summary of current medical knowledge about risk factors for heart attacks at this point. ... social perceiver is not mute: she or he will ask the questions that need asking. .... controlled in her weight and what she eats, a health-food nut. She smokes a ..... a health belief schema for heart attacks which is best summarized as a.
David L. Morgan and Margaret T. Spanish Social interaction and the cognitive organisation of health-relevant knowledge
Abstract Relying on recent work in social cognition, we introduce the term health belief schema to summarize how an individual organises knowledge about health issues, in this case, knowledge about 'who has heart attacks and why'. Using data from group discussions of this topic, we show several ways that social interaction influences the formation of an individual's health belief schema for heart attacks, and demonstrate that these schemata typically consist of differentially weighted risk factors. Lay knowledge and use of risk factors does not, however, mirror medical knowledge of risk factors, and we offer suggestions as to how health practitioners can benefit from an accurate perception of lay-knowledge about heart attacks. Introduction
Although a vast medical literature exists on the causes and prevention of heart attacks, we know surprisingly little about either the content or the development of the layperson's health beliefs about heart attacks.' The research we report explores how people obtain their beliefs about heart attacks. More generally, we see this as part of a larger investigation of how people convert their everyday experience with health and illness into usable knowledge about specific areas of health. Recently there has been an increasing amount of attention paid to the layperson's general conceptions of illness and its causes (Blaxter, 1983; Herzlich, 1973; Locker, 1981; Pill and Stott, 1982), but there has been considerably less attention to lay understandings of specific health problems such as heart attacks. Our approach to the adult acquisition and organization of knowledge about the causes and prevention of heart attacks derives from recent work in cognitive social psychology. At the core of this approach is the schema concept, which Taylor and Crocker describe as '. . . a Sociology of Health and tllne.fs Vol. 7 No. 3 November I9S5 © R.K.P 1985 ()141-9889/85A)703-()401 $1.5(V1
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cognitive structure that represents some stimulus domain. It is organized thTough experience; it consists of a knowledge structure . . . and it also includes plans for interpreting and gathering schemarelated information' (1981: 123-4). Our approach will treat the content and organization of individuals' knowledge about heart attacks as one example of a 'health belief schema*. We examine three basic issues in this paper: first, the existence and content of health belief schemata related to the cause and prevention of heart attacks; second, the processes through which these schemata originate and develop; and third, the role that interaction within social networks plays in the process of schema development. We address these issues with data gathered through a series of tape-recorded group discussions. The transcripts from these 'focus groups' provide both a body of material illustrating everyday thinking about the topic of heart attacks and a demonstration of the importance of various interactive processes in cognitive development (for a general description of the focus group technique, see Morgan and Spanish, 1984). In addition to our concem with the cognitive and interactive development of heart attack-relevant health beliefs, we will generate practical applications by examining the issue of lay versus practitioner knowledge. Our research indicates broad discrepancies in terms of both the importance assigned to various risk factors and the language used to describe them. We discuss such discrepancies and point to the implications they have for the patient-practitioner relationship. As we will delay the expiidt comparison between lay and practitioner knowledge until the discussion section, we would like to provide a summary of current medical knowledge about risk factors for heart attacks at this point. This information should help the reader in evaluating the content and organization of the lay knowledge presented in the next several sections. According to the United States' National Heart, Lung, and Blood Institute (U.S. National Institute of Health, 1981: 16-18), proven risk factors can be separated according to their importance, with the three most important being elevated blood serum cholesterol, hypertension, and cigarette smoking. Other risk factors that are considered to have scientifically established but smaller effects are diabetes, obesity, family history, exercise, Type-A behaviour pattem, age, and gender.
Background
We begin by advancing the term 'health belief schema' as a summary
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way of describing aa individual's knowledge about the causes and prevention of some specific health problem. Although the influence of health beliefe upon patients' health-related decision-making has been acknowledged (Becker, 1979), investigations of the content of these beliefe are still relatively rare. If, however, we wish to understand an individual's efforts at risk avoidance, we need to begin with some basic summary of how the individual recognizes and assigns importance to risk factors; it is this knowledge that is contained in a particular health belief schema. We believe that the development of schematic knowledge about cause and prevention is an age-based phenomenon, linked to age differences in the incidence of heart attacks. It is a key tenet of the cognitive approach that repeated exposure to a phenomenon of interest increases not only the quantity of a person's knowledge, but also the organization of that knowledge, and it is precisely this organizing function that the schemata fulfil. Thus one is much more likely to find a 20-year-old than a SO-year-old who is 'aschematic' with regard to health beliefs about heart attacks. Indeed, the proper question is not so much whether health behef schemata for heart attacks exist, but to what extent any particular individual has developed such a schema. Abelson (1976; 1981) has described three levels at which knowledge can be organized, moving from episodes to categories and finally to abstractions. According to Abelson, cognitive orgnization proceeds as individuals begin by collecting specific bits of raw (episodic) knowledge with regard to a phenomenon; they then use a set of episodes as a basis for extracting categorical knowledge; finally, they combine these categories into abstract or hypothetical knowledge. In our terms, the episodes are equivalent to stories that our participants tell about people they have known who have had heart attacks; the categories are risk factors that participants perceive as increasing or decreasing the likelihood of having a heart attack; and the abstract knowledge is the resulting model or set of beliefs that participants have about the causes or prevention of heart attacks. While we find Abelson's framework provocative and remarkably parallel to the findings in our study, his work, as well as most work currently done in the field of social cognition, is notable for failing to include interaction as a source of cognitive development. Taylor has commented upon the image of the person presented by sodal cognition research, suggesting that researchers should perhaps concentrate on interactive as well as perceptual models of social cognition.
