Health behaviour, illness behaviour and the sick role

Parsons wrote in the tradition of structural functionalism, which treats society as a system of interlocking roles that must keep functioning if the whole is to survive. Seen from that angle, illness is a form of deviance. It removes a person from the roles he occupies — worker, parent, spouse, neighbour — and therefore reduces what the social system receives from him, while adding the cost of his care. Deviance of this kind cannot simply be forbidden, because nobody chooses to fall ill and a society that denied illness would be absurd. Parsons’ answer was to make the release conditional. The sick person receives legitimacy, but a limited, temporary and supervised legitimacy: he is excused in proportion to the illness, he is not blamed for it, and in exchange he must treat the condition as an unwanted state to be removed as quickly as possible. The physician is the institution that certifies the claim, and this is why Parsons described medicine as a mechanism of social control quite as much as a service of healing: the doctor legitimates some claims and rejects others, and can return a suspected malingerer to work. The arrangement also contains secondary gain — the advantages of being ill, such as escape from an unwanted job, attention from relatives or the avoidance of blame. Because those advantages are real, the role builds in pressure towards recovery, and the patient who lingers is suspected of enjoying them. Three assumptions date the model: a stable nuclear family with an adult — historically a wife — free to absorb the patient’s duties; employment that carries paid sick leave; and an acute, self-limiting, physically caused illness that ends in a return to normal. None of the three is universal. In most Cameroonian households the carer is already fully occupied, most workers are self-employed or subsistence farmers with no leave at all, and the dominant burdens — hypertension, diabetes, HIV, tuberculosis, sickle-cell disease — do not end.

How does a symptom become a consultation? David Mechanic listed the variables that decide it: the visibility of the symptom, the extent to which it disrupts daily activity, its perceived seriousness, its frequency and persistence, the person’s tolerance threshold, the competing needs that demand attention, the cultural knowledge available about the condition, and the tendency to deny or minimise it. Illness behaviour is therefore not a fixed trait but the product of a situation, which is why the same person consults quickly for one symptom and ignores another for months. Irving Zola added a more concrete list of triggers, drawn from interviews with patients: an interpersonal crisis; perceived interference with work or social life; sanctioning, when somebody else insists; the temporalising of symptoms, meaning the private deadline a person sets before acting; and the nature and quality of the symptom itself — its pain, bleeding or visibility. Eliot Freidson described the network through which these judgements travel as the lay referral system, and distinguished closed systems, where everyone shares the same lay culture and the advice keeps the person inside the network for a long time, from open ones, where the network passes him quickly to a professional. Community screening makes the same point with numbers: a week of blood-pressure checks in one market commonly finds several times the number of cases that the clinic register recorded in an entire year. Epidemiology therefore separates prevalence in the community from consultation rates in the service, because they measure two different things. For nursing, the practical rule is a question: ask who was consulted first and what they advised. The answer identifies the principal lay consultant, predicts what the patient may already have taken, and shows which beliefs the plan will have to work with rather than against.

Parsons’ model works best for an acute, physical, curable illness in a person who has savings and a substitute. Four groups break it. The first is chronic illness. Michael Bury described chronic illness as biographical disruption: it damages the assumptions on which a life was planned, rather than forming a single episode, and it never reaches the recovery that closes the sick role. Kathy Charmaz added the loss of self, the erosion of a valued identity as a person can no longer do what defined him. The patient is left permanently in a half-legitimate position — exempted, but never restored. The second is mental illness, where the exemption from responsibility, the second of Parsons’ rights, is precisely what is refused: patients are blamed for weakness, or held morally responsible before they are granted any exemption at all. The third is poverty. The model assumes a carer who is free to take over and a wage that continues while the patient rests. In an informal economy there is no sick leave, the carer is usually already working, and stopping means the household does not eat; the exemption is simply not available, so the person continues to work while ill and is then called unmotivated. The fourth is stigmatised illness. Erving Goffman showed that a condition can spoil an identity, and that relatives carry a courtesy stigma through their association with the patient. Under these conditions the sick role is not a benefit at all, and refusing the label can be the rational act. Sociologists therefore distinguish degrees of legitimacy: unconditional for acute physical illness, conditional for chronic illness, and illegitimate for conditions such as alcoholism or mental disorder, where the person is blamed for the condition itself. Goffman’s insight is also why nursing has moved from the word “compliance” towards shared decision-making: a plan the patient does not follow is evidence about the plan, the barrier and the network before it is evidence about the patient.