Health Decisions and Sick Role Variations: An Exploration

Author(s): Andrew C. Twaddle

Source: Journal of Health and Social Behavior, Vol. 10, No. 2 (Jun., 1969), pp. 105-115
Published by: American Sociological Association
Stable URL: https://www.jstor.org/stable/2948358
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 Health Decisions and Sick Role Variations:
An Exploration'
ANDREW C. TWADDLE
Harvard University

Case interviews are used to explore variations in illness behavior and Parsons' sick role
formulation. A decision-making model, focusing on the influence of status and role definers
(significant others), produced findings relative to the nature of being "well", assignment of
a "sick status", and illness behavior. While Parsons' formulation describes modal categories
when each component is taken alone, his total configuration describes only a minority of
responses. Seven sick role configurations are identified. In addition to interpersonal influence,
the nature of "well roles" and the nature and severity of the illness are important variables
for the study of illness behavior.

THIS paper reports an exploratory studysick role formulation. While his study in
of illness behavior with reference to
Parsons' conception of the sick role. While
there had been attempts to apply Parsons'
formulation (Mechanic, 1965) and critical
discussions had been published (Freidson,
1962), at the time when this study began
there had been no attempts to empirically
assess its utility.
A unique opportunity to make such an
assessment was presented in the summer of
1966 when the author received permission
to re-interview panelists from the Brown
Health Study, which had been investigating
health and role changes associated with
aging.2 The Brown Health Study Panel of
older couples in Providence, Rhode Island,
allowed selection of a sample of persons
with known characteristics who had re-
ported an illness of recent onset. This sam-
ple, which is the focus of this report, was
interviewed in detail about their behavior
with reference to a specified illness episode.
While the study was in progress, Gerald
Gordon's Role Theory and Illness (1966)
was published, in which he explores the
1 This is a revision of portions of the author's
doctoral dissertation (Twaddle, 1968:Ch. 8)
which was supervised by Martin Martel. In addi-
tion to Dr. Martel, the author wishes to thank S.
Frank Sampson, John Hudson, Roger Sweet and
Victor Sidel for critically reviewing several drafts
of this paper. Shortcomings found herein may
safely be attributed to occasional failures to take
their excellent advice.
2The Brown Health Study is being conducted
by the Population Training Center at Brown Uni-
versity. A debt of deep gratitude is owed to
Robert Burnight, Director, for his encouragement
and facilitation of this study.
105
some ways parallels this one, it differs in
crucial respects: (1) while both studies
focus on variations from Parsons' concep-
tion of the sick role, Gordon focused on
the social class dimension while this study
focuses on the ethnic dimension. (2)
Whereas Gordon focused on criteria, this
study emphasizes the processes which deter-
mine variations. (3) Gordon used a large
sample and emphasized statistical validity,
while the present study examines a few
cases and emphasizes richness of detail.
The two, therefore, are seen as comple-
mentary and additive.
THE PROBLEM
The study of illness behavior from a
sociological perspective began in earnest
with Parsons' formulation of the sick role.
Derived from the emphasis of modern in-
dustrial societies on instrumental activism,
Parsons posits the following norms for the
behavior of a sick person as being most
generally applicable in the society as a
whole:
1.... exemption from normal social role
responsibilities, which, of course is relative
to the nature and severity of the illness.
2.... the institutionalized expectation that
the sick person cannot be expected by "pull-
ing himself together" to get well by an act
of decision or will . . . he is in a condition
that must "be taken care of."
3.... the definition of the state of being ill
as itself undesirable with its obligation to
want to "get well."

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106 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

