located in different parts of the country. In each centre, 50 patients were randomly sampled from all those who consulted a doctor or nurse in December 1991 and January 1992. The sampling procedure in each health care centre was the following: if the number of visiting patients was, for instance, 5000. every 100th was chosen for the study. Initially there was a total of 258 patients interviewed. This sample was checked to make sure that the common illnesses of Finnish health-care patients were represented. A focused interview was conducted on the patients’ explanations of health and illness, their social networks, and their experiences of the health-care services. At the end the interviewees were given a semi-structured diary to fill in for 2 weeks [24,25]. They were instructed to record daily their activities, intentions, and thoughts they related to health maintenance, self-care. coping resources and causes of feelings of helplessness. Since we were particularly
Research Note Table 1. Age and sex of the sample Women
All
Men
Age
N
%
N
%
>30 31-40 41-50 51a >60
14 13 14 I5 17
IO 9.3 10 10.7 12.1
6 11 14 14 22
4.3 1.9 10 10 15.7
All
13
52.1
67
47.9
% 14.3 17.2 20 20.7 21.8 100
interested in the patients’ own definitions of mastery, the interviewers therefore emphasized that there were no right or wrong answers, but that the patient’s personal understanding of these issues was of main interest. Of the 258 interviewed patients, 142 returned the completed diary (55%). No attempt was made to obtain more diaries. The group of 142 who completed the diaries and the 85* who did not return the diaries were compared in order to check the distributions of sex, age and place of residence. This showed that those who returned and those who did not return the diaries were similar in sex (x * = 0.79, df = 1, P = NS) and in urban or rural residency (x * = 0.12, df = 1, P = NS). The group that returned the diary was, however, older than those who did not (t (227) = 6.62, P = 0.01). The sample was distributed across all adult age ranges with a mean age of 48.7 + 15.8, The proportions of men (48%) and women (52%) were almost equal (Table 1). The majority (73.5%) of the subjects lived in the countryside, while a quarter (26.5%) lived in towns. Data-analysis The
diaries were analyzed using qualitative methods of content analysis. This analysis consisted of three stages: (1) Both researchers read the data repeatedly and performed a primary classification of the answers. For this analysis, it was felt important that the original text formed the basis of the classifications. A saturation principle was applied here, i.e. the search for new dimensions was completed when no new or different categories emerged. (2) The primary categories were further analyzed and grouped together, using the theoretical criteria for the motive or goal of self-care and health maintenance, and the domain of people’s coping resources and helplessness. (3) All the diary entries were coded on the basis of these primary dimensions. This was done in order to determine the frequencies for each category and to study their relationships to the demographic factors. *Of the original sample 31 cases were dismissed dw to missing information. tThe diary instructions for health maintenance were: every day, record issues (activities, intentions, thoughts) that in your own opinion are related to health maintenance. The instructions for self-care were: every day, record what you do in order to care for your health and the health of those close to you.
135
Reliability of the classification was achieved in two ways. First, the primary search for and identification of categories was done independently by the two researchers. The primary categories were then negotiated. Coding reliability was checked by two judges who simultaneously classified the entries in 40 of the diaries. The percentage of agreement indicates the proportion of responses that both judges coded as belonging in the same category. For instance, both judges coded 205 causes of feelings of helplessness from 40 of the diaries, and of these they coded 14 of the responses into differing categories. The agreement percentage of 93% reveals that 191 of the 205 responses were coded into the same category. The following two-judge reliabilities were attained: Health maintenance 90%, self-care 88%, coping resources 80% and sources of helplessness 93%. One characteristic of the diaries was the diversity of responses: on a daily basis, people recorded many different kinds of self-care practices and multiple sources of helplessness. In order to preserve this diversity in the analysis, Korhonen’s [26] Multiresponsesprogramme was applied. This makes it possible statistically to document the occurrence of all the different responses covering a given theme. The programme then creates dichotomous variables for each response, thus taking into account all the responses. The response categories were constructed using qualitative content analysis, and the relations between indicators of mastery and demographic factors were assessed by cross tables with ,y* statistics and analyses of variance.
