Family Practice Vol. 17, No. 6, 529-534
© Oxford University Press 2000
Beliefs and Behaviour |
Men's self-assessed personal health resources: approaching patients' strong points in general practice
a Research Unit and Department of General Practice, Institute of Public Health, University of Copenhagen, Denmark and
b Section of General Practice, Department of Public Health and Primary Health Care, University of Bergen, Norway.
Correspondence to H Hollnagel, Central Research Unit of General Practice, Panum Institute, Blegdamsvej 3, DK-2200 Copenhagen-N, Denmark.
Hollnagel H, Malterud K and Witt K. Men's self-assessed personal health resources: approaching patients' strong points in general practice. Family Practice 2000; 17: 529–534.
Received 28 January 2000; Revised 7 July 2000; Accepted 21 July 2000.
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Abstract |
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Objective. To explore resource-oriented, gender-sensitive approaches in general practice by identifying what men perceive to be their personal health resources.
Methods. A key question was developed to invite men to tell their GPs about personal health resources during ordinary visits. The answers of 39 consecutive male patients (aged 19–84 years) visiting two female GPs were audio taped and analysed, qualitatively inspired by Giorgi's phenomenological approach, supported by theories on salutogenesis, patient-centredness and gender perspectives. The main outcome measures were personal qualities and strategies considered by men to be their health resources.
Results. Men considered that the following were personal health resources: optimism, good self-esteem, job satisfaction, ability to cope with stress at work, leisure activities and relaxation with friends producing energy, and fitness and lifestyle activities.
Conclusion. A key question can give a doctor access to men's thoughts about their strong points. Self-assessed personal health resources can be identified and mobilized by the GP and support a salutogenic approach, which contrasts with the tendency of contemporary medical practice to focus on risk. Asking people about their own ideas may reveal that coping patterns are more complex than reflected in prevailing research.
Keywords. Coping, general practice, men, salutogenesis, self-assessed health resources.
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Introduction |
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Behavioural medicine and psychoneuroimmunology have shown how the incidence and progress of various diseases depend on the individual's psychological strength, the self-healing power of the body and the social network.1–4 Antonovsky suggested that one should investigate the origins of health (salutogenesis) rather than the origins of disease (pathogenesis).5,6 Yet, patients' strong points are largely ignored in medical theory and practice, even in preventive health care. The opposite perspective, identification of risk factors, is more apparent.7
We have previously presented a clinical model8 based on Antonovsky's salutogenetic perspective and his concept of general resistance resources, McWhinney‘s patient-centred clinical method9 and critical theory about empowerment. Our model encourages the GP to include general resistance resources in their agenda, and to identify and include the patient's self-assessed health resources in the patient's agenda. We suggest that the practitioner pursues patients' self-assessed health resources through a dialogue where agendas of resources/risks/disease and illness/self-assessed health resources are combined. The importance of finding out more about patients' strong points is also stressed by the patient-centred clinical method.9 We focused on self-assessed health resources, rather than the general resistance resources5 objectively recognized by the doctor.
Our overall objective was to demonstrate a clinical strategy for identification and encouragement of patients' strong points. We translated our theory into clinical action by developing key questions inviting patients to tell doctors about their strong points.10 From clinical experience, we knew that men and women may differ not only in the sociocultural stressors they encounter but in their strengths and resource strategies. Carmel et al.11 observed notable gender differences in the use and effects of psychosocial coping resources, and Eisler and Blalock12 concluded that culturally approved masculine schemata may create gender role stress predisposing men to unhealthy behaviour patterns. We therefore decided to explore self-assessed health resources in both men and women, applying a gender-sensitive approach without assuming that resource talk and strengths are similar for men and women. The purpose was not to test hypotheses about gender differences. We started by studying self-assessed health resources in female patients, based on key questions. The principles and outcomes of this strategy have previously been reported.10,13,14 The same principles are applied in this study. We aimed to demonstrate a clinical strategy for identification and encouragement of self-assessed personal health resources in male patients.