4.... the obligation-in proportion to the decision was conceived as being influenced,
severity of the condition, of course-to seek in part, by the judgements of a variety of
technically competent help . . . and to co-
other persons, or status and role definers,
operate with him in the process of trying to
get well. (Parsons, 1951).3 who differentially reflect ( 1 ) societal norms
as mediated by a variety of sub-societal
While this formulation may be useful norms and (2) the nature and scope of
when the focus is on the society as a wholetheir interest in the "sick" person, which is
(Gordon, 1966), it tells us nothing about in part determined by their relationship to
(1) normative variations among various and identification with the individual in
subsocietal populations, such as social strata question. The constants posited by Parsons
or ethnic collectivities, or (2) expectations were hence taken as guidelines for the ex-
brought to bear on (classes of) individuals ploration of sick role variables.
subject to different patterns of interpersonal A second source of sick role variation
influence. was conceived to be nature and severity of
Several studies, none of which was speci- the imputed illness, as suggested by Par-
fically oriented toward the sick role formu- sons. Included here are the clarity of symp-
lation, have demonstrated variations in both toms, the risks thought to be inherent in
perceptions of illness (Baumann, 1961; the illness, the degree to which the illness
Freidson, 1962) and in illness behavior is seen as "voluntary", and the expected
(Davis, 1963; Barker, 1953; Roth, 1963; outcome, with attendant rewards and costs.
Mechanic, 1962a). These variations have In addition, the "well roles" of the individ-
been related to social stratification (Koos, ual or his activities as a person with "nor-
1954; Lynd and Lynd, 1929; Brightman, mal" health, determine which specific dis-
1958; Ross, 1962), cultural differentiation abilities might be regarded as important,
(Paul, 1955; Wolff, 1954; Zborowski, which risks the individual must accept as
1952), and individual differences resulting, a person in normal health, and which goals
in part, from differences in the significant may conflict with the goal of "good" health.
others who influence decisions (Freidson, As a guide for exploratory research, then,
1961; Knutson, 1965; Mechanic, 1962b; illness was approached from the standpoint
Bloom, 1965). of a starting time before there is any ques-
This paper reports one attempt to ex- tion, to the individual or anyone else, of a
plore variations in the expectations and be-condition having implications of present or
haviors associated with illness with specificfuture role disabilities, or both.5 Into this
reference to Parsons' sick role formulation.situation, a more or less ambiguous change
As described below, an attempt was made in biological or social functioning may be
to place these expectations in a context of observed which stimulates the questions of
group interaction and influence reflecting re-defining the health status of the individ-
sub-societal as well as societal norms. ual, the need for outside help, and the ex-
pected behavior of the individual under
CONCEPTS414 consideration. In other words, the individual
may be conceived as having a set of rights,
Illness was conceptualized as a matter of commitments, obligations and duties which
social definition which varyingly reflects may be placed in jeopardy if he is defined
cultural and individual differences in orien- as "sick" or "becoming sick." This orienta-
tations toward the biological organism. In tion is taken as a guide for the study re-
the time perspective of the individual, ill- ported below.
ness was conceived as involving a series of
decisions which have to be made by the METHODS6
"sick" or potentially "sick" person. Each
The sampling frame for the present in-
3 Other statements of the sick role formulation
vestigation is the panel of the Brown Health
may be found in Parsons (1958) and Parsons
and Fox (1952). 5 This assumes, of course, that the individual
4 The conceptual framework is only briefly in question is born within the normal capacity
outlined here, as it is the topic of another paper range of his culture and group.
now being prepared. For more detail, see Twad- 6 A more detailed statement of the methods
dle (1968:Ch. 3). employed is available in Twaddle (1968:Ch. 4).

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 SICK ROLE VARIATIONS 107

Study, an audit of behavioral and health perience with an illness they defined as
changes among a sample of white, non- serious but had recovered, or (3) they were
institutionalized couples in Providence, told by a physician that their health was
Rhode Island, in which the male partner good, or (4) they did not expect to become
was between the ages of 60 and 64 in ill.'0 These orientations are illustrated in
1961.7 A total of 605 couples were initially the following statements.
interviewed in 1962 and panel survivors My health was all right. There was nothing
were re-interviewed in 1963 and 1965-66. wrong. In fact, for someone my age I'd say
From that panel, a subsample was selected I was in very good health. (Case 29).
of males who at the time of the third inter- My health was really good. I had to be; I
view (1) identified themselves as Italian went through hell the last two years. (Case
20).
Catholic, Protestant, or Jewish, (2) were
Very fine. That's what the doctor said. He
still married and living with their spouse,
said to my wife that "you have a healthy
and (3) reported a new health condition husband, but he has a little hernia." (Case
in the second or third interviews.8 16).
During the summer of 1966, case inter- My health was all right. Let me put it this
views were conducted with these males way: the stroke was completely unexpected.
(N-29) focusing on their most recent ill- That's how well I felt. (Case 7).
ness experience. These interviews obtained From an analysis of the healthy subsam-
information on the decisions made during ple (see footnote 8), it seemed that older
the course of a discrete illness experience males in Providence, Rhode Island, "nor-
and on the patterns of influence bearing on mally" became increasingly isolated as they
these decisions.9 Special attention was given grew older, as measured by two interviews
to the criteria used to determine health spaced one year apart. They tended to with-
status, the processes by which deviations draw from work roles, which provided not
from "normal health" were determined, only intrinsic satisfaction but also a means
and the kinds of behavior expected of and for structuring interpersonal contact with
engaged in by the individual defined as "not others. They also tended to withdraw from
well". organized recreational activities and to turn
increasingly toward hobbies. While they be-
FINDINGS came more oriented toward their families
for major satisfactions, it seems that they
I. The Well Status and Well Role. The
became increasingly isolated from family
case interviews indicated that males in their
exchange networks (cf. Cumming and
early and middle sixties defined themselves
Henry, 1961). Coupled with this increased
as "well" when (1) they had no identified
isolation was increasing health conscious-
medical condition, or (2) they had had ex-
ness as the individual presumably focused
7 These couples were interviewed extensively more and more on himself."1
in 1962 using structured data collection instru- The rate of increasing isolation and
ments. health consciousness was not uniform, how-
8 Two other subsamples were analyzed on the ever. Analysis of the ethnic subsample (see
basis of their responses to structured interviews
footnote 8) indicated that different ethnic
in 1962 and 1963. A healthy subsample (N= 173)
consisting of persons initially reporting their groups varied in the extent to which they
health as good, and better than that of others showed changes bver a one-year period.
their age, was used to assess changes over a one While Italian Catholics, Protestants and
year period in activities and health behavior as- Jews all gave responses consistent with these
sociated with aging and illness. An ethnic sub-
patterns, changes seemed to be most rapid
sample (N=389) consisting of Italian Catholics,
Protestants and Jews was used to delineate cul- for Jews and least rapid for Italian Catho-
tural variations in these changes as an illustration lics. It is not clear, however, to what extent
of one type of subpopulation variation. This these differences reflected differences in
paper, however, focuses on the case interviews.
9 These patterns of influence are as perceived 10 These are presented in the order of decreas-
and reported by respondents. A more direct ap- ing frequency of response in the case interviews.
proach, which would involve interviewing the "Data on these points, which are to be in-
significant others, was ruled out for the present cluded in a planned paper, are reported in Twad-
study because of time and cost considerations. dle (1968:Ch. 5).

