Similarly, the meaning construct arguably subswnes affective responses as
contributors to underlying important existential questions. For example, as Dunlop ( 1 992) points out, anger as a common affective response, typically is coupled with the 'why
me?' and 'what have I done to deserve this?' type of questions. Dunlop (1 992) suggests too that affective responses such as fear of death and the unknown, sometimes coupled with information or misinformation, contributes to the related concept of a sense of losing control. Fear of death particularly invokes existential questioning, and was specifically addressed in the measurement process. The present study explored how orientation in and treatment of these existential issues was associated with treatment choice. In a sense, therefore, the role of underlying affective factors associated with existential issues was accounted for.
Finally, in the specific context of the present study, the view that affect and cognition should not be treated separately is supported by the argwnent that affective responses in isolation are unlikely to clearly differentiate between users of conventional
and
non-conventional medicine. That is, all cancer patients are likely to have affective responses. For example, a response such as anxiety, resulting from concerns aboutwhether treatment is working, will still be focused on curing the disease. There appears to be no theoretical basis for suggesting that a particular affective response will necessarily result in a particular choice of treatment. It may, for example cause a conventional medicine user to investigate conventional medicine in more depth, or try non
conventional, and vice versa for a non-conventional user. That is,
it
may influence factors such as commitment to treatment and a treatment regimen more than the type oftreatment chosen. Evidence of behavioural implications of affect in the context of care seeking behaviours seems to be limited to the decision about whether to seek treatment at all (e.g., Easterling
&
Leventhal, 1 989), and whether to delay treatment (e.g., Dracup et al., 1995) rather than decisions about type of treatment. It is possible that the affective response would add strength to a treatment decision already made, rather than influence its direction.CHAYfER FOUR
THEORETICAL FOUNDATIONS OF THE COGNITIVE APPROACH ADOPTED IN TIllS STUDY
Conceptual framework
Understanding the links between health-related cognitions such as health beliefs
and actionlbehaviour has long been a problem for researchers. As Calnan and Rutter
( 1 986) pointed out, behaviour can often be predicted from beliefs, but what kinds of belief are the most significant is an elusive question. Furthermore, Fiske and Taylor ( 1 984) have shown that the question of how direct the relationship is between cognitions and behaviour is also a difficult one to answer. They suggested that researchers may
expect too many and too varied behaviours to be related to any given cognition. This is,
perhaps, an underlying difficulty with the social cognition models identified in the
present study. That is, that treatment choice as a specific health-related behaviour may be related to a specific group of cognitions, especially when applied in the context of life threatening illness. Social cognition models may not always relate to the specificity of the
behaviours they are expected to predict or explain.
Another consideration in developing the conceptual framework was the way existing health behaviour models tend to comprise cognitions that are generated mainly by the experience of illness, which in a sense, reflects the illness focused biomedical approach. In the present study it was posited that the determinants of illness-related behaviour are not necessarily derived from the cognitive response to the fact of illness. This underscores the rationale, as previously mentioned, for using the Schwarzer ( 1 999)
tenninology of 'health-related cognitions' rather
than
illness cognitions. Health-relatedcognitions may have their basis in the wider belief systems that generally pre-exist
illness?' etc.) that inevitably lead to existential questions about life itself, and about death, which are especially relevant issues for those in a life-threatening illness situation.
In the present study the investigation of health and illness behaviours was
approached in this wider context wherein possible influencing factors were drawn from a larger and more expansive pool. It is larger in the sense that, arguably, people are
embracing a wider variety of health related concepts (e.g., philosophical and spiritual aspects, and holism in general), have more knowledge and understanding about health and illness, and are prepared to incorporate these in their health care, than was the case even two decades ago. It is more expansive in the sense that these philosophical and spiritual concepts are pervasive of the lifespan, existing during both well and unwell phases. In this sense, they are not only products of the illness experience.
These 'wider belief system' concepts are operationalised in the present study through the meaning construct, and as such are addressed in some detail later in the chapter. However, the psychological processes that explain how a belief system may influence cognitive functioning and eventually behaviour, can be descnbed in terms of attribution theory. It is attribution theory therefore, that underpins the psychological theoretical basis of the present study.
From this point the chapter first distinguishes this theoretical approach from that taken by social cognition models and then explains the attnlmtional basis of the study. The conceptual link between attribution theory (operationalised in the attributions of control, responsibility and blame construct) and meaning in life and its events is
addressed before the particular conceptualisation of meaning in this study is explained.