RESULTS
Health Maintenance, Se[f-care and Coping Resources
Content analysis involving health maintenance and self-care showed that they consisted of similar actions, plans, and thoughts. It was therefore concluded that no differences exist in lay definitions for the concepts of maintenance and self-care.7 Coping resources were also, to a great extent, of the same nature as health maintenance and self-care. The following example of one day’s diary entries for a 33-year old woman depicts this. Her response concerning health maintenance was: “My plans: I’m going to jog in the forest. I’ll start a diet in order to lose weight”. Her response concerning self-care was: “I’ve been jogging in the forest, about 3 kilometres. I’ve started a diet.” And for coping resources she records: “I went jogging with our dog. The countryside is beautiful and quiet. It makes me serene and happy. I was in a radiant mood.” Table 2 shows the contents and frequencies of health maintenance, self-care, and coping resources in the sample. The percentages indicate the number of people who recorded that particular category of mastery at least once in the 2-week period.
736
RAIJA-LEENAPLJNAMAKI and HANNA ASXAN Table 2. Frequencies
and percentages of categories of mastery’
Health maintenance (N = 115) Meaningfulness of /i/e Philosophy and faith Nature Social r&lions and togetherness Activities Work and achievements Hobbies and activities Recreation and pleasure Leisure and relaxation Enjoyment and pleasure Discipline and good health Sports and exercise Food and diet Avoiding risks Sauna and hygiene Hea/ing of symptoms Official health care
Lay care ‘Differences
Coping resources (N = 140)
Self-care (N = 139)
Al
V”
N
a/”
N
35
30.4
25
18.0
9 38
7.8 33.0
12 40
8.6 28.8
28 54 55 74 82
20.0 38.6 39.3 52.9 58.9
43
37.4
34
24.5
68
48.6
27
23.5
25
18.0
62
44.3
55
47.8
41
29.5
I2 70
8.6 (Creativity) 50.0 (Recreation)
IO
8.7
IO
7.2
75 52
65.2 45.2
88 43
63.3 30.9
I8
15.6
16.5 25.2
I9 29
in sample sizes across variables
reflect missing
I4
IO.I
36
25.9
I4 69
IO.1 49.6
data. For instance,
only
I I5
%
II
completed
(Religiousness) (Philosophy) (Family) (Other social relationships)
7.9
diaries on health maintenance.
The primary content analysis of the diaries revealed 13 categories of health maintenance and self-care. These categories were grouped according to the goals served by self-care and health maintenance: (1) Meaningfulness of life, (2) Social relations and togetherness, (3) Activities, (4) Recreation and enjoyment, (5) Discipline and good health, and (6) Treatment of symptoms and diseases. When the domain of coping resources was used as a criterion, similar categories emerged. Examples of responses classified in each category are presented below.
I remember my mother often used to say: ‘There is always a good feeling to be found’.
(I) The meaningfiilness of life
(2) Social relations and togetherness
The daily recordings concerning health maintenance, self-care, and coping resources contained aphorisms and reasonings which were interpreted as seeking and safeguarding the meaning and purposefulness of life. Nature as a healing agent combined the search both for belonging, as well as for a broader meaning of life. Philosophy, faith, and inventories of life. In the diary entries which revealed a philosophy of life, the subjects estimated the course of their life, the sufficiency of their own resources, as well as their ability to cope. The ‘blessing’ of some moments of everyday existence and the maintenance of some comforting rituals were also interpreted as search for meaningfulness of life. As well, religiousness and the relationship to God were interpreted as important coping resources. Examples included:
Seeking and maintaining social support and feelings of belonging are important sources of healing in people’s everyday lives. Feelings of togetherness with family, grandchildren, relatives, friends, and colleagues were frequently described in one-third of the diaries. It is important to note that not only receiving social support, but also providing it, were recorded as means of health maintenance and self-care.
I listen to religious music and the morning a half-hour’s
service, and keep
silence.
I’m like a cat. Who would lift its tail, if not the cat itself? in life.
You need imagination
I enjoy the small things in life. I generally experience joy just from little things. It’s typical of me to feel alienated in the midst of very dramatic events, even if they are positive.
Nature. The responses referring to nature included remarks on the change of seasons, the beauty of the landscape, and to the sun as a healing agent. There were also observations of plants and animals, and the subjects’ own involvement with natural phenomena. I love plants, they heal me. I wait for spring, so that I can go out into the fresh air and admire nature and observe the development of plants.
We had a picnic together, therapy for a person. I discussed
death
the whole family.
and the after-life
I read aloud to a blind person. a good mood.
It is the best
with my cousins.
Helping
I discussed my worries with my mother a little bit easier.
someone
put me in
and this made things
(3) Activities Work and hobbies were frequently mentioned as means for health maintenance and self-care. The responses revealed an active motivation to change conditions to achieve important goals, and to see the results of effort. The connections between activity, good mood, and health were often explicitly reported.
Research Note Work and achievement. Though working at a job was reported as a source of satisfaction and joy, it was usually described only briefly. In contrast, work at home or at a summer cottage was discussed more extensively. The satisfaction
of achieving
short-term
work
objectives.
It was wonderful to work for many hours with my plants in the fresh air without any hurry and then to sit on a tree stump, and to listen to the spring-time voices in the forest. Friday is both my working day and my therapy day. I tested myself a test to see if I could finish cleaning the house and also bake some coffee cake and pastries. I did it!
Hobbies and recreational activities. A wide variety of hobbies and recreational activities was recorded in the diaries. There were entries such as: I went fishing. In a few days the rally will start. Then I’ll get some exercise; I’ll wash the tyres of the cars, and fill the tanks with petrol for the next race.’ (4) Recreation and enjoyment
Leisure and relaxation. Some of the responses involving recreation and rest reflected the goals of ongoing self-care and the conscious release of tension and stress. The goal of attaining a balance between work and leisure was often explicitly expressed. The ways of relaxing were almost as numerous as the people studied. They included travelling, reading newspapers, sleeping, going to exhibitions, going to restaurants with dancing, window shopping, spending time alone, and engaging in creative activities. Today I went shopping by myself. It was a luxury to be alone and to be able to go around and shop wherever I liked. Just time for myself, without anyone rushing me or putting pressure on me. An important feature of my holidays is the spontaneous rather than organized aspect of them; I don’t like planning anything in too much detail, I’d rather decide things on a day-to-day basis; I want as much contrast as possible to the 8 to 4 o’clock, 5 days a week job which I have the rest of the year.
Enjoyment and pleasure. In these responses, pleasure was the explicit motive and aim. The sources of enjoyment included the arts, good food, good company, and varying rituals for satisfying the body and soul. Another day gone and it’s time for the sauna. We warmed ourselves up in the smoke sauna, again and again, and enjoyed
some beer.
Making
love.
*All hobbies related to sport and exercise were coded in the category ‘Exercise and sports’ which, in turn, belongs to the main category ‘Discipline and good health’, Watching sports was, however, included in the category of hobbies, because it was interpreted as a form of active social participation.
137
(5) Discipline and good health The majority of the people studied strove to achieve and maintain good health through organized sports, exercise, and diet. In addition, avoiding risk behaviours and attending to personal hygiene fell into this category. Sports and exercise. Two-thirds of the subjects mentioned sport and exercise as their means to healthmaintenance and self-care. This category included many types of sports and exercise, such as jogging, slalom and cross-country skiing, weight-lifting, tennis, squash, volley ball, cycling, swimming, archery, gymnastics, aerobics as well as simply membership in fitness clubs. Sometimes these activities were characterized as things one ‘should-do’. If only I could get my act together and do more walking. If I could cycle to work three times a week, I would improve my fitness. Today, when I’m not working exercises.
in the fields, I’ll do some
Food and diet. The descriptions of diet and references to healthy eating habits also tended to have the tone of ‘shoulds’. Typical diets involved the inclusion of vegetables, berries, and fruit into meals. Regular eating hours, consuming a variety of foods, and the preparation of food at home were also mentioned. The different Finnish food cultures were present in the descriptions, such as the eating of reindeer and elk meat, as well as the preparation of blood soup. I proposed to my wife that we should order to purify products. I should traditions surprised.
our bodies of dangerous
fast sometimes in and foreign waste
have the courage to change our daily food and try some new menues, we might be positively
Avoiding risks. Here, the subjects examined their daily activities from the perspective of their health consequences. Regular routines and reasonable, or even zero, consumption of alcohol and tobacco were mentioned in reference to health maintenance and self-care. Consciousness of other risk-avoidance measures, such as using car seats for children and having ergonomically well-designed working conditions, were also included in this category. I say to myself, never smoke or drink do, do so with restraint.
alcohol.
And if you
I’ve been considering the healthiness of coffee drinking after discussing it with my colleagues during the coffee break at the office.
Sauna and hygiene. In a quarter of the diaries the taking of saunas was mentioned as a self-care practice. Some of these entries clearly referred to enjoyment and recreation, leading to both bodily and spiritual benefits. However, the answers included in this category reflected the hygienic rather than the ‘purification’ aspects of the sauna.