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108 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

values or to what extent differences capacity for innormal

socio-role performance, and
economic status and objective health ex- (3) other symptoms, or changes in the bio-
periences were reflected in the results." logical state of the organism which were
Within each ethnic group situational regarded as important because of their pre-
variations were found. It seemed that peo- sumed implications for longevity or future
ple who were working had the most ex- capacities. This latter category involved
tensive contact with others and had the neither feeling state changes nor role in-
least health consciousness. The case inter- capacity (cf. Baumann, 1961). Examples
views further indicated that retirement of these three signs are illustrated in the
brought increasing isolation from on-the- order indicated above by the following
job relationships and other interaction net- statements.
works that directly or indirectly depended
on work activity. Some persons, however, I had acute pain. I thought it was my ab-
domen, so I went to the doctor. My abdo-
who managed to continue participation in
men was so tender that he couldn't examine
voluntary organizations, clubs or church me, so I had to go home for a few days for
managed to maintain a good deal of contact the pain to subside. (Case 28).
with others. In this respect, it was assumed
I was driving through an intersection and
that those organizations provided a substi- the car swerved. I thought it must have
tute for work. Those who kept active in been a lapse of attention, but the next
this sense seemed to be less health con- morning I sounded like Donald Duck . . .
scious. Most people interviewed, however, (In a later episode) I was bringing a car-
load of kids home and I almost hit another
decreased their participation in clubs, or-
car. I thought it was a lapse of attention.
ganizations and church, and turned increas- Then . . . I almost hit another car and
ingly to hobbies which could be pursued in didn't even know it. Then, in Boston, I side-
private. swiped a car I was passing. Again, I didn't
The introduction of a specific illness, or see it . .. I knew something was wrong, so
I drove to the doctor the next day and he
the respondent's assessment that his health
referred me to a neurologist. (Case 27).
was otherwise declining, accelerated this
process of isolation and dramatically in- The first sign was a hard lump in my neck.
It felt like a swollen gland, but there was no
creased health consciousness. In contrast
discomfort. I mentioned it to my wife . . .
with persons reporting their health as and she said I should see a doctor about it.
"good," those reporting themselves as "not (Case 25).
well" tended to organize their lives around
illness, as indicated by their giving a virtual While pain was the most important sign
medical history when asked about their of illness for all groups when compared
normal activities. For example: with other signs, the case interviews suggest
that it was relatively more important to
I was tired all the time. Had no strength. I
. . .had hardening of the arteries and a Italian Catholics than to either Protestants
heart condition and prostate trouble. I or Jews (cf. Zborowski, 1952). Fear of
would say my health was not good because outcomes was relatively more important
I couldn't work any more with all this. to Jews when compared to other groups,
(Case 28).
and incapacities as a first sign of illness
I was feeling pretty good. I've been sick
with rheumatoid arthritis since 1960. I got were found only among Protestants (cf.
pain across my back so that I bent over like Zola, 1966). These cultural differences
this (demonstrates). Sometimes the pain were quite striking.'2
got so bad I would go right down and can't In a few instances, the illness described
get up. My hands and face would get dark in a case interview presented no signs which
like charcoal. (Case 26).
were apparent to the respondent. Under
II. The Sick Status. Responses to case these circumstances, the illness was desig-
interviews indicated that older males began
to redefine themselves as "not well" when 12 Pain was reported as a first "sign" of illness
certain "signs" appeared. These signs re- by 7 out of 12 Italian Catholics, 2 out of 8
Protestants, and 3 out of 9 Jews. Fear of out-
solved into three types: (1) changes in
comes was reported by 1 out of 12 Italian Catho-
feeling states, the most important being licstheand 3 out of 9 Jews. Incapacities were re-
occurrence of pain and weakness, (2) in- ported by 2 out of 8 Protestants.