There are a number of distinguishing features between the theoretical approach adopted in the present study and previous approaches to understanding the relationship between cognitions and heahh-related behaviour. For example, social cognition models are deliberative models which may only be applicable when individuals have the
(Norman & COIUlor, 1996), which may or may not be available to a given cancer patient. Norman & Connor ( 1 996) contrasted that approach with the automatic or spontaneous processes that may influence heahh behaviour, which is the approach underlying Fazio's ( 1 990) (cited by Norman & Conner, 1 996) model. In that model certain cognitions, such as highly accessible attitudes, may guide behaviour in an automatic, non-conscious way. This approach, which Nonnan and Conner ( 1 996) recognise needs further exploration, has a certain congruence with the approach taken in the present study, particularly in relation to belief structures and attitudes towards existential matters. Enduring belief systems and attitudes, for many people, may guide behaviour in a non-conscious way.
The point was made in the previous chapter that there are three main types of social cognition theory. These are: attribution theory, models of decision making, and schema theory (Stainton Rogers, 1 99 1 ). Also as indicated in that chapter, social cognition models, particularly those that have been found to be useful in the field of health and illness related behaviour, have been mainly based on decision making theory and have focused mainly on the health enhancing and compromising behaviours of otherwise healthy individuals, particularly in the context of prediction of future health-related behaviours (Conner & Norman, 1 996). On the face of it, it would seem reasonable to use a decision-making model as a framework for exploring treatment choice decision-
making. The present study, however, was based on an attribution theory approach, the reasons for which are addressed below. As Conner and Norman ( 1 996) pointed out, health behaviour researchers have employed social cognition models that have been based on an attributional approach. However, they have been utilised mainly in
explaining response to treatment (Conner, 1 993) and in particular, their use has focused on people's responses to a range of serious illnesses (e.g., for cancer, Taylor Lichtman & Wood, 1 984; for diabetes, Tenner, Affieck, AlIen, McGrade, & Ratzan, 1 984; for
coronary heart disease, Afileck, Tenner, Croog, & Levine, 1 987; for renal failure,
Witenberg et al., 1 983) (Conner & Norman, 1 996). The value of an attributional approach in the context of serious illness has, therefore, been recognised.
Before the role of attribution theory as proposed in the present study, it may be helpful to reiterate at a theoretical level, albeit at the
risk
of being repetitious,why the decision-making theory approach of social cognition models was not adopted. The opportunity is also taken to briefly review another theoretical model that appears to have developed along similar decision-making theory lines but also takes account of social and cultural background. This theory of behavioural diversity (Co hen & Machalek,
1 988) is of particular interest as it
has been suggested to be a useful basis forunderstanding the decision to use non-conventional treatments (e.g., Clavarino & Yates,
1 996), although, as demonstrated below, the dimensions of the model are of limited
usefulness in the context of the present study.Firstly, with reference to decision-making theory and models that take that approach, these have their roots in expectancy-value theory (Peak,
( 1 955),
cited in Conner & Nonnan,1 996)
and particularly in subjective expected utility (SED) theory(Edwards,
1 954)
(Conner & Norman,1 996).
This approach assumes that individuals make deliberate choices on a rational basis that take account of the volume andprobability of the consequences expected from choosing either of the alternatives
(Janis,
1 989). The methods for decision analysis that have been developed from these theories
are difficuh to apply to decision making by patients because in maximising the expected utility of the decision they require quantitative estimates of the benefits of the outcomes of each alternative and of their corresponding probabilities(Janis, 1 989).
In the treatment choice decision making arena there seems to be no theoretical basis or any evidence pointing to such a rational and " mathematical" cost-benefit analysis process such asmight be expected, for example, in the business world, where these approaches tend to be particularly applicable. Furthermore, the subjective utility aspect of these approaches is somewhat lost on cancer patients. There is an underlying assumption of the need for efficacious treatment, so ascertaining whether a cancer patient cares about or wants a cure is likely to be of less relevance.
Cohen and Machalek's ( 1 988) theory of behavioural diversity, which was advanced to explain the selection of specific behaviours, was considered by Clavarino
and Yates ( 1 996) in the context of the decision to use non-conventional treatment. This would see the use of non-conventional therapies as a variation of nonnal behaviour. lbat is, a behavioural option "performed by nonnal individuals in unexceptional social
circumstances" (Cohen & Machalek, 1 988, p.466). The model is based on four assumptions. The first is that individuals are predisposed to act in terms of their own interests as they perceive them. In the context of illness, self-interest is reflected in the desire to get well or find a cure. Behaviours or strategies are refined or altered until this goal is achieved, which corresponds with the evidence that non-conventional medicine is often turned to after conventional approaches have failed (Clavarino & Yates, 1996). In the present study, however, patients at all stages of the treatment process were surveyed, including those whose decision was to use both conventional and non-conventional treatment, and not just those who believed that their conventional treatment had failed.