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[W]e often forget that there are other ways of dealing with problems than thinking about them, particularly when those problems involve social interaction . . . . Put simply, there are a lot of circumstances in which the social perceiver is not mute: she or he will ask the questions that need asking. (1981: 206) While we would agree with Abelson and others that individual, schema-based cognitive development is an important piece of the puzzle, we see, as Taylor does, social interaction as a fundamental frame within which such development naturally occurs. Our own view stresses the importance of social interaction as a source of vicarious information about heart attacks, allowing most people to acquire and organize information on this subject long before they themselves are notably at risk. In later sections, we will discuss Abelson's three-part description of cognitive development to show how interaction affects the ways in which health belief schemata are formed and elaborated, using examples from our group discussion transcripts. The data we present, largely in the form of quotations from our research participants, come from a series of focus groups that we conducted in 1982. Focus groups are a qualitative data collection method adapted from marketing research, in which participants are brought together in small groups to discuss a topic of mutual interest. Our participants were drawn from a listing of older 'returning' students. We initially contacted them by phone, recruiting them for specific discussion times. Anyone who had experienced a heart attack or who expressed reservations about discussing the subject was automatically excluded from the research. We also required that participants be between the ages of 35 and SO, since people from this age group are likely to have varying degrees of contact with heart attacks within their own social network. We assembled individuals in groups of four or five and asked them to discuss two topics for IS or 20 minutes per topic. We first asked participants to consider the general question, 'who has heart attacks and why'; we also specifically asked them to use this first discussion to tell stories about people they knew who had had heart attacks. After a brief break, we asked them to consider the second topic, 'what causes and what prevents heart attacks'; we also asked them, when possible, to continue using material from their first discussion. At the close of each discussion, we had a brief conversation with the participants to discuss their feelings about the experience and then paid them $S for their time. Altogether, we ran nine primary focus groups with a total of 40 participants, plus a pre-test with an additional five participants. All of the discussions were tape-recorded and later transcribed.
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Using the transcripts, we devised a substantive coding scheme based on heart attack-relevant dsk factors (see Table 1 for a summary of the risk factors we considered). Our coding emphasized risk factor categories because we see this as the most 'basic level' in the development of health beliefs about heart attacks. We see categories as basic in that they serve as a means for systematizing the knowledge contained in episodes, and provide the raw material for constructing more abstract models. In keeping with Abelson, our discussion of cognitive development examines first the basic nature of episodic knowledge, then the conversion of episodes into more schematic knowledge about risk factors, and finally the possibilities for further schematizing this categorical knowledge into more general models about the causes and prevention of heart attacks.
Episodic knowledge
We begin by describing how to determine if participants are using health belief schemata when they present episodic knowledge (i.e. tell stories) about heart attacks. Evidence for schema usage can be found in both the content of stories and in their narrative structure. Remembering that our initial instructions asked participants first to discuss 'who has heart attacks and why', the content of aschematic or 'episodic' stories is notable primarily for what it lacks: any systematic attention to the issue of why the person had a heart attack. If information relevant to this topic is included in an episodic story, it is largely incidental; instead, the participant is likely to organize the story around information about who the person was or to use alternate schemata such as descriptions of personal tragedies or. medical emergencies, etc. Use of a health belief schema is thus most noticeable through a participant's systematic attention to information about risk factors, and his or her efforts to link any one episode to more abstract issues conceming 'who has heart attacks and why'. The participant's application of a health belief schema is demonstrated not only in greater quantities of categorical or abstract material, but also in the use of this higher level knowledge to structure the way that the participant narrates the lower level, episodic materials. Consider this example of a participant who presents two stories.^ The two closest people to me who have had heart attacks would be my father and my grandmother, my maternal grandmother. She'd been having them since I can remember as a child. She died when I was about thirteen
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or fourteen, but she had had a long series of them. And, when she was having one, our first indication - she lived right below us in an apartment building - would be loud, loud breathing sounds. She did it through her mouth, however, she was trying to pull air in. It was just a ghastly sound. But from when I knew her, she never smoked or drank, you know, just a little wine once in a while. But she was always overweight. But I don't know what she had done before that time, whether she smoke or drank heavier. I doubt if she ever drank heavy.
And after a brief interruption, he continues.^ My father on the other hand, smoked very heavily for as long as I knew him. He was always at least forty or fifty pounds overweight. He was a salesman, so he had a fairly driving, competitive Hfe style. And his first heart attack should have been a warning for him to change all those - slow down smoking and lose a few pounds, cut down on his drinking - but that kind of all gained back over the next couple of years and he had another one while he was cycling. But he finally died of a stroke rather than a heart attack. I'm sure.he must have had high blood pressure through it all.
Although this pair of stories begins with an emphasis on the participant's relationship to the victims, even the first story is not wholly aschematic, as risk factor information is used to summarize the influences on the grandmother's heart attack. By comparison, some of our completely episodic stories consist entirely of rambling personal narratives that are more than twice as long as these two stories combined. Here, however, the important comparison is to the story about the father: the initial context and the entire content of the story are organized around a set of risk factors, and it is now personal details that are incidental to the account. The schema that is only partially apparent in the first story is clearly evident in the second. Another important indicator of schema usage is found in a specific element of story content: mentions of risk factors which are in fact absent from the episode being presented (e.g. in the story about the grandmother, 'she never smoked or drank . . . ' ) . Indeed, the absence of risk factors may itself serve as an organizing principle in the presentation of stories. No. 1: My girl friend had a heart attack Friday, this Friday. She's only 42, and she's not the type at all. She's assertive, I don't think I could call her aggressive. She's not really kicked back and complacent but she's . . .. She's married, happily married, she doesn't work, her husband is financially stable, has a good job. She belongs to the country club, she plays golf at the country club, generally about three times a week, in fact she's won several trophies at the country
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dub playing golf. She's very conscious of her own diet, very controlled in her weight and what she eats, a health-food nut. She smokes a half a pack a day. She doesn't drink. No. 2: Has she been on the pill? No. 1: No, she's not on the pill or anything. She doesn't have any high blood pressure problems. She has had some problems with hypoglycemia, but it really should have nothing to do with heart attacks. And she had been out golfing that day, came in and bent over to take her shoes off and developed a chest pain, and they rushed her to the hospital, and she's in [local hospital] now, intensive care. Really unusual. The use of absent risk factors is strong evidence for the presence of more abstract schematic knowledge, which exists apart from and is applied to specific episodes. That is, risk factor categories are not just a convenient way of discussing why a person had a heart attack; instead, the frequency of absent factors indicates the use of a separate system of knowledge which is available to process and interpret any one episode. Up to this point, we have concentrated on the ways in which episodic material can reveal the presence or absence of schematic knowledge in individuals, but what about the role of social interaction? One fundamental element, question asking, demonstrates the influence of group processes upon cognitive development. Since the participants in our focus groups are involved in a truly interactive situation, they frequently interrupt a presentation with requests for more infonnation. In this first example, the question follows a very extensive and episodic story. What elements of the whole situation do you directly point to the heart attack, his drive and what else? In another instance, the story which prompted the question was one in which the presenter focussed only on risk factors which were absent. Do you know him well enough to know if there were any things that led up to it? Such 'what caused it?' questions are among the most general questions that we see, and seem to arise as a simple request for further information. In more specific questions about stories, participants directly demonstrate their interest in risk factors as a source of further infonnation. Thus after hearing an episodic narrative, one of the listeners interjects the following.
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What about things like overweight, smoking, exercise, that kind of thing? And this from another group. Did he smoke, did he have any pressure, was he overweight? I'd like to kind of, using the examples that we've used, see if there are . . . [the speaker is interrupts i before finishing this thought] The purpose served by these questions, if achieved, is to move the discussions away from simple episodic material to a higher level of abstraction. Overall, we observe a disappearance of episodic stories after the early portion of the first discussion, and we suggest that this is due to more than individuals' ability to use more schematic presentations as 'models'. At a minimum, questions alert group members to each other's interests. But, it is also the case that these requests for further information are at least mildly embarrassing to the person who receives them because they implicitly point to deficiencies in his or her account. Through their discussion, participants leam certain standards for an 'adequate' episode, and it is the application of these standards that moves them in a more schematic direction. A final type of questioning draws upon the broader, overarching context through which information must be filtered for meaningful interpretation. The classic example is in fact the single most common question in our data: 'How old was he (she)?' In many cases, the response indicates that the question was simply taken as a request for more information (e.g. 'She was in her early sixties when she died'). In other cases, the results are more complex, as in this exchange. No. 1: Who did you write about? No. 2: A friend of my parents. He had the usual life with a lot of work and a lot of food, a lot of smoking. No. 3: How old was this fellow? No. 2: Seventy, something like that. But my guess is that life style is very important . . . The second person's 'story' is so brief that it is little more than a catalogue of risk factors, yet the question about age provokes not just an answer to the question, but a reaffirmation that the risk factors are indeed what matters. What is being explored here, and throughout our data, is the possibility that a set of risk factors can be discounted due to the presence of advanced age. One of our participants makes this quite clear in the form of a joke. My ex-husband, his father died of a heart attack, but he weighed 300 pounds, he drank at least twelve cans of beer a day, he smoked three packs of cigarettes, and he was 97. [general laughter]
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Age is something more than a simple risk factor; rather, it is part of a larger context which aids in the interpretation of more specific risk factors. Where this contextual infonnation is not available in a person's story, it is frequently elicited through interaction. It is this necessity for the reinterpretation of risk factors according to advanced age that leads to the frequency of this question. Still more to the point is the restructuring of an account that can be produced in answering this question. Up to this point, our consideration of episodes has demonstrated the presence of individual schemata and the importance of interaction. Further, we have shown that interactive processes as simple as question-asking not only elicit more information, but can, as in the case of age, point to much larger issues in the interpretation of episodic material. As an interactive process, question asking is basically an interruption, calling attention to the fact that presentations of episodic material are likely to be individually oriented tasks. For a closer look at the true give-and-take of interaction, we need to examine participants' more general discussions of risk factors.