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Methods |
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Design, definitions and context
The study was designed as an action research project.15 The experiences were elaborated and systematized according to principles of qualitative evaluation.16
A key question is a vital component of a communicative strategy; it invites the patient to share his or her ideas about illness and health within a specific theme.17 This strategy was originally worked out by Malterud to increase the doctor's understanding of ‘unexplained' disorders in women patients. It is focused, problem-oriented and supposed to promote specific action, in this case to make the patient share his ideas with the doctor and to shift the discourse towards resource talk.18 The key question was developed through a systematic procedure based on the clinician–researcher's previous successful experiences in discussing a particular topic.
Key questions were used to identify self-assessed personal health resources in a clinical context. We first developed the key question and then started asking it and studying patients' responses in detail. Below, we present findings from this step.
Based on our understanding of gender differences, we expected that talking about resources might require different linguistic approaches in women and men, so that a key question for women would not be suitable for talking to men. In January–February 1997 we began to develop a new key question on self-assessed health resources for men, aiming to formulate a question which would promote resource talk in different male patients consulting for various problems. We used the same procedure as for women,10 gradually adjusting and elaborating the question according to responses from patients.17 The question was developed and applied in the context of ordinary consultations by the female authors, both of whom are GPs, one working in Norway and the other in Denmark. Both doctors worked in stable practices with patients of various ages, educational backgrounds and social class.
Through these steps, the final version of the key question became: "Most people have hidden reserves which usually take care of their health. What are your reserves?", with the possible extension: "Do you have other reserves as well?" The patient seemed to understand our question better when it was preceded by some reminders about his basic health, such as "Apart from the present matters, I understand that you are really quite healthy?", or "Knowing that you suffer from these rather serious diseases, you are nevertheless remarkably healthy, I would say."
Material and analysis
We purposefully sampled16 various health problems and individuals; altogether we studied 39 consultations with men aged 19–84 years. The men varied widely in terms of social and educational background, types and seriousness of medical conditions, and duration of relationship with the doctor. In order to obtain diversity, although not a random sample, the informants were consecutively enrolled in the study from the ordinary appointment book and represent a broad variety of people and conditions, ranging from seriously ill elderly cancer patients to a middle-aged alcoholic and a young man with ‘flu’. All eligible patients agreed to participate.
The consultations were audio taped and sequences succeeding the key question were transcribed in modified verbatim format. These quotations constituted the material for qualitative analysis inspired by Giorgi's phenomenological approach:19 (i) reading all the material to get an overall impression, bracketing items that conformed with our preconceptions; (ii) identifying units of meaning, representing different aspects of self-assessed health resources and coding these; (iii) condensing and abstracting the meaning within each of the coded groups; and (iv) summarizing the contents of each code group to give concepts that reflect the main categories of identified self-assessed health resources. The analysis followed a data-driven editing analysis style20 in which we aimed to categorize dimensions of personal qualities and strategies mentioned across the group of men as self-assessed personal health resources. The analysis was a collaborative process with both the female authors participating, continuously checking that we had a mutually consistent understanding of the patterns. Our findings were organized into four descriptive categories, each with a statement where we summarized the men's expressions illustrated by typical quotations. The analysis was inspired by our theoretical frame of reference,21 drawing on Antonovsky's salutogenic perspectives,5 McWhinney's patient-centred clinical method9 and a gender perspective.22 However, the categories were not defined in advance, but derived from the material.
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Results |
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Summarizing the four categories in more general terms, we found that self-assessed health resources for men were related to optimism and good self-esteem, job satisfaction and ability to cope with stress at work, relaxation with friends and energy-producing leisure activities, and fitness and lifestyle activities. The code in parentheses after each quotation indicates the informant number, with D meaning Danish and N Norwegian.
