USING

HEALTH
SERVICES
When and how do we decide that we are sick?
Symptoms; from very early on we get to connect illnesses with certain symptoms. For example, let’s say we have
strep throat. The person will have some symptoms like sore throat, pain, maybe high fewer, maybe headache.
When we were young and had this symptoms, our parents took us to a doctor and the doctor gave a
prescription. So from experiences like this we have learned to connect symptoms with illnesses and we have also
learned that some symptoms are more serious compared to others. So based on our understanding of our
symptoms we may or may not going to see a doctor.

How do we know that we are ill?

• Recognizing symptoms
• Interpreting symptoms
• Cognitive representations of illness (which is a very interesting social psychological sort of perspective)

Symptom Recognition: Individual Differences

• Some people report more symptoms more quickly (some people are more likely to objectify their emotional
problems, or there might be a noisy stomach and the person becomes preoccupied with the idea that she is
seriously ill although she is not. Or she may have a symptom like pain, but she gets overly obsessed about
it/exaggerates the problems and her functioning does get affected;
o Illness Anxiety Disorder (Previously called hypochondriasis)
- Preoccupied with the idea that you are seriously ill, based on normal sensations (such as a noisy
stomach) or minor signs (such as a minor rash)

o Somatic Symptom Disorder

- You do have a symptom or symptoms (ex. pain, cough) but you're obsessed with it, think the worst
about it and it causes you an exaggerated amount of distress and problems functioning.

• People high on neuroticism (who feel emotional ups and downs and don’t feel very good about themselves)
and negative affect also recognize and report their symptoms more quickly.

Symptom Recognition: Attentional Differences

• People who are more focused on themselves (bodies, emotions, reactions) also notice symptoms more
quickly
• But, sensitivity to symptoms is not necessarily related to accuracy!
o Individuals on the treadmill who were more focused on their internal states (breathing) were more likely
to overestimate changes in their heart rate compared to those who listened to city sounds (noises
outside) (Pennebaker)=is a health psychologist
o So focusing on your state is not necessarily related to having an accurate perception of symptoms.

Symptom Recognition: Situational Factors

• Lack of stimuli, boring job, lack of physical activity, living alone may actually report more symptoms
• On the other hand, people who are more physically active will have fewer symptoms
• A situational factor that makes illness or symptoms salient
 o Ex. ‘Medical students disease’ (you’re in an environment where there is a lot of information shared about
symptoms. Medical students who are interviewed 2/3 s of them in one research said that; they probably
had personally experience symptoms that they have been talked about. You might have a similar
experience when you take the psychopathology course. Every week you introduced to a different
disorder; anxiety, depression, obsession. So you might have the psychopathology of the week syndrome,
where you think “I might be anxious now”.

Symptom Recognition
More symptoms may be reported under
• Stress
• Negative Mood
• Cultural differences in perceptions of and reactions to illness symptoms
o Ex. Level of distress and disability in response to pain symptoms may vary depending on the cultural
norms for reinforcing stoical vs distressed/disabled behaviors (pain seems to be experienced and
expressed differently.)
o For example in a comparison of American and Mexican subjects; American subjects show highest
disability in response to pain. Whereas Mexican subjects show a more stoical (teveküllü) response to pain.

Interpretation of symptoms
• May be affected by:
o Seriousness of the symptoms
o Expectations
o Prior Experience

Interpretation of symptoms: Seriousness of the symptom

• Symptoms are more quickly reported if
o Affecting highly valued parts of the body such as the face
o They cause pain (pain seems to be something that we pay a lot of attention to, which brings us to the
healthcare system. It usually pain that patient may want to talk about when they’re going to the doctor’s
office and the doctor may want to try to understand where this is coming from. So pain is reported more
than other symptoms)
o Also, the person’s life quality may be affected by the seriousness of the symptoms. Ex: The person has
shortness of breath which can manage most of the time, but if she moves to an apartment building where
there is no elevator and she has to climb up 4-5 stairs, that’s when this becomes a serious symptom for
her, because the problem affects the quality of her life