Categorical knowledge
The version of cognitive development that we have been using emphasizes the importance of categorical knowledge, both as a means for extracting more general information from a set of specific experiences, and as the basis for generating more comprehensive abstract models. In this section we consider each of these processes, beginning with the transition from episodic to categorical knowledge, and concluding with the transitions from categorical to abstract knowledge. We have already noted some individual and group processes which tend to shift our focus group participants from episodic to categorical summaries of experience. We continue this theme, introducing another process which occurs at the individual and group level: the use of comparisons. At the individual level, one presenter may make comparisons among various heart attacks which are drawn from his or her personal knowledge, as in our earliest example of the stories about a grandmother and a father. More common in our discussions are the comparisons at the group level in which participants examine stories presented by others and find parallels with stories of their own. In one sequence, a presenter relates a story about a young man, 'in perfect condition', who, suddenly and without warning, had a heart attack.
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She notes the unusual nature of this particular heart attack, and agrees with another participant who suggests that, since the victim was so young genetic factors must have been involved. A third participant then tells a similar story, and, unable to explain the causes of the heart attack, concludes that, 'it might go back again to the genetic thing'. Thus, by comparisons, the participants begin to sort out the categorical risk factor information that can 'explain' a series of examples. Question-asking is another way of drawing together several stories in attempting to locate points of commonality. In one group, all four members had exchanged at least one story when one of the participants made this observation. Each of us have mentioned men. Does anyone know a woman who's had a heart attack? This question led the others to a rambling discussion in which they compared their vicarious experiences and coticluded that most heartattacks happen to men. As this example shows, question-asking plays a continuing role in the interactive aspects of cognitive development. In both individual and interactive aspects of cognitive development, the important function of comparisons is to collect and systematize the knowledge present in two or more episodes. What happens when individuals use their shared experiences as a basis for comparison is not only that more materials are collected from several individuals, but also that the comparisons and derivations tend to be much more explicit than in individual cognitive development. We are not arguing that what goes on between individuals is identical to what goes on within individuals, but we do want to make the point that such interactions have both sufficient frequency and sufficient impact to represent a potentially large influence on cognitive development. As participants proceed through the session, they spend increasing amounts of time on comparisons between stories, and eventually devote more and more time to direct comparisons among risk factors themselves. As they begin to share their views on risk factors, discrepancies arise at the categorical level. Participants become aware of the fact that they may disagree with one another over what the relevant risk factors are. In addition, they may find that they are assigning different weights to the risk factors that they do collectively find meaningful. This process can be illustrated with a fairly large segment from a single group. This group begins with a set of relatively schematic stories, and rapidly moves to a consideration of stress and Type A personality.
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One member of the group who has been silent until this point then offers the following. I think heredity - from my experience - has been the big thing. My father died of a heart attack, his two brothers died of heart attacks, his sister died of a heart attack, his mother died of a heart attack. And he outlived them by ten years. They all died by the age of 51. So he considered himself lucky to have lived to 61. And then most of the people that I know, I have a friend's father died of a heart attack before he was SO, and all his brothers died by their SOth birthday. And they were not the Type A personality, necessarily. And my father was careful of his weight, and he didn't smoke, his blood pressure was down, his diet was veiy careful. And he even had by-pass surgery. He did everything that he could to ensure that he would live, and it got him anyway.