1. I take pleasure from my life and regard myself as a strong person
Many of the men perceived their positive and cheerful attitudes to life as personal health resources. Several of them spoke about their appetite for life and said they enjoyed their lives. Others mentioned their good moods, their optimism or their tendency to look upon most things in a positive way, or having a reasonably carefree perspective. One man said,
"At least I do not feel like a gloomy person. I have a positive approach to most things, to most things at least." (D-14)
One of the men referred to his disease and said that he had learned to live his life and make the best of it. Since he had been told that he would not die from the disease, he had decided that he would have to find out how to live with it instead of sitting there and yielding to pain. Two of the men mentioned their religious convictions, saying that they believed in God, said their prayers and felt that it helped. One said,
"I guess it is my determination to live—my strong will to keep going." (D-1)
Several men answered by describing themselves as strong and steady. Some added that they were able to persevere and would always be able to give an extra push. Others added that they had mastered the art of resting, feeling quiet and relaxed, and that they enjoyed sitting alone with a newspaper and the radio. One of the men, suffering from a chronic condition, announced that he would have to rely on himself in his everyday life where nobody else would help him, and that crisis intervention was not for him. Another man noted the steadying effect of his upbringing, and another mentioned his marvellous body.
"In general, I feel strong, most of the time. Both at home and at work." (D-8)
2. I am happy when I go to work
Most of the men who were still in the labour force referred to their jobs when we asked about resources. Several of them viewed their job as interesting and exciting: a teacher emphasized the importance of having a job where he could see the effects of his work, i.e. when his students started working after graduation. One of the informants remarked that he felt strong at work, while another underlined the importance of having plenty to do all day and several talked about work that was physically challenging.
"I am happy every day I can get out of bed and go to work." (N-18)
Several of the men had recognized that pressure from work can make people go to work in spite of illness. One man said that his job motivated him to try his best and that that kept him going. Another referred to a period after an accident. He went to work and did not feel sick, because nobody did his work while he was away.
"You know that it would probably be better for you to stay at home, but you know that you have promised somebody something. This is not about pounds and pence, but it is about having promised, and other people expecting you to be there." (D-2)
However, the men also answered the question by telling us about various strategies for relaxation from a tough job. Many seemed to be able to leave the stress at work, and one stated that he took one day at a time. Several men described afternoons, holiday and weekends when they were able to sleep or relax completely. One of them said that he used to sleep for a quarter of an hour when he was tired, and another prevented stressful situations in a hazardous workplace for himself and his co-workers by planning in advance. One man, a teacher, said,
"I think I can tolerate the stress of my work—if you have a class with difficult students, I usually forget it when I have left the actual situation." (N-17)
3. I unwind with my friends, and my hobbies give me energy
Many of the men answered our key question by mentioning friends. They have a good time with their friends, sometimes every week, and some of them see friends from school. They have a beer and escape from the troubles of everyday life.
"You know, that is balsam for big boys. We meet out there, on the island, on Saturdays and Sundays. You have always something to do when you have a wooden boat ... You just look at the other boys out there—they are all dressed in overalls. You are anonymous—nobody asks about your title, for out there you are just the owner of the boat you are maintaining. And this is what gives the big boys real fun ... I feel when I go out there that I have a really good time. It gives me energy to go to my job." (N-20)
Some men mentioned their wife or girlfriend; for example, one said
"I have a good marriage—painful matters are shared between my wife and me—that is very important."
Another man said he was fortunate to have a family and not be alone, and a third said that his wife took him out for a walk when he forgot to exercise. Many referred to children and grandchildren, one of them saying that having to get them breakfast and dinner every day was important in structuring his day.
"I have something to strive for. My wife is only 55 and I am turning 72, you know. I have always been surrounded by young people. And that also makes you feel more—you know. At least I do not feel like a 72 year old." (D-1)
Responding to our key question, several of the men said that they took great pleasure from their hobbies and leisure activities. Some remarked that they had no problems filling their time. Doing nothing was regarded as passive and boring, and one of the men said he felt weary and dull when nothing happened. One man, who characterized his interests as "rather normally healthy" talked about a fishing trip planned for the next day, while another liked birdwatching.