Interpretation of symptoms: Expectations

• Expectations may make it difficult to recognize and interpret symptoms
o Ex. Cardiac symptoms for women (uzun yıllar kalp hastalıkları sadece erkeklerde oluyor gibi düşünülmüş,
kadınlarda kalbe dair bulunan semptomlara gerekli ilgi gösterilmemiş bu sebepten dolayı. Ama artık böyle
değil durum. We know particularly that post menopausal women may be at the heightened risk of heart
disease. For sometimes that was just ignored.)
o Breast cancer risk ignored for men. Men are of course, not at all affected to the same degree by breast
cancer, but they may actually get it. It is possible.
• Symptoms that are expected may be amplified, symptoms that are not expected may be ignored
o Ex. Diane Ruble’s study on report of premenstrual symptoms
(She took a group of women and gave them a physiological test that she postly described it as being very
accurate in predicting the timing of their next menstruation. Then she said, “this group is within a couple
of days of beginning their menstruation and other group was told that “their menstruation was about a
week to 10 days”. So there is a difference in expectation between the two groups. In reality, the
beginning of their next menstruation was about the same for both groups. Then, all the women asked to
fill out the questionnaire that asked about premenstrual system that they were experiencing. So what she
found in line with her expectations; women who were believe that their period was about a couple of
days away as opposed to a week or 10 days later, reported more symptoms. Yani reglisi yaklaştı dedikleri
daha çok semptom hissetmeye başlamış. Bu da şunu göstermiş;
It doesn’t mean that premenstrual symptoms don’t exist, but just reported symptoms may result not just
from biological changes occur in our body, but from our beliefs and expectations. So power of
expectations!!!)

Interpretation of symptoms: Prior experience

• Mostly, helps people make correct interpretations
o Ex. Whether to take the child to the doctor (mothers’ previous experiences)

Interpretation of Symptoms
• Sometimes, expectations and previous experience will result in incorrect interpretations
o Ex. Incorrectly attributing symptoms to old age (“at my age of course I will have problems like this” ama
bunlar tedavi edilmesi gereken bir hastalığın semptomları da olabilir) or to stress reaction (you are under
stress and you might misattribute your symptoms to stress. “It’s about stress and it will going to go away
when I’m not under stress anymore.)
o Ex. Ignoring symptoms out of fear (maybe there is cancer in the family or heart disease in the family and
the person gets in to the avoidance mode. So maybe there is a lump under the arm, but because she is
afraid that she could actually be diagnosed by breast cancer,) and delaying treatment

Lay Referral Network (Eş Dost Yönlendirmesi) and the Internet

• People consult their social network before deciding to ask for medical attention (we ask our neighbors,
friends, people around us what to do for
o Help with interpreting a symptom
o Advice about seeing a doctor/healer
o Recommendation for a remedy

*In our society people like to give advice about what they did, what worked for them (It is pretty common). “Şu
çayı içtim ve hastalığım iyileşti-koca karı ilaçları”, veya doktor önerirler vs.
*İnsanlar tüm hastalıklara, semptomlara internetten bakmaya başladılar. Doktora gitmeden önce.

Cognitive Representations of Illness

• We also have organized conceptions of specific illnesses and beliefs about illnesses that help us interpret our
symptoms and influence what we do (we have common sense notions about illnesses)
So if I were to say lung cancer what comes to mind? Biopsy, hair loss, loosing weight, chemotherapy etc.
Illness representations
• Lau’s research Q: ‘What does it mean to be sick?’ was answered by certain cognitions about illness:
o Not feeling normal
o Specific symptoms (like nausea etc.)
o Specific illnesses
o Consequences of illness (ex: what you may not able to do as a result of having cancer; for example not
able to socialize etc.)
o Time line (how long has the symptoms been going on etc. Is this a short term illness or long term illness?)
o Absence of health

Common sense model (CSM) of self-regulation of health and illness (Howard

Leventhal & colleagues) common sense= ortak akıl
• Illness representations: We hold implicit commonsense beliefs about our symptoms and illness that result in
organized illness representations or schemas.
• Phenomenological approach
(We talked about the Biopsychosocial model versus the Biomedical model at the beginning of the class. One
advantage of the biopsychosocial model is because it can take an inside review of the patient and try to
understand how the patient looks at their illness, which has implications for how she will go about it. So a lot
of research was done on various samples; people who are chronically ill or people who just diagnosed with
cancer etc. (devamı aşağıdaki maddede var))
• Much research has been conducted on the chronically ill, just diagnosed with cancer, healthy adults to
understand these illness representations/beliefs and how they relate to what people do about their illness
• So the theory is trying to connect how people understand their illnesses and what they do about it.

Components of Illness Representations

• According to CSM, the way people think about their illness is organized around 5 questions:
o What is it? (Identity)
o How long will it last? (Time-line)
o What caused it? (Cause) For example for lung cancer; cigarette smoking
o How will it/has it affected me? (Consequences)
o Can it be controlled or cured (Cure/Control) -> For example, cancer being a terminal illness suggest that
there is really not much cure for it. If it were a less serious illness, maybe that would be controllable with
penicillin or some other ways like take our of tumor with surgery etc.