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 SICK
nated first by a physician during the course
of a routine physical examination or during
the course of treatment for another condi-
tion. For example:
I didn't have any sign at all. I went in for a
physical. It was the first I've had in my life
except when I was in the service. Dr.
M found the hernia then. I never
had any symptoms at all. (Case 16).
I was hit by a car.... When I see doctor
about the accident he find damage to ankle
and back. Say I have high blood pressure.
That's how I find out. (Case 13).
At the other extreme, there were a few
instances in which the signs were familiar
to the respondent. When these signs were
regarded as trivial, the respondent reported
self-diagnosis and self-treatment. In some
cases, however, the reported signs were so
severe and so evident to others that there
was "no question" that the respondent was
ill and needed professional treatment, as
illustrated in the following:
The first symptom occurred when I was
shaving to go out to the club. I felt a
quivering on the left side of my face by the
temple. Then I just seemed to lose strength
and my legs folded up under me nice and
easy.... My wife and son-in-law were here
when I went down . . . I guess they heard
me fall. They moved me to a chair. I was
weak and couldn't talk. There was no dis-
cussion and my condition was so sudden
that there was no question about what to
do. If it had been slow there might have
been some way of telling you what was im-
portant and what wasn't. As it was, I
couldn't move or talk and there was noth-
ing to do but call the doctor. (Case 7).
In the majority of cases, however, there
were important ambiguities surrounding the
meaning of the relevant signs to the individ-
ual involved. Under these circumstances,
there was a process of "bargaining" over
the definition of his current health status.
Generally, for these married men, this bar-
gaining seems to have begun with an ex-
change of information between the respon-
dent and his wife, and in most cases there
was immediate agreement that the sign re-
quired the attention of a physician. For ex-
ample:
(Constipation was) just something new.
(Wife: He's never been off. He's the most
regular person I ever knew).... She just
thought I should check with a doctor.
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ROLE VARIATIONS 109
(Wife: With something new, it's always a
good idea to check and make sure.) I went
to the doctor. (Case 2).
In those instances where disagreement
occurred between the husband and wife, or
where the wife's opinion was regarded as
unimportant, other people such as co-
workers, children and friends were con-
sulted. If one of these others was regarded
as authoritative, because of professional
training or personal experience with illness,
and suggested seeing a physician, the phy-
sician was usually consulted. Otherwise,
long delays resulted before treatment was
initiated and in some cases the condition
went untreated. For example:
(My wife) kept telling me to see somebody,
but she says that every time I sneeze. I don't
run to the doctor every time I sneeze or
something. She say not to do the things that
bother the arm, but I did them anyway
Life can't stop because my arm was hurting.
This fella . . . just said someone should see
it. He told me to see a doctor. The dietitian
at work, she had the same thing, except she
had it in the shoulder. She said she went to
a doctor and got cortisone shots and that
made her feel better. We talked about the
pain a lot and she told me I should go down
to the employees' clinic and tell the doctor.
So that's what I did. (Case 11).
There were suggestions that the relative
importance of medical and lay referral sys-
tems varied among the three ethnic groups
studied, particularly in these ambiguous
situations. It appeared that the Jews were
more oriented toward the use of physicians
than the other ethnic groups, and they
further seemed more likely to see a physi-
cian without consulting non-medical per-
sonnel in advance. By contrast, Protestants
seemed to be most resistant to seeing physi-
cians and most likely to use extended re-
ferral networks. Among Italian Catholics,
significant delays in seeing a physician were
apparent, often until the symptoms became
quite severe. The pattern here was less uni-
form than among Protestants, however.
The function of non-medical status de-
finers was limited, in this sample, to guiding
the individual toward or away from a physi-
cian.'3 While it was expected that family
and friends would exercise an important
13See discussion of the "lay referral system" in
Freidson (1961).
110 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
influence at all stages of the illness ex-
perience, once contact with a physician was
made he tended to become the sole status
and role definer. In this sample both the
respondent and his other status definers
accepted the physician's definition of the
situation.
III. The Sick Role. In this sample, Par-
sons' formulation of the sick role success-
fully described the modal pattern of ex-
pectations and behavior for older, married,
urban males when each component was
treated separately. It was further found,
however, that the combined configuration
described the response of only a minority.
(1) Exemption from Normal Roles.-
Of the four main elements in Parsons'
formulation of the sick role, the most vari-
able response in the case interviews cen-
tered on the expectation that the sick per-
son is exempted from normal social role
obligations. A large proportion of the re-
spondents reported that they neither sought
nor were they expected to seek such an
exemption. For example:
The doctors said to do anything I wanted,
so my life hasn't changed at all except that
I have checkups twice a year instead of
once. (Case 25).
I never had to stop work, though. I worked
every day. In fact, the more I rested the
worse it got. Once I started to exercise the
pain got better. (Case 6).
Those who sought exemption from nor-
mal roles were most likely to be (1) defined
as "sick," 14 (2) forced to give up a work
role entirely, especially when that role was
highly valued, (3) forced to modify their
daily activities, such as diet, and (4) under
the "orders" of a physician. By contrast,
exemption was least likely to be sought or
performed when the individual was (1) re-
quired to "cut down" on work activity, (2)
required to give up work which was not
highly valued, (3) defined as "not sick,"
(4) designated as having an illness defined
as "not serious," (5) treating himself, and
(6) not required to modify food habits.
Behavior consistent with exemption from
14 Remember that all respondents had reported
an illness. Not every illness, however, was de-
scribed as sickness. While the criteria used in
making this distinction are not clear, the distinc-
tion seems to discriminate behaviors and expecta-
tions.
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normal social role obligations was found
most frequently among Protestants who
identified themselves as "sick," especially
when no highly valued activities were
threatened by the specifics of the exemp-
tion (see Table 1). Inconsistent behavior
was most frequently found among Jews
identifying themselves as "not sick," especi-
ally when their highly valued activities were
threatened. It further appeared that while
on one hand exemption was partly depen-
dent on a judgment that the illness was
sufficiently severe, on the other hand the
demand that the respondent seek exemp-
tion served to define the condition as severe,
as in the following statement.
I don't know if it was serious. They took me
to the hospital, so I thought it was serious
then. If you have to go to the hospital, you
think it is serious. (Case 24).
TABLE 1. NUMBER OF RESPONSES CONSISTENT
AND INCONSISTENT WITH PARSONS' EXPECTA-
TIONS REGARDING EXEMPTION FROM NOR-
MAL SOCIAL ROLE OBLIGATIONS BY
ETHNICITY AND HEALTH STATUS
Response
Consistent Inconsistent
Ethnic Not Not
Group Sick Sick NI* Sick Sick NI*
Italian Catholic 2 1 2 1 4 0
Prostestant 1 3 0 0 1 2
Jewish 3 0 0 3 3 0
* Response could not be categorized according
to the respondent's perception of his health status
as "sick" or "not sick."
(2) Responsibility for Illness.-One of
the least variable responses in the case in-
terviews centered on the expectation that
the individual is defined as being not re-
sponsible for his condition. Only a scatter-
ing of respondents teported even the remote
possibility that they could have been re-
sponsible for the onset of their conditions,
and few took responsibility for its continua-
tion.
Persons identifying themselves as "not
sick" uniformly stated that they were not
responsible for either the onset or the con-
tinuation of their conditions, most often
blaming them on the inevitable result of
aging. In addition, most of those identifying
themselves as "sick" either reported the ill-
 SICK ROLE VARIATIONS 111