This story is highly schematic. For one thing, it refers to no fewer than eight individuals who had heart attacks. It is also organized around a more abstract argument for the importance of a single risk factor, heredity, and information about other risk factors is largely used to demonstrate its dominant influence. As this segment of interaction illustrates, material based on personal experiences is not entirely eliminated from discussions devoted to risk factors, but is presented and used in a very different way than in mere stories. Throughout this interchange the comparison between heredity and other factors continues to affect the presentation of episodic materials. Within a couple of minutes after this story, another participant seems to agree with the previous speaker, but the assessment soon changes. My experiences have been of two types - one heredity, my father and my uncle. But I think their behaviour had a lot to do with it. Not only was it hereditary, but they kind of gave up on life and quit and I try to see that as a factor primarily because of my other experiences which is in business and many experiences I've had - every one of them boil down to Type A behaviour. Young, driving, paranoid type behaviour.
From this point, the emphasis shifts from the consideration of heredity to more detailed considerations of stress and personality as an influence on reactions to stress. Discussions which centre on the direct comparison of risk factors lead to a process we call the 'differential weighting' of risk factor information. Our observations suggest that such differential weighting is one of the first steps in the transitionfiromsimple categorical to more abstract knowledge. The fact that discussions such as the one just presented occur regularly in the first half of our discussion groups, where there is nothing in our instructions to direct participants to this
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issue, indicates a 'natural drift' toward model building. Once groups are given the instructions for the second half, to focus on Vhat causes and what prevents heart attacks', issues of differential weighting tend to dominate the discussion. Here is an exchange in which participants weigh risk factors with regard to prevention. No. 1: Speaking of prevention, though, and statistics in the same breath, the incidence of heart attack or people dying of heart attack is going way down as our diet changes. We're moving to low cholesterol foods and . . . we're doing more exercises now . . . No. 2: . . . perhaps the reason for it is the large amount of bypasses that have been done these past 10 years. No. 1: I don't think they can change the statistics of a nation with a few surgeons. No. 3: . . . I think it's due to both aspects . . . heredity is important . . . and your own control . . . you can't say one or the other.
Clearly these participants do not agree as to which factors are involved, nor do they appear to assign anything like equal weights to those they do agree on. In another group, one participant mentions high blood pressure, a second emphasizes the importance of diet (especially salt), and a third responds. It seems to me that there are so many things to look at and it's not just the one that we can blame a heart attack on . . . One of the biggest things to me would be life style and how a person does handle the stress. We all have stress . . . but how we deal with it is important. A fourth participant continues this effort to summarize. Certainly worrying about it might even contribute to the heart attack, it certainly doesn't help. But we have also heard that there are things like diet and weight control and exercise and smoking and so forth that are probably causes of a heart attack and also the emotional side of the issue, can probably cause a heart attack . . .
In this exchange, the first two participants are simply drawing in single risk factors that they deem important. The third member begins to imply some integration across separate factors, but he fails to follow through with it, falling back instead on his favoured single factor, stress. And the fourth person attempts to consider everything at once. Thus the last two contributors are engaged in some preliminary but unsuccessful attempts to move the discussion from a strictly categorical level to a more abstract level.
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As this last example shows, producing a list of risk factors can carry our participants only so far. Even with attention to differential weighting, attempts to summarize and compare risk factors are not the same as efforts to build abstract models, as we shall see in the next section.
Abstract knowledge
Abstract knowledge represents the final stage in the development of health belief schemata. In our groups, this is best summarized in terms of 'model building', i.e. the generation of all-encompassing firameworks to interrelate risk factors. In considering episodic and categorical knowledge, we have implicitly argued that analogous processes operate at the individual and group levels; for model building, we do not think this is the case. In particular, interaction creates a potential for inter-individual agreement and disagreement which has no clear analogue in individual cognitive development. Given the nature of these data, our examination of model building will necessarily be an examination of group model building. Of the ten focus groups, two succeeded in creating high degrees of consensus around a single model, two engaged in a little systematic effort at model building, and the remaining six met with varying degrees of success. Among the less successful groups, we often observed members agreeing that there either is no one best model, or, if there is, they 'agree to disagree' over what that model is. Thus we find a number of explicit 'confusion statements' in these groups, which summarizes their difficulties with model building. No. 1: I think all we can talk about is the obvious causes of heart attacks that we all can see . . . No. 2: What is the obvious? We sat here and told all different stories and there doesn't seem to be any common denominator.
Even among those groups that fail to build an abstract model of what causes and what prevents heart attacks, the interaction surrounding efforts at model building still serves as an important influence on individual-level cognitive development. That is, the encounter with the other participants' models, incomplete as they may be, can advance any one person's degree of abstract thinking about heart attacks.* It is also possible, of course, that many individuals did come to believe in some abstract model, and it is only the groups that fail to reach a consensual model.