"I have always been one who needed to potter with something—difficult to sit quiet for a while—hikes, and having ideas—always. If I was not in the attic, I was in the basement. But recently I have tended to become too passive." (N-22)
4. I do my exercise and go for a healthy life
Several of the men said that they thought regular exercise of various sorts contributed significantly to staying healthy. They mentioned organized sports, such as football or golf, as well as individual fitness activities like running, swimming, cycling, weight lifting, hiking or deep-sea diving, and said that this made them feel more energetic and gave them a sense of well-being. One answered that he always needed to go out and move.
"I participate in several kinds of sport, playing football, badminton, bowling and tennis—that is a must. I feel very well afterwards. For periods, I also do some running, usually from February. That is also a must. Feel it ... I am certainly more healthy when I have been running or doing some of the other things, that is for sure." (D-3)
Some of the informants answered our key question by referring to their lifestyle, including a healthy diet (including vegetables, milk and vitamins), or to low or no consumption of tobacco or alcohol:
"My food is wholesome and I exercise regularly—it's quite a healthy lifestyle.' (N-7)
One of the men remarked that even though he smoked and occasionally went out drinking, his regular exercise gave his body resilience. Others emphasized their understanding of how their health would be favoured by a reasonable balance.
"I do not avoid any food or drink, but excesses will usually be during weekends. I eat what I want every day, but generally no more than one beer a day. And smoke some more on Fridays, Saturdays and Sundays, but apart from that, not much." (D-3)
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Discussion |
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Contextual validity and transferability
By choosing a qualitative research approach and a purposeful sample emphasizing diversity, we aimed for transferability beyond the setting where the study had been performed, although we do not claim that our findings are representative in the traditional epidemiological sense.23 Transferability in this case implies that male patients, when seeing a GP who encourages them to talk about health resources, may identify resources similar to those exemplified by our findings. Other colleagues may obtain diffent responses, but the approach may easily be reproduced. As the doctors in this study are women, they are not typical Scandinavian GPs, where the majority of GPs are male. However, in this study, the main measure of outcome is the answer from the patient, and the variety of patient beliefs is more important for the qualitative notion of representativity than diversity of doctors. We are not only researchers, we are also experienced clinicians running our practices within the ordinary primary healthcare systems in Denmark and Norway. Neither our practice populations nor the patients included in the material are very homogeneous. We think that this context holds the potential for developing transferable knowledge.
Content validity of the key question
The findings we have presented are drawn from the material that emerged when the key question was asked. As researchers, we must assess whether this tool was adequate for the proclaimed purpose: to invite the patient to share his knowledge about his personal health resources. Is the key question really probing this or has it been interpreted differently? The study was based on the theoretical framework of the health resource/risk balance model.8 This model implies an understanding of self-assessed personal health resources as compared with doctor-assessed health resources, and to health as compared with life in general. It does not exclude the possibility of conceptual overlap, such as when health contributes to a good life, or when doctor and patient agree about the assessment of the patient's resources. However, our understanding of self-assessed personal health resources is grounded on a phenomenological perspective, where the experiences of the patient are regarded as valid knowledge, even if the patient's understanding of health or resources differs notably from that of the doctor.
The key question was developed through a procedure where the intention of the question was constantly focused. We wanted the question to facilitate talk about patients' self-assessed health resources. Through all steps of the project, we reminded each other of this purpose. The key question was supposed to reflect our theoretical frame of reference, where a salutogenetic approach was combined with a patient-centred per-spective, and yet be feasible for application in the busy everyday life of clinical practice. During the development process, the question was continuously refined, by adjusting it so that it elicited talk about the required subjects.10,13 Doing this in the context of normal consultations made it possible for us to check that the patient really understood what we were asking about. Misunderstandings certainly occurred along the way and made us adjust the question according to the responses we had. Applying the key question systematically in its final version during the second step of the project made it possible to double-check whether it was sufficiently robust to survive the challenges of various clinical problems and still serve its purpose. Finally, we made sure that the question was logical linguistically. Considering the outcomes, we concluded that the question was an adequate tool for learning more about men's perceptions of their own health resources.