ness as inevitable or as caused by someone TABLE 2. NUMBER OF RESPONSES CONSISTENT

with whom they were in conflict. The con- AND INCONSISTENT WITH THE EXPECTATION
THAT ONE WILL GET WELL BY ETHNICITY
flict orientation is illustrated in the follow- AND HEALTH STATUS 1
ing statement:
Response
Lots of people have high blood pressure.
You know why? Goddam juveniles. They Consistent Inconsistent
pick on old people and we get nervous. And Ethnic Not Not
you can't touch them. You know why? Group Sick Sick NI* Sick Sick NI*
Politicians. They never help the middle
man. The real poor, they can go on welfare Italian Catholic 3 2 2 0 3 0
and make more than they can working. Protestant 0 3 1 1 1 1
And the rich buy what they want. That kid Jewish 6 2 0 0 1 0
hit me (with an automobile). Nothing hap-
pen to him. He got a lawyer and paid off 1 The respondent's expectation that he will or
the politicians. There's an old man up here, will not recover is believed to be associated with
about 85 years old. The kids hide behind his desire to get well, although this relationship
walls and stone him. What can an old man was not explored. See text.
like that do? He's afraid to go out. If I say * Response could not be categorized according
anything to a kid they come around and to the respondent's perception of his health status
wreck my house . . . I have the high blood as "sick" or "not sick."
pressure (Case 13).
most often to report themselves as both
I can tell you why this happened. It was
"sick" and likely to get well. The former
brought on by my daughter and son-in-law.
They've been married for 22 years, and tended to have chronic and impairment
conditions more often and the latter tended
they've needed financial help every year. I
finally called a halt to that last year after
to have acute conditions more often. In
the ulcer. (Case 23).
the absence of other role definers it is
thought that these "expectations" reflected
There seemed to be no ethnic differentia-the physician's definition of the situation.
tion on this item and no relation to well(4) Cooperation with Treatment Agent.
roles. Role definers were strikingly absent
-Although a majority of case interview
in most cases, although one respondentrespondents
re- reported that they were ex-
ported that the physician admitting him pected
to to cooperate with a treatment agent,
the hospital told him he had delayed too and in fact did so, there were some who
long in seeking help.
did not. Those who did cooperate more
(3) Desire to "Get Well".-Without often identified themselves as (1) "sick,"
exception, case interview responses were or (2) retired, and (3) the nature of the
consistent with the expectation that illness
cooperation demanded did not include
should be defined as undesirable. There modification of food habits, the treatment
was variation, however, in the extent to consisting of taking medication or resting.
which respondents reported that they ex- By contrast, those who did not cooperate
pected to get well. Those who reported
that they expected to recover were most TABLE 3. NUMBER OF RESPONSES CONSISTENT
likely to both identify themselves as "sick" AND INCONSISTENT WITH PARSONS' EXPECTA-
and to report themselves as retired. By TIONS REGARDING COOPERATION WITH A
TREATMENT AGENT BY ETHNICITY AND
contrast, those who reported that they did HEALTH STATUS
not expect to recover were most likely to
both report themselves as "not sick" and Response
as working. In addition, the expectation Consistent Inconsistent
that one would not recover seemed to be
Ethnic Not Not
slightly more common among those whose
Group Sick Sick NI* Sick Sick NI*
conditions were defined as "trivial" or as
both severe and irreversible. Italian Catholic 2 2 1 1 3 1
Protestant 1 2 2 0 2 0
Protestants were most likely of the Jewish 5 3 0 1 0 0
ethnic groups studied to report themselves
as "not sick" and not likely to recover (see * Response could not b
to the respondent's perc
Table 2). Jews, on the other hand, tendedas "sick" or "not sick."