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Let US now examine the two groups that did 'succeed' in model building. In both cases, the members concluded their discussions by constructing a general 'combined factors' model, hammering out their differences with respect to weighting the various risk factors. These two groups are characterized by 'consensus statements' which indicate the degree of convergence in the members' perspectives. In one of the two groups, the second half of the session begins with new stories and a few returns to stories from the first half. From these stories, participants begin to extract an agreed-upon list of risk factors. As the discussion proceeds, one participant gives a lengthy summary of his opinions in one risk factor ('the wearing out of parts') and then moves to a consensus statement, summarizing their discussion up to that point. He is interrupted by others who comment on the emerging model. No. 1: But I think maybe what we're saying here is that there's no one cause of heart attacks, there's no one type of person, there's probably umpteen different types of heart attacks and causes coming from maybe smoking, maybe obesity, maybe stress, maybe design fault, hereditary, overwork, change in life style. Any of these things in themselves could be . . . No. 2: And when you start putting them in combination [unclear] be speeding up on yourself. No. 3: Yeah, you may be really magnifying each one of these particular things. No. 2: Yeah, and depending on how, and in each person that magnification is different. Some people can take a little stress without doing any damage, some people can take a little smoking, a little drinking, a little obesity, without doing any damage. But you take a little of each of these and put them together and you're starting to increase the chances of damage. And any one of these that takes a magnitude leap increases the chances. In the other successful group, consensus statements are also prevalent. The first speaker in the second half of the session proposes a model emphasizing heredity and stress as causes, and moderation as a means of prevention. The next speaker replies, 'I agree. It does sound like moderation probably is one of the keys to the solution of the problem', and then proceeds to give a list of the categorical factors (^personal habits) which should be pursued in moderation. The third speaker offers a consensus statement. Well, it looks like we're talking about three areas. One is kind of what you're bom with, the physical stuff. I really don't think that's a big contributor myself. I see more the sort of life styles and attitudes as being
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bigger contributors . . . [he continues by clarifying the fact that for him, life style means personal habitsi The final member of the group indicates that while he might place more importance on the genetic component, he does agree with the emphasis on moderation. What can we leam from these two groups that did generate consensual models? In evaluating these two models, it is clear that 'combined magnitudes' and 'moderation in all things' constitute highly abstract health belief schemata. Indeed, one of their chief virtues may be that they are so abstract that they preempt disagreement over their explicit implications. In the final accounting, not only were most of our groups unable to produce models, but those that were successful produced models which had few explicit applications. Such an outcome is probably due to something larger than individual ignorance or failures in group dynamics. In our view, these results indicate that our culture contains few, if any, broadly diffused, abstract models of what causes and what prevents heart attacks. If there are such models, they may exist only among physicians and other experts; we certainly find little evidence for their presence among one fairly well-educated segment of the general public.
Discussicm At this point, we wish to shift from the study of how our participants discuss their knowledge about heart attacks to an examination of what they discuss, and how health professionals could profit by a better understanding of what the lay person knows about heart attacks. As we have seen, lay knowledge goes well beyond the idiosyncrasies of personal experience, but seldom reaches as far as comprehensive models, so we will concentrate our attention on categories of risk factors. Table 1 presents a percentage breakdown of the risk factors that were mentioned in our groups.^ Although this tally is based on the sheer number of times a factor was mentioned, rather than the actual time that was devoted to each factor, it does provide a preliminary view of the risk factors that lay people consider when they talk about heart attacks. The table is divided into two separate tallies for factors that participants mentioned in stories about specific heart-attack victims, and factors mentioned in general discussion. This division reflects the
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Table 1 Risk factors mentioned by 40 participants in 9 focus groups* In stories
In discussion
57% 18 15 8 8 2 4 2
10 9 4 8 7 2 2
Gender Genetics Other
15% 6 1 7 1
2 4 15 2
Medical factors High blood pressure Other
10% 6 4
4 1
Personality, and stress Job stress Type A personality . Stress and coping Other
18% 4 6 7 1
Controllable factors Smoking Overweight Drinking Exercise Fats and cholesterol Diet Other Uncontrollable factors
Age
100% N = 162
Total
48%
52% 14 11 6 8 5 2 2
23%
/9% 3 2 12 2
5%
7% 5 2
24% 5
2 13 4
22% 5 4 11 2
100%
100%
223
385
'Does not include one pre-test group.