CSM-Identity (this is a function of two things; what is the diagnosis & concrete signs and symptoms)
• The person’s label for the illness (patient’s own diagnosis) as well as concrete signs and symptoms
associated with it
o “I have rheumatoid arthritis (label), with concrete signs (affected joints) and symptoms (pain)”.

CSM-Causes
• Perceived cause of illness, e.g, genetic “I have a genetic vulnerability to breast cancer”/biological (virus etc.),
or psychosocial (stress or some health behavior such as smoking) factors
o “My cold was caused by a virus”
o “I got a cold because I was very stressed out & run down”
CSM-Consequences
• Patient’s perceptions of the possible effects of the illness on their life
o Physical o Economic
o Social o Emotional

• “My cold will prevent me from going to the party on Friday night and from seeing my friends.”

CSM-Time-line
• Patients’s beliefs about how long the illness will last, & whether it’s acute, chronic or cyclical.
o “My cold will be over in a couple of days” (acute time line)
o “My hypertension is a chronic condition”
(if you think, you do not have to take your hypertension medicine, unless you feel like your blood
pressure is high; you never going to be in a good state. Because hypertension medicine is something that
need to be taken every day, because it is a chronic condition.)

CSM-Cure and controllability

• Patients’ beliefs about whether illness can be cured, and the extent to which the outcome of their illness is
controllable (by themselves or by powerful others)
o “If I rest and drink lots of fluids, my cold will go away”
o “If I go get medicine from my doctor, my cold will go away”
o “My cancer has no cure!”

Cognitive Representations of Illness

• Most people have at least 3 models of illness (Leventhal)
o Acute
o Chronic
o Episodic/Cyclical (meaning we maybe symptomatic sometimes and other times we may not be
symptomatic; like asthma)
• One’s perceived model has implications for how to cope!

Common sense model (CSM) of self-regulation of health and illness (Howard

Leventhal & colleagues)
• Lay theories
o guide coping,
o entry into and use of medical treatment,
o evaluations of treatment effects.

• The earlier work on the effect of fear message (there was initial work in the 70s on the effect of fear
messages, “can we get a person to take action when we make them fearful about their condition”.) What
the researchers found was that:
o Fear by itself did not necessarily promote action (in fact it may turn some people off, people may want to
avoid, ignore their problems; if they are extremely afraid of what might be happening to them)
 o *But, combination of fear and action plans changed the “cognitive representation” of the threat and did
motivate the person to action! (so it moved to person being passive and avoidant towards being active)
o *Stimulated interest in how people represent health threats and the interaction between representations
and behavior— CSM was developed

CSM is based on the model of Self-regulation

• Self-regulation as ‘problem-solving’:
o Identification of the goal: e.g., getting to school in time for class in the morning.
o Selecting a strategy to achieve that goal and implementing: e.g., drive?
o Decide whether the implemented strategies achieved the goal or not
- If not, try another strategy, ex. take the shuttle

*So this is like your typical problem solving strategy and gets applied to context of dealing with health problems

The CSM assumes that...

• Individual:
o is a commonsense scientist/problem solver trying to make sense of the health threat (e.g., his/her
somatic experiences or information from outside-it can be a diagnosis)
o selects methods to deal with the threat (COPING) (danger and fear)-> the patient has to deal with both
the danger caused by the illness and the fear/anxiety that threat poses to the person. (yani hem sağlık
sorununun kişi için yarattığı tehlike hem de o tehlikenin yarattığı korku)
o evaluates the effectiveness of his/her actions for controlling these changes

Responses to illness follows 3 broad stages

1. Cognitive Representation of the health threat by which the patient identifies the meaning of the threat:
o Messages about our health can come from:
- Internal Cues (eg., symptoms)
- External Cues (eg., diagnosis, an illness running in the family)

2. An action plan to cope with the danger as well as with the emotional state such as anxiety or fear
3. An appraisal of the action plan
o A feedback loop
o Health related decisions are seen as dynamic (there is no single end point)