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112 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
more often identified themselves as (1)
"lnot sick," and (2) working, and (3) their
treatment programs tended to require mod-
ification of food habits. Italian Catholics
were generally the least cooperative and
Jews were generally the most cooperative
of the groups studied (see Table 3). For
both groups the extent to which non-co-
operation centered on food was striking.
The following responses illustrate:
I saw Dr. B when my friend made
the appointment for me. The doctor took
some fluid out of my knee and told me to
take off forty pounds. He injected some
fluids into my knee, right under the knee-
cap. I guess I had two or three treatments
with him, but I wasn't satisfied so I changed
over to an old friend, Dr. S . He
took x-rays and charged me $20. . . . He
injected some fluid just like the first doctor. the continuation of the illness, and Item (3)
When I went back the second time he dis-
charged me. Told me I was all right.
(Probe: Why did you change doctors?)
Well, after three treatments I wasn't any
better, and he wanted me to take off forty
pounds. I'm about five pounds over right
now, but I know that when I take off weightones who were uniformly designated as
I don't feel right. (Case 6).
I have a special diet, but I don't follow it
anymore. (Probe: did the doctor tell you
you could stop?) (Wife: no, he's supposed
to be on it, but he refuses.) Milk and cream
is too fattening, and besides, I like other
foods. Since stopping that diet I've lost 15
pounds. (When) I went into the hospital
and my doctor examined me there . . . he
gave me the special diet and sent me home.
I have to follow the diet and take it easy.
I still take it fairly easy but I stopped the
diet. That's about it. (Case 23).
For Protestants, non-cooperation centered
more on the taking of medication.
(5) The Combined Expectations.-
While Parsons' formulation of the sick
role described the modal response of older
males in this sample when the elements
were treated discretely, a quite different
conclusion emerged when the elements
were treated together, as shown in Table 4.
Respondents who accepted responsibility
for their conditions and who cooperated
with their treatment agents were the only
ones uniformly designated as "sick." Those
who either did not cooperate with their
physicians or who did not see a physician
at all and who either rejected exemption
from normal roles or accepted respon-
sibility for their conditions were the only
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TABLE 4. COMBINATIONS OF SICK-ROLE EXPECTA-
TIONS FOUND IN CASE INTERVIEWS WITH NuM-
BER OF RESPONDENTS REPORTING EACH
COMBINATION, BY REPORTED HEALTH
STATUS
Items 1 Reported Health Status
(1) (2) (3) Sick Not Sick Undecided
- - + 1 0 0
+ - + 2 0 0
- + + 3 5 2
+ + - 2 1 1
+ + + 2 2 1
+ - - 0 1 0
- + - 0 3 0
1 Items refer to the sick role expectations pos-
ited by Parsons. As everyone reported that ill-
ness was undesirable, Item (1) refers to exemp-
tion from normal roles, Item (2) refers to as-
signment of responsibility for either the onset or
refers to cooperation with a treatment agent. A
"plus" (+) indicates a response consistent with
Parsons' formulation, and a "minus" (-) refers
to a repsonse inconsistent with Parsons' formula-
tion.
"not sick." For the other three combina-
tions found, the respondents varyingly
designated themselves as "sick," "not
sick," or they were undecided about their
health status (cf. Footnote 14). The com-
bination specified by Parsons was included
in this latter group and represented only
a minority of reports.'5
IV. Sources of Variation. The nature of
the well role was important with respect to
exemption from normal activities. The
more highly valued the activity, the more
likely elimination of that activity would be
resisted. In addition, well roles seemed to
influence the degree of cooperation offered
a treatment agent, although in that case the
more important factor seemed to be the
nature of the cooperation demanded. If
the demand on the patient was for passive
cooperation (e.g. allowing things to be
done to him), he was more likely to co-
operate than was the case if he was asked
to participate actively in a treatment pro-
gram. Well roles, in this sample, seemed
15 Because a detailed description of the "sick
roles" identified here would take considerable
space and place strains on the general context of
the present report, such a discussion is deferred.
A paper detailing case illustrations of each com-
bination of sick role variables is being prepared.
 SICK ROLE VARIATIONS 113
to have little to do with either the assign-
ment of responsibility for a condition or
expectations relative to recovery.
In this sample, the nature of the condi-
tion, especially the degree to which it was
incapacitating for certain kinds of tasks,
was important with respect to exemption
from normal roles and cooperation with
a treatment agent. Within broad limits,
the severity (life threat) of the condition
seemed to be related only to cooperation
with a treatment agent. Responsibility for
an illness tended to be assumed by the
"sick" person in those instances where
the condition was initially defined as
trivial and later resulted in an acute epi-
sode which was either incapacitating or
life threatening.
Status and role definers, other than the
physician, seemed to have more limited
spheres of influence than was initially
anticipated. Among these urban males, the
spouse was generally consulted about the
first "sign" of illness, and consultation with
other non-medical personnel occurred only
when there was disagreement between the
husband and wife or when the wife's
opinion was not highly valued. In this
sample, the "role-set" (Merton, 1957) 16