fact that people tend to discuss rather different factors when considering what is important in any one episode than they do when left to pursue their general interests freely. In particular, concrete risk factors such as smoking, weight, and alcohol consumption are more common in stories, while less specific factors such as genetics and family background, or stress and coping are more common general discussion. We interpret this difference in terms of a distinction between what participants find to be important and what they find to be interesting. On the one hand, smoking is important enough to be the most frequent risk factor mentioned by participants when they exchange their vicarious experiences with heart attacks. On the other hand, smoking occupies only third place among factors they mention in discussion. This is due, we would argue, to the lower level of interest that participants have in smoking. Once one says that you should not smoke, but it is tough to quit, the topic of tobacco
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consumption has pretty much been covered, no matter how important it is as a risk factor. By comparison, our participants show an almost boundless interest in stress and coping. If anything. Table 1 seriously underestimates the amount of discussion devoted to stress. If a participant made an extensive, uninterrupted set of remarks that were all related to stress and coping, this would generally be coded only as a single mention. If one were to somehow count the proportion of time spent on stress, it would be by far the dominant topic in these discussions. Intuitively, we suspect that our participants would not rate stress among the two or three most important risk factors, but it is also clear that they allocate their contributions to the discussion as much by what interests them as by what they believe to be important. Interpreted as a reflection of either importance or interest, the picture of risk factors given in Table 1 offers only a weak correspondence to medical knowledge on the subject (cf. US National Institutes of Health, 1981). Given our previous remarks, it is not surprising that participants overemphasized stress, but this fact is particularly telling in combination with their lack of attention to high blood pressure. This is only one instance of a general concentration on personal activities, rather than on their physiological consequences. Another example would be the small number of references to serum cholesterol in comparison to mentions of fatty foods, obesity, and diet in general. If one conceives of a causal chain linking personal behaviours to intermediate physiological outcomes, and then internal physiological states to the level of coronary risk, it is clear that the lay person thinks largely in terms of the two endpoints of this sequence of events. To the extent that physicians see risk only in terms of physiological manifestations, there is a serious difference in perspectives. Seen in this light, our general lack of knowledge about the lay person's health belief schema for heart attacks becomes a serious problem. The data summarized in Table 1 are a step toward filling this gap, but much more remains to be done. What about risk factors recognized by medicine that are absent from this list? Notable among these would be diabetes. We were able to locate only one clear reference to diabetes. I'm thinking of my story, it's about a man who probably least expected to have a heart attack of anybody. He was not overweight, he did not smoke, he didn't do all the wrong things that you hear about people who get heart attacks do. He did have diabetes, and I don't know whether that is something that can bring about heart attacks or not.
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Simply treating this and other instances of distorted perceptions of risk factors as ignorance on the part of the general public ignores the broader problem of tensions between the lay and medical perspectives. Imagine the likely outcome of a doctor-patient interaction where the practitioner is determined to take a family history on incidence of diabetes, and the patient is determined to discuss the level of stress in his or her life. Both of them want to focus on what they conceive of as risks, but the difference in perspectives is a serious threat to effective communication. If we summarize this impasse as a problem in differential weighting of risk factors, then it is dear that both partners to the interaction need to take at least minimal account of the other's point of view in order to reach a satisfactory outcome. This is not the only work that needs to be done. One age-old problem that deserves re-emphasis based on what we heard in these discussions is the difference between lay and professional vocabularies. Put simply, we find virtually no mentions of hypertension, high density lipoproteins, or arteriosclerosis, not because the participants are completely lacking in knowledge on these topics, but because they don't express their knowledge in these words. There is little point in trying to reach a mutual understanding of the more abstract differences between lay and medical perspectives on heart attacks if effective doctor-patient communication is blocked at an even more fundamental level. We also interpret our findings as a call for a clear, readily communicated, abstract model describing current scientific knowledge about the causes and prevention of heart attacks. Such a model should go beyond a simple listing of risk factors, as our participants already are moderately knowledgeable in this regard. Recent publications (e.g. Dietrich, 1981) that allow people to estimate their level of risk by assigning point values to a number of risk factors may be a useful development in this area, but what we envision is still more abstract. What is needed is something that not only summarizes risk factors, but gives a broader interpretation of the principles that interrelate risk factors - literally an explanation of why risk factors are associated with increased or decreased likelihood of heart attack. The fact that our experience with this topic is based on the investigation of lay rather than medical knowledge prevents us from offering such a model, but it does make us keenly aware of the need for it. We also sense the need for a second general model to guide people in their efforts to lower risk factors. Even something as broad as a health belief schema that emphasizes moderation could be of use here. A caricature of the American who decides to do something about
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coronary risk might consist of someone vowing to quit smoking instantly, lose forty pounds, jog five miles a day, and finally leam how to handle stress. Perhaps we 'need' the belief that massive change in our lives is the only way to modify bad habits, but an attempt to eliminate only one problem while moderating other risk factors is more likely to succeed than a total revamping of one's life style. Ultimately, professionals need to help [)eople acquire knowledge that converts an understanding of risk factors into reasonable efforts at risk moderation. We would like to conclude our discussion of practical applications by returning to the dominant interest in stress among our participants. We can demonstrate the importance of beliefs about stress by linking these beliefs to another item absent from Table 1 - mentions of going to the doctor or otherwise seeking medical advice prior to a heart attack. Tliis is not just an omission from our coding system; as we made a conscious effort to tally this factor, but it appeared only rarely in these transcripts. Here is one instructive Instance where it does occur. No. 1: There was a time in my hfe, before I got smart and came back to school, I was trying to make it in business. I was under a lot of pressure . . . I thought one day I'd relax and go to the ball game, and the ball game was a little exciting and I started jumping up and down and yelling and screaming, and I felt a pain in my chest - 1 thought to myself, it's time to stop, it's time to change something. And for the next four, five, six months I really took it easy. It was about this time that I decided to go back to school and I changed my whole life style. No. 2: Did you go to the doctor? No. 1: No. I didn't. I just saw it as self-induced stress. There was no reason for me to get that excited over a play in the ball game . . .