RAIJA-LEENAPUNAM~~KI and HANNA ASCHAN
738 I am going cleanliness.
to the sauna
with my spouse
to ensure
our
I keep an eye on both the cleanliness of the environment and of my own body. (6)
Treatment of symptoms and diseases
The treatment of symptoms and diseases included both the use of official health services and lay care. Both were employed for specific purposes. Although both professional help and lay care were used for treating pain and illness and to solve medical problems, lay care was also used for pleasure and health maintenance. UfJicial health care. Official health care is presented in the diaries in terms of consultations with doctors and the obtaining of laboratory tests.
Table 3 shows the contents and frequencies of causes of feelings of helplessness. The percentages indicate the number of people who recorded that particular source of helplessness at least once in the 2-week period. (I)
The global, political and societal circumstances
News of violence, starvation, and national or global difficulties caused feelings of helplessness. The responses revealed frustration due to the inability to help
other
people’s
despair
News about war, starvation,
and
injustice.
and homelessness
I must admit that I feel hatred European Community. Again I don’t have any influence government
among others.
and even fear towards on the activities
the
over the
Walking and wandering about the countryside, dieting, and trying not to get tense. I made an appointment with a doctor and I was seen immediately. He sent me for an X-ray; apparently I have another gastric ulcer. LUJ care. Half of the subjects used lay care practices for self-care. while one-third used them for health maintenance. Lay care has three aspects: the taking of medications, the use of non-medical remedies and cures, and treatment by ‘traditional healing’. Medications included various vitamins, non-prescription drugs, and painkillers. Remedies and cures included massage, fasting. breathing exercises, stretching, and the use of respirators, electric cushions. and cold bandages. I massaged 1 warmed
my wife’s aching my aching
back
neck.
using an electric
cushion.
In the forest, a big ant hill was bristling with life. 1 took a birch twig, moistened it in my mouth and let the ants urinate on it. OK, let’s taste it. I’m sure it’s healthy.
Sources of’ Helplessness The analysis of the diaries revealed nine causes of everyday helplessness: (1) global, political and societal circumstances, (2) the circumstances of the subject’s own life, (3) human relationships, (4) the discrepancy between demands and capabilities, (5) diseases and symptoms, (6) psychological and emotional states, (7) death, (8) everyday hassles, and, then, (9) other. Table
3. Frequencies
and percentages (N = 140)
of sources
Source of helplessness
N
Global and political
and .socirtal situation of the suhjc~ct’s ~MTI liw.\
Circumstance
Loss of vigor Poverty
and unemployment
Human
relurionships
Longing and worry Difficulties m relations Discrepancy
hetn~em
demond.~
Work and its demands and symptoms
Psychological
and emotional
Death Ewryday Other
hassle.\
%
8
5.7
7 15
5.0 10.7
30 26
21.4 18.6
44 41
31.4 29.3
and capabilities
Willpower and abilities Diseases
of helplessness
state
64
45.7
36
25.7
7
5.0
14
10.0
29
20.7
Environmental risks and pollution were a source of feelings of helplessness within the subjects’ own society. These feelings sprung from a sense of alienation and impotence in relationship to their everyday lives. I couldn’t sleep when I started to think about the fluoride solution that the dentist had spread on my teeth. I wondered how many other dissolvents and chemicals had gotten into my body. The factory visitor noticed the smell of gas. I must have become accustomed to it. Now I realize that, now and then, you need to open the doors. The dirty air and lack of oxygen in my workplace are a source of helplessness.
(2) The circumstances of the subjects’ own lives Helplessness due to the subjects’ own life circumstances was varied and very personal in nature. It concerned aging, loss of physical and mental vigour, poverty, unemployment, loneliness, and alienation. Every day I feel helpless. I am only 53 years of age and I feel that there are still lots of things that would be nice to do, but I have to leave a lot undone. I simply cannot do any more. I fear the future
and unemployment.
(3) Human relationships Human relationships were sources of helplessness in two distinct ways: missing, and worrying about loved-ones and, then, having relationship difficulties at home and work. Missing and worrying about loved-ones. As children, respondents were concerned about the well-being of their parents, while, as parents, they worried about the future and happiness of their children. The subjects also expressed great concern for the spouses and parents that they lived with, as well as for the raising of children. Parents of grown-up children worried about their children’s problems with finances, alcohol, studies, work, and marriage. Long distances, living abroad, as well as earlier deaths led to the missing of loved-ones.