of the individual seeking redefinition of
his health status expanded to include more
lay persons until some person who was
regarded as authoritative suggested contact
with a physician. If this suggestion was
made late in the search for redefinition,
the "role-set" tended to be larger. In all
instances, once contact with a physician
was made, he became the sole status and
role definer for the "sick" person.
DICUSSION
The Problem of Generalizability. The
problem of the extent to which the findings
reported above might be generalized is a
particularly bothersome question about
which only some speculations can be
offered here. The universe to which these
results might be applied is limited and
partly circumscribed by (1) the location
16 See Merton (1957: 368-384). The use of the
term "role set" in this report differs from Mer-
ton in that here it refers to types of "significant
others" rather than to the types of expectations
they hold.
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of the research site in an urban New
England setting, (2) the restriction of the
sampling frame to white, married, non-
institutionalized, older males who were
living with their wives, (3) a high propor-
tion of foreign born respondents in the
sample, and (4) a relatively low propor-
tion with a college education. Under these
circumstances, one can only wonder to
what extent the findings reported here
would apply to a less secularized and less
traditional population, or one that included
females, the unmarried, widowed and di-
vorced, a wider range of ages, and a higher
proportion of college educated persons.
The findings reported above, then,
should be taken as suggestive of leads for
further research. The extent to which they
might be generalized is a problem which
must be left to future research incorporat-
ing improvements in sample design and
data collection techniques.
Some Implications.-Some of the find-
ings reported above seem more important
than others from the point of view of their
supposed generality and their implications
for the development of medical sociology.
These are highlighted below in the form of
propositions which are thought worthy of
more systematic exploration.
1. Sick Roles. While Parsons may have
successfully described the nature of the
sick role, as defined by many Americans,
when the elements he posited are treated
discretely, the total configuration seem-
ingly applies to only a minority. When
the elements are treated together, there
are a variety of sick roles.
This study found that Parsons' model
described the modal response of older
males in the sample relative to each sick
role component. As long suspected, how-
ever, there seems to be a variety of sick
roles (cf. Freidson,.1962). When sick role
components were taken together, seven dif-
ferent configurations were found, of which
Parsons' was only one, describing the ex-
pectations and behaviors of a minority of
respondents. Furthermore, the data in this
study suggest that the configurations de-
pended in part on cultural values and in
part on whether the respondent defined
himself as "sick" (see footnotes 14 and
15). While the content of these alternative
"sick roles" is imperfectly understood and
 114 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
their distribution unknown, there is little
doubt as to their existence.
2. Sick and Well Statuses and Roles: Rela-
tionships.-There is a complex relation-
ship between exemption from normal
activities and the severity of a health
condition.
Whereas Parsons suggested that exemp-
tion from normal activities depends on the
severity of the illness, it seems equally true
that the respondent's assessment of severity
depends on exemption from normal roles.
The relationship would seem to be more
complex than originally formulated.
3. Sick and Well Statuses: Diflerentiation.
-There are cultural variations in the
nature of the first "sign" of illness recog-
nized by different groups. For example,
it is likely that Italian Catholics tend to
emphasize pain; Protestants place rela-
tively more emphasis on incapacity; and
Jews place relatively more emphasis on
the implications of symptoms for longev-
ity.
It has long been known that ethnic fac-
tors influence response to pain (Zborowski,
1952) and that different medical and non-
medical considerations influence Italians
and Jews to seek medical care (Zola,
1966). These studies, however, have not
focused on the broad range of first symp-
toms of illness perceived by respondents,
nor have they looked at illness experiences
outside the hospital setting. This study sug-
gests that their findings can be extended
when such factors are taken into considera-
tion, at least among older, married urban
males.
4. Status Definers.-Lay status and role de-
finers are important in assigning a "sick
status." Beyond that, their function may
be limited to guiding the individual to-
ward or away from a physician. It is
possible that once contact with a physi-
cian is made he tends to become the sole
status and role definer for the "sick"
person. The individual and his lay "con-
sultants" may then accept the physician's
definition of the situation.
It was initially anticipated that lay status
and role definers would be influential
throughout the course of illness and that
Freidson's (1961) concept of "lay referral
system" could be extended. No evidence
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was found to support this anticipation. This
study lends support to Freidson's original
formulation and suggests physicians exer-
cize even greater power in relations with
patients than initially thought. Moreover,
"delay" in contacting a physician may be
a function of the time taken to have such
a decision "legitimated" by an authoritative
layman.
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 CHANGING GHETTO WOMEN 115