This was the only participant who reported anything that was interpreted as a heart-attack related symptom, but we believe that his reaction is unlikely to be unique. In cognitive terms, this participant assimilated his experience to an improper schema: he interpreted it in terms of knowledge about stress as a threat to health, rather than knowledge about when to seek medical advice. We are not medical experts, and thus not in a position to assess the actual impacts of stress on health, but when beliefs about stress actually appear to steer potential patients away from medical assessment, it seems clear that things have gone too far. As health professionals, and in particular as social scientists, it is high time that we investigate whether popular conceptions of health and illness place too much stress on stress.
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Summary and condusioiis Whereas our discussions have summarized some of the practical applications arising from our substantive investigation of the lay person's knowledge about heart attacks, the main body of the paper demonstrated the importance of three basic issues: the existence and content of health belief schemata; the processes through which these schemata originate and develop, and the role that interaction within social networks plays in this process of schema development. From the study of social cognition, we have borrowed the idea of a schema as the basis by which knowledge is stored, retrieved, and applied. For our purposes, the principal importance of a schema is its ability to translate immediate experience into usable knowledge. In the present instance, we have demonstrated the common existence of a health belief schema for heart attacks which is best summarized as a set of differentially weighted risk factors which can be used to understand the occurrence of heart attacks. Schemata develop through a process of continuing abstraction. As individuals encounter more knowledge about heart attacks, they also develop a more sophisticated structure for representing and using this knowledge. Health issues which are related to age or life cycle generate particularly clear demands for cognitive development. The predictable onset of these health problems points to periods of life in which individuals both encounter more specific episodes among their peers and pay increasing attention to problems that are becoming more self-relevant. Although cognitive development is an inherently individual-level phenomenon, the things that affect this process include a wide range of social activities. For heart attacks and other health problems, vicarious experiences provide a person with far more knowledge than he or she would usually obtain through direct experience. Interactions within social networks are also important infiuences on the interpretation of this knowledge. By allowing comparisons across the experiences of different individuals, interaction facilitates well-known aspects of cognitive development. In addition, by creating an opportunity to expose individuals to explicit evaluations of their knowledge, in the form of either agreements or disagreements, interaction can have a unique impact on cognitive development. The broader significance of interaction becomes clear when we realize that cognitive development is not a process which automatically moves every individual from episodic experience to higher levels of abstraction: much of what we know depends on what we are able to
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learn from our fellows. In the case of heart attacks, the information that is routinely available in our culture includes only a set of differentially weighted risk factors, and does not go as far as abstract models. It is at this point that health professionals can make a distinct contribution by creating and disseminating models that will aid individuals in the further development and more intelligent application of their knowledge. Department of Sociology University of California, Riverside Riverside Califomia 92521-0419 USA Notes An earlier version of this paper was presented at the 1983 meetings of the Society for the Study of Sodal Problems under the title 'Focus groups and Health beliefs: Leaming from others' heart attacks'. 1 Throughout we use the term 'heart attack' essentially as a lay person would, given that our topic of interest is in fact lay knowledge. We are, however, aware that this is a very inexact term, and we recommend Tesearch into the forms of heart and circulatory diseases that fall under the lay person's summary heading of 'heart attack'. 2 The examples we present are subject to only minor editing (elimination of pauses, stuttering, etc.). Although we did emphasize clarity of self-expression in our selection of examples, the quality of these passages should remind the reader that our retuming-student participants were both more educated than the general population and more mature than typical undergraduates. 3 Another participant mentions that drinking in moderation may in fact be preventive, and the presenter agrees. 4 Doise and his collaborators (1978; Doise and Mackie, 1981) have advanced a similar argument with regard to the impact of interaction on childrens' cognitive development. They argue that children who have partially mastered Piagetian tasks may have 'different centrations', and that interaction between them will lead each to an improved performance on the task. Note especially that this argument does not depend on 'modelling', but on a conflict between individual states of knowledge that is uncovered through interaction. 5 All transcripts were scored by two coders, and the overall rate of inter-coder agreement was 60%. Although not high, this level of agreement is acceptable for the kinds of materials being coded here. Most of the coding problems did not result from disagreement over how to code a risk factor; instead, most problems were one person choosing to code something which the other coder ignored. The results presented here contain only the risk factors that were recorded and agreed on by both coders. Examination of a tally based on all codes given by either coder shows substantially the same pattem as Table 1.
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