The CSM
This is sort of how we can see it visually. For both the representation of the fear and illness risk you engage in
certain procedures, you make an appraisal of them and then based on the effectiveness of your actions and your
coping strategies; your representation of the illness may change, your representation of the fear may change.
And so there is a sort of a dynamic system that the Common Sense Model suggests.
So, for example you have anxiety that results from the fact that the pain that you have maybe coming have to do
with the coronary heart disease. -> So this is the difference between Common Sense Model and more attitudinal
models like Health Belief Model or the Theory of Planned Behavior, because it includes an appraisal stage. When
we talked about the Health Belief Model, we said; that model is more predictive and more applicable one time
only health decisions such as going for a screening (single point decisions) but for chronic illnesses this model
(CSM) is a much better predictor of adherence (reçetelere uymak, uzun vadeli hastalıklarda özellikle gerektiği
zaman böyle bir dinamik model çok daha anlamlı oluyor)/ going along with the prescribed treatment whether its
medication or whether is exercise or there is something else that we’re prescribed is important, because in the
context of chronic illnesses that need to be managed and that are long-term.

(Daha sonra doctor patient interaction işleyeceğimiz zaman CSM modelden tekrar bahsedeceğiz.)

Using health services

• Who mostly uses health services and why?
o Very young (childhood illnesses, check-ups, vaccinations), elderly (illnesses that come with age), women
(are seen more in health services compared to men, yani kadınlar daha çok doktora gidiyor)-> some
reasons: pregnancy periods of women, also women go for reproductive care like smear tests every year,
after certain age mammography, also men are less likely to go on their own
o Those with money and access to health services
(ex: right now in state hospitals fewer and fewer available slots for appointments when you have to get
an emergency appointment; it may be hard. If you’re in a private intuition you’re in a better place. But
healthcare is very expensive.)
o Those with favorable attitudes

Misuse of health services

Psychological problems can be medicalized for different reasons
• Mistaking symptoms of anxiety or depression (ex. Upset stomach, shortness of breath) for a physical health
problem, taking psychological problems to a medical doctor
o Medical problems are seen as more legitimate than psychological ones (so rather than trying to see a
psychologist or psychiatrist, a medical doctor with a specialty expertise in internist (dahiliye) seems more
legitimate and more prestigious. We also like pills (yani ilaç tedavisi sadece tedaviymiş gibi geliyor bazı
insanlara))

• Secondary gains
o Illness may bring benefits such as being taken care of
(such as missing work, if you don’t particularly like the job that you’re working in. so it could be an
excuse)
Delay Behavior
• Delay: Period between when a person recognizes a symptom and when s/he receives treatment (there is
patient delay but there is also medical delay as well)
• Reasons for Patient Delay
o percieved expense (“I don’t want to pay this much money”),
o little contact with doctors (not having much experience and just having stayed away from the medical
system),
o fear (of what you’re going to find out when you go for that check- up) ,
o nature of symptom (ex. does it hurt, does it change quickly?)-> “okay, maybe if I don’t pay attention to it,
it was away”etc. veya hemen geçiyordur vs.

Different stages of delay: Time Periods of Delay Behavior

Appraisal Delay: The time it takes a person to decide that a symptom is serious (ex: maybe that lump grow in to
a big one before you take it seriously)
Illness Delay: The time between recognizing that a symptom implies an illness and the decision to seek
treatment
Behavioral Delay: The time between deciding to seek treatment and actually doing so (“Right now I’m engaging a
behavioral delay, because I know I should go get that colonoscopy appointment, but I’m not actually doing so,
I’m waiting when I’m less busy.”)
Medical Delay: The time between making an appointment and receiving appropriate care (didn’t receiving the
right assessment at the right time, mesela doktorun randevusunu geç bir zamana vermesi buna örnek)

Delay and CSM

• Major problem in relation to breast cancer
• CSM helps explain delay behavior
o Delay may be a way of coping with fear that the felt lump is a tumor
(remember, we said the person deals with both the health danger and has to cope with the emotions
(anxiety and fear). So the behavioral response of the delay behavior can be seen as a way of coping with
the emotion generated by the cognitive representation.)
o Delay may be reinforced by
- Symptom perception, that lump gets smaller
- Observation that the less she thinks about it, the better she feels

Medical Delay
• Correct diagnosis may take longer when patient doesn’t fit the standard profile for a particular illness
(For example, if a cardiac doctor has assumed that the symptoms are more typical in a male; a female may
have a harder time being diagnosed etc. or breast cancer for men, erkekte olmayacağı düşünüleceği için geç
teşhis edilebilir doktorlar tarafından. Mesela yaşlılara da bazı doktorlar senin yaşında bu semptomlar normal
vs. olarak yaklaşabiliyorlar)
• Q: What are some of your experiences with delay?
o On your side?
o On the side of the provider? (misdiagnose delays your correct treatment and cure)