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630.

A Field Experimental Attempt to Change Beliefs

and Behavior of Women in an Urban Ghetto*
S. STEPHAN KEGELES
University of Michigan

Using standard personal messages within an urban ghetto, an attempt was made to: (1) change
women's beliefs in vulnerability to cervical cancer and in the eflectiveness of cytology, and
(2) persuade them to visit a cytological clinic. More women with higher post-belief scores
made visits than their counterparts. The experimental message was more successful than th
control in eliciting clinic visits. Though the experimental message did not change beliefs more
than the control message, more experimental subjects high in post-beliefs came to the clini
than (1) experimental or control subjects low in post-beliefs, or (2) control subjects high
in post-beliefs.

liefs for programming.' All activities in

Two different philosophical approaches
r have been used for social action pro-
such programs are directed toward a goal
gramming in the past several years. The
first approach-evident in many "demon-
stration" activities-entails changing the
environment of a population with the
intention of producing a desired outcome.
Thus, black children are bussed to white
schools, houses are purchased in middle
class neighborhoods for public housing,
health services are provided in "headstart"
programs for indigent children. Certain
advocates of this approach either ignore or
reject the importance of attitudes and be-
* The investigation was supported by the Pub-
lic Health Service, Research Grant No. CH 00044
from the Division of Community Health Services.
which is "intuitively" good. Programming
of this style is not evaluated but rather
"defined" as "successful" or abandoned.
As Rossi (1966} noted, as of 1966 no
program supported by the Office of Eco-
nomic Opportunity had used experimental
methods for evaluation. Without such data,
explanation of differential program yield
I For example, see the following statement,
"The belief that needed changes must take place
in the attitudes and behavior of the poor, rather
than in the programs of the agencies that serve
the poor, I consider to have been one of the
major deterrents to the development of better
health services for the poor in the past." (Ban-
berger, 1966:597)

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