Folk Models: Psychologically Aligned Approaches

3.3.1 Attitudinal, Lay Models, Health Beliefs and Illness Representation approaches

Over the past few decades, mental health professionals, chiefly psychologists have documented a range of approaches that empirically measure and quantify beliefs and attitudes of psychiatric and medical illnesses. They include a range of Attitude Questionnaires (Bhugra, 1990) and more formal theoretically overlapping approaches to elicit illness beliefs such as the “Health Belief Model” (Rosenstock and Becker, 1988), ‘Lay Models” (Fumham, 1988) and more recently, “Cognitive Representation” of Illness (Illness Perception Questionnaire, Weinman et al., 1996).

Such approaches owe their popularity to the ease with which large data set can be generated within a relatively short time and on a low budget. A recent example is the Royal College of Psychiatrist’s Defeat Depression Campaign (1992). In order to understand how ‘depression’ is popularly conceived, a MORI telephone poll was conducted to elicit Likert style responses towards a checklist of discreet propositions that were centered around the word ‘depression’. Responses elicited were then taken to be subject’s concepts about depression, not a function of the proposition which was framed in a manner understood by psychiatrists. Further, statistically analysed responses towards ‘depression’ and its treatment were then considered evidence to justify the

launch of a major national educational programme to help the public re-label their experiences (which were not elicited in full to know whether it connoted an everyday experience, a symptom or a syndrome) as a disorder for which suitable treatment facilities and interventions were made available, largely through training GPs in the detection of this disorder. Such an approach does not capture the full complexity of folk models on depression: its conceptualisation, ideas and actions, involving nomenclature, causation, agency, recognition and recourse to treatment (Jadhav and Littlewood, 1994).

These approaches have largely focused on static and discreet units of analysis, in the form of set propositions to which respondents are rated as Yes/ No, or Likert scales that allow for a degree of agreement or disagreement. Apart from multivariate analysis, there is little scope to examine the complex network of relationships between individual attitude items, particularly since these individual propositions are themselves dynamic and influenced by a variety of social and moral forces. A related method, that of using standardised vignettes, is flawed by similar difficulties. Moreover, the attitudinal sets elicited fi’om both the above methods are actually responses to decontextualised statements or accounts having little resemblance to live social situations, particularly when viewed in the context of a significant discrepancy between reported attitudes and observed behaviour. Taken together, these approaches also offer little to assess the stability of ideas or concepts over time, and across cultures.

3.3.2 Categorical approach

This approach attempts to discover the structure o f indigenous illness categories by analysing the meaning of a disease terminology. Frake’s (1961) study on the “diagnosis of disease” among the Subanum was one of the first significant attempts to provide a systematic account of folk medical knowledge based on linguistic data. For example, the degree of penetration differentiated Subanum categories for different types of ulcers. This approach is based on the view that the ‘disease world’, like the ‘plant world’, is exhaustively divided into a set of mutually exclusive categories, therefore illness either fits into one category or overlaps with several categories. However recent research in cognitive anthropology clarifies folk categorisation as generally neither discreet nor exclusive. Unlike classical set theory, which requires that any given object either is or is not a member of a given category, the categories of ordinary language admit degrees of membership. One type of object or folk category may be a ‘prototype’ of a certain category whilst other members of that category may be “sort o f’ like that category. For example, sadness may be a good example or prototype of a certain category “depression”, while other members of that category e.g. ‘low self-esteem’ may only be a sort o f ‘like that’ category.

3.3.3 Prototypical approach

An extension of the ‘categorical method’; in this approach, basic categorical structures are analysed in terms of relations of contrast and inclusion, although these relations may be fiizzy rather than discreet. Psychological research applying this approach (Tversky 1977, Szolovits and Pauker 1978) reveals differences in judgements about degrees of membership of a higher order category that are highly predictable, and based on the extent of overlapping or intersecting semantic features. Such fuzzy sets or ‘prototypes’ provide a

more refined and better way of representing folk knowledge as compared to the ‘categoricar approach. One of the appeals of this taxonomic model is its ability in describing a conceptual structure in terms of subset-superset relations. Taxonomic relations also provide an economical way of organising, storing and retrieving complex knowledge fi'om memory, which people use to talk about and discriminate a large variety of illnesses. Consequently, this has been a persuasive model in ethnographic accounts of disease concepts. However, D ’Andrade (1976), who himself used this method describes its shortcomings which include the cross-cutting, non-exhaustive and shallow nature of categories that did not fit into a neat taxonomy. Also, informant’s responses tended to be idiosyncratic and individuals fi’cquently changed their responses fi'om one session to another. D’Andrade (1976) suggests that responses forming the core of different belief clusters or categories are consequences and preconditions of the illness rather than features that define them. This also highlights more a difference between the informant’s and ethnographer’s notion of definition rather than an inherent problem with the taxonomic model approach. Sontag (1978) provides an example fi'om research on American concepts about tuberculosis, where her informants had knowledge about contagion and seriousness but little understanding of the bacterial pathogen that biomedically distinguishes it fi'om other infections.

3.4 Anthropologically Aligned Approaches