Today, mother would have had her 80th birthday, but she died 20 years ago. I still miss her. A moment her grave, incurable longing.
of sorrow
by
Research Note
739
My children live far away, I can’t sleep. My youngest child may still hate me and that is difficult to bear. He never visits me.
I have the feeling that I’m inferior and not good for anything, both in my own and in other people’s eyes. I feel that nobody cares for me.
D@cult human relationships. Human relationships both at home and work caused many feelings of helplessness. Not being accepted as a member of a working group or suffering because of one’s own behaviour are examples in this category.
(7) Death
I suffer from loneliness, I don’t think any of my children care whether I live or die. Continuous difficulties with one person in particular work, and whatever I do, the conflict continues. (4)
Work and its demands. Work and activity were very important in this Finnish sample as resources for coping, health maintenance, and self-care. However, work was also a cause of helplessness. The subjects mentioned a variety of well-known work stressors: on the one hand, work overload, unfinished tasks, and constant time pressure; on the other hand, monotony, and boredom. Strain, tiredness, insecurity, and a lack of knowledge and expertise also made people feel helpless. Furthermore, poor work organization, unclear or overwhelming responsibilities, and inadequate communications were also mentioned. For me, it’s difficult to work with the computer. There are lots of things I don’t understand and afterwards I feel ashamed. I had to perform in the meeting. In my opinion it was a complete failure. Will-power and abilities. Feelings of incompetence, frailty, and ineffectiveness in relationship to aspirations were mentioned as sources of helplessness. The discrepancies had implications for life-styles, happiness, and ambitions. The negative thing which depresses me is my dependence on smoking: I should really try+ne day soon---to do something about stopping. I found myself eating too much again, even after I had decided to go on a diet. (5) Diseases and symptoms The most common symptoms experienced as sources of helplessness were pain, insomnia, dizziness, stress, and fatigue. The attitudes of other people and the public health authorities towards one’s illness also contributed to the feeling of helplessness. thought I’d die.
I can’t figure out how much sleep I need in order not to be constantly tired and feel lack of energy day and night. (6)
Psychological and emotional states
Depression, grief, loss and anxiety were the sources of feelings of helplessness in this category. I feel helpless morning,
because
generally in the night I’m alone.
Deep in my soul, there is an immense
and sadness.
early
of a lack of control with helplessness.
over death
was
I witnessed a car accident. A small boy died and I could do nothing. I saw that, again, acquaintances have died. They are the same age as I am, some of them are even younger.
at
The discrepancy between a’emandr and capabilities
An asthmatic attack--I
A feeling synonymous
in the
(8) Everyday hassles Everyday hassles such as worrying about how a kitten would cope alone outside a house or running a car battery down by leaving the lights on were, in a few cases, causes of feelings of helplessness. In this category also belonged technical problems with machines, repairs, and services. It is interesting that nature functioned not only as a healer and a resource, but also as a cause of helplessness. Experiences of having no control over nature and of its coldness, unfriendliness, and greyness were described. For example, descriptions of snow, storms, and frosts recalled the ‘struggle against the powers of nature’. (9) Other One-fifth of all diary entries mentioned causes of helplessness that did not fit into the above categories. These responses were often very personal and specific to a particular situation. Factors Related to Mastery and HeIplessness A one-way ANOVA was applied in order to assess the differences in everyday mastery and helplessness according to sex and place of residence. As dependent factors, a combination of variables were constructed by summing up identical or similar categories within health maintenance, self-care and coping resources. The results showed differences between women and men in philosophy and faith (P < O.lO), social relations and togetherness (P < O.OOl),and diet and food (P < O.Ol), as sources of everyday mastery, with women expressing these sources of mastery more often than men. The results of the ANOVA are summarized in Table 4. The ANOVA results for the relationship of sex and helplessness showed that the women recorded more helplessness due to a discrepancy between demands and capabilities, F (1,138) = 2.70, P < 0.10, and to psychological and emotional states, F (1,138) = 4.78, P < 0.03. The men, on the other hand, recorded more helplessness due to global, political, and societal conditions, F(l,138) = 2.80, P < 0.09. The ANOVA results for the relationship of place of residency and mastery showed that there were differences between people from different parts of Finland. This variation, however, did not follow the town-countryside or north-south dimensions that have previously been found to differentiate Finnish
740
RAIJA-LEENA
Meaningfulness l?fII/k Philosophy and faith Nature Social relalrons and rogerherne.rs Acfioities Work and achwements Hobbies and activities Recreation and pleasure Leisure and relaxation Enjoyment and pleasure Discipline and good health Sports and exercise Food and diet Avoiding risks Healing ofsymproms Official health care Lay care ‘F(l,l
PUNAM~~KI and
1.59 0.98 2.75
1.90 1.82 3.08
2.30 I.13 5.45
3.19 1.63 4.88
2.68 I.91
2.19 2.54
2.64 1.57
2.63 1.97
0.90 0.62
1.90 2.79
2.54 3.08
1.56 3.43
1.97 3.39
0.62 I .06
4.17 1.35 I.15
3.49 2.02 2.13
4.29 2.62 0.88
3.05 3.21 1.57
0.04 6.16** 0.50
0.33 I.91
0.84 2.51
0.67 2.00
1.50 2.55
2.12 0.03
2.61’ 0.22 11.90***
IO); *P < 0.10; **p < 0.01; ***p < 0.001
health behaviour [27]. Overall the six places of residence differed significantly with respect to social relations and togetherness F(5,106) = 2.09, P < 0.09, sports and exercise F(5,106) = 3.29, P < 0.008, and lay care F(5,106) = 3.50, P < 0.003 as sources of mastery. All these differences were due to the people of one town consistently recording the lowest number of sources of mastery. This town is an industrial port, and much of its population has moved there from other parts of Finland. Hence this factor may explain the result. Correlation analysis between age and sources of mastery showed that older subjects recorded philosophy and faith (r = 0.32, P < 0.001) and lay care (r = 0.21, P ~0.01) as their resources for mastery more frequently than the younger subjects. The older subjects recorded more discrepancies between demands and capabilities, especially work and its demands, as sources of feelings of helplessness than the younger ones (r = 0.30, P < 0.001). DISCUSSION
The aims of this study were two-fold. The first aim was to further understanding of the contents of everyday health maintenance, self-care, coping resources, and causes of feelings of helplessness. In addition, people experiencing everyday life both causes of helplessness as well as resources for coping, and so the second aim was to learn more about the formation of a positive balance between them and to analyze the demographic factors related to them. The subjects comprehensively described their everyday lives in diaries. They tended to understand the activities of health maintenance, and self-care and their resources for coping in similar ways. In all of these domains, the main themes involved work, activities and accomplishments, human and spiritual affiliations, the enjoyment and recreation, and the meaningfulness of life. Sources of helplessness and
HANNA ASCHAN
coping resources were not exactly of the same nature. In other words, the deprivation of certain coping resources did not necessarily mean helplessness in that area. However, good human relationships and rewarding work were experienced as resources, while bad relationships and work difficulties were experienced as sources of helplessness. This indicates the importance of these two domains for the experience of mastery of daily life. It is important to note that social affiliation did not mean only receiving social support but also giving it. Helping and bringing joy to others were recorded as self-care and health maintenance activities, while relying on others and sharing feelings were recorded as coping resources. In this study, the starting point was the patient’s own concepts and definitions of self-care, health maintenance, coping resources, and sources of helplessness. Mastery has been found to be essential in preventing illness and recovering from it [7, 281. The patient practising self-care controls the everyday means and resources that enables him or her to live a healthier life. The promotion of people’s health and mastery in primary health care setting is not possible without knowledge of the content of the patient’s own resources for health. The results of this study showed that patients utilize a variety of means for attaining this mastery. This picture of a patient challenges the view of a ‘normal consultation’ [29], in which a patient is portrayed as passive and docile, a target or object of care, and in which the patient easily becomes helpless and irresponsible regarding his/her own health. One of the reasons for the previous rather narrow picture of self-care may have been the approach and method of previous studies. Self-care has been mostly analyzed as a response to a certain illness, symptom or problem. However, the results in this study concerning the content of mastery indicate that patients exercise a diversity of health maintenance and selfcare practices. ‘Medicalization’ [30] of the everyday life is not evident from this data. It is apparent that treating symptoms is only one, but not the most frequent, self-care practice. The conceptualization of self-care and health maintenance should be more comprehensive and include social and phenomenological domains. It should also include existential and ritual methods for experiencing the meaningfulness of life, as found in philosophies of life and in affiliations with the creator, nature, and other people. It should also include everyday activities and enjoyment in life, as well as recreation as a potential source of accomplishment. REFERENCES
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