Although this key question may be suitable for this study on gender, the answers can sometimes still be inadequate, for instance if the question was misunderstood or if the informant was for some reason not honest about the matters in question. Given the theoretical framework we chose for our study, we have scrutinized the results to determine whether self-assessed health resources are different from doctor-assessed health resources. We do admit the probability of a cultural effect and a bias appearing when informants want to please the doctor. Therefore, it might have been difficult to distinguish between cultural ideas of publicly acknowledged health resources, and the ‘authentic’ ideas of the individual informant.
As this was not intended as a comparative study on gender, we did not analyse the differences in the key question between men and women. Our initial belief that it is necessary to develop separate key questions for women and men may still be justified. However, although our original approach to developing this key question followed different paths in men and women, our experiences suggest that any significant gender differences perhaps reside more in the sensibility of the doctor's ear, than in the way such a question is phrased. We would not deny the possibility that the same question could be used with men and women. However, by choosing a gender specific approach, we were reminded as doctors to be sensitive to the different ways in which men and women talk about their health and coping. From these experiences, we propose that a gender-sensitive approach to discussing health resources must then be considered even more carefully through the doctor listening and responding to the patients, rather than talking to them in specific ways.
Health resources and gender
Research indicates that both female and male patients perceive female doctors as more sensitive than male doctors.24–26 The fact that the doctors involved in this study were both women may have had both advantages and disadvantages. The male patients studied here may well have censored answers considered inappropriate in the company of a woman, which they might have mentioned to a male doctor, such as sexual matters or issues indicating abuse by a partner. When being asked about health resources by doctors, informants may have censored their replies, avoiding mention of behaviour or attitudes that usually are considered to be detrimental to health, such as smoking or lack of exercise. However, we do not claim that we have provided a complete overview of this field. We have shown that men's self-assessed health resources can be accessible during an ordinary consultation.
Personal health resources can be regarded as a specific aspect of coping strategies. Lazarus and Folkman27 define coping as constantly changing one's cognitive and behavioural efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person. Lazarus describes different ways of coping as confrontational, distancing, self-controlling, seeking social support, accepting responsibility, escape–avoidance, problem solving and positive reappraisal.4 Our analysis was not based on predefined theoretical templates20 and the categories were established by an inductive process. Yet, some of Lazarus' categories can be recognized among our findings, such as seeking social support, accepting responsibility and problem solving.
Different studies have suggested gender differences in coping, where women appear more likely than men to use emotion-focused coping methods, while men tend to use problem-solving approaches.28 Our findings indicate that social support, including different levels of emotional involvement, is also part of men's coping strategies.
In a previous study, women reported health resources related to internal strength mobilized by external strain, interactive networks within and outside the family, lifestyle practices, physical and social activity, acceptance and facilitation of the natural course of disease, and constitution.13 Although we did not compare males and females in this study, we believe that there are important differences between the findings of these two studies, even across headings with apparently similar content. The meaning of social activity may for example be dissimilar for men and women, when it is referred to as a salutogenetic resource. House et al.1 emphasize the need to distinguish between different classes of social relationship, especially as regards relational content, which can be divided into social support, demands and conflicts, or social regulation and control. Our hypothesis is that social relationships can be health resources for men, while the health resource aspect can be more ambiguous for women as providers of social support. These hypotheses have encouraged us to perform a comparative analysis, which will be presented elsewhere.
This study has demonstrated that it is possible to find out about men's perception about their health resources by deliberately talking about resources in general practice. GPs are invited to develop their own key question about self-assessed health resources, phrased in their personal language. Changing the dialogue to focus on health resources rather than risks may contribute to salutogenesis in clinical practice.
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