Cohen and Machalek's ( 1 988) second assumption was that behaviours are acquired through social interaction and socialisation processes rather than being of a dispositional nature. This is picking up on the suggestion of Becker ( 1 974) and Fabrega (1 974) that symptoms are interpreted subjectively and that the factors influencing
response to them include social and cultural background and past experience. Co hen and Machalek ( 1 988), however, argued against decision-making theory, suggesting that instead of rationally calculating advantages and disadvantages of a strategy, people often choose a strategy that
has
been successful in the past either for themselves or others. Yates et al. ( 1 993), for example, found that those who were encouraged by family or friends to use non-conventional cancer treatments were up to four times more likely to do so than those who were not so encouraged. In the present study the potential influence of cultural and social factors and socialisation processes was seen in terms of moderating effects on the central constructs of control attributions and meaning, rather than as these factors having a direct effect on the decision, as was proposed in studies such as Yates et al. ( 1 993).Cohen and Machalek's ( 1 988) third assumption concerned the perceived success of a given strategy based on frequency of use by others and how it compares with the
alternatives. Notwithstanding the way the model tends to avoid the SED approach, this component comprises elements of that approach in the way that it proposes a weighing up of the potential "success" of the behaviour. For reasons already mentioned, the present study also avoided the SED approach. Furthermore, perceived efficacy was not explored as a potential determinant.
The fourth component involved the assessment of factors that Cohen and Machalek (1 988) considered affected the extent and range of use of the behaviour decided upon. In the context of the present study questions of adherence, continued use, or extent ofuse of non-conventional treatments were not seen as determinants of the choice, and treatment choice was not conceptualised in terms of extent and range of use.
Attribution theory as an underlying theoretical perspective
In its broadest sense attribution theory deals with how people explain and make sense of the events they experience in their lives (Kelley & Michela, 1 980) and provides a framework for explaining people's actions and behaviours associated with these events. It
is
important to acknowledge, however, that attnbution theoryis
by no means settled. There are no well-accepted assumptions or hypotheses, noris
there a coherent logical network of conclusions about attributional processes (Weary, Stanley, & Harvey, 1 989).Attribution theory assumes that people are likely to look for causes,
and
to make causal attnoutions when something untoward occurs in their life (Howitt et al., 1 989; Semin & Manstead, 1 983). This underlying focus on cause or perceived causation was inherent in the earliest formulations ofthe theory (e.g., Heider, 1 958). Kelley ( 1 967), who contributed to the expansion of attribution theory in the 1 960's, saw threat or change in a person's life as provoking a search for causes and reasons in order to understand, controland
predict the future of the situation. Situations of high uncertainty have also been found to encourage the search for causal attributions (Tumquist, Harvey, & Andersen, 1 988), as has salience of the event for the individual (Weiner, 1 986),particularly for cancer patients (Taylor, Lichtman, & Wood, 1 984). The concept of causal attribution comprises a number of dimensions. These dimensions are drawn together to form the partiCUlar attributional approach adopted as the theoretical basis ofthe present study. They include the notion of locus (internal or external), controllability and the attributing of control, and the attribution of responsibility and blame either to self or another. If the search for causes of one's cancer results in self-responsibility or self blame, this represents the regaining of a sense of personal control (Taylor et al., 1 984).
In terms of locus, the question that arises is: Does this illness originate with me or from some external cause? Attribution theory suggests that when faced with an illness situation most people tend to search for an external cause, and when no plausible external attribution is possible, internal dispositional attributions are searched for within
themselves (Sensky, 1 997). For Heider (1958), locus of causality was either in the person (personal) or in the environment (impersonal), or both. Kelley (1967) introduced the notion of attributions of causality to other people as part of the focus of external locus of causality. The making of attributions to others
has been found to be a particularly
relevant concept in the context of serious illness (e.g., Turnquist et al., 1988; Tennen & Afileck, 1 990) and the potential for this as an external attnbution was acknowledged in the theoretical basis of the present study.
Blaming others is a dimension that arises out of the making of an attribution to an external cause. T ennen and Afileck ( 1 990) identified three conditions that are usually necessary for blaming of others to occur in serious situations. These are that someone else is available to blame, that that person is in a position of authority, and thirdly, that the person blamed is not well known to the patient. A distinction must be made, however, between blame and cause (and responsibility) (Tennen & Afileck, 1 990; Sensky, 1 997;
Weary et al., 1 989). Sensky ( 1 997) illustrates the difference between cause and blame with the example of the family who blames the surgeon (in whom the three conditions may be fulfilled) for a patient's death, although acknowledges that the surgeon did not directly cause the death. On the other hand, attributing blame or responsibility for a situation presupposes some attempt at attnbuting causality (Shaver, 1 985), demonstrating