Ann. Rev. Public Health. 1983.

4:181-201
Copyright © 1983 by Annual Reviews Inc. All rights reserved

SELF-CARE IN HEALTH

Lowell S. Levin
Annu. Rev. Public Health 1983.4:181-201. Downloaded from www.annualreviews.org

Department of Epidemiology and Public Health, School of Medicine, Yale

University, New Haven, Connecticut 06510
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Ellen L. Idler

Department of Sociology, Yale University, New Haven, Connecticut 06510

INTRODUCTION

Self-care in health in this paper refers to those activities individuals under­

take in promoting their own health, preventing their own disease, limiting
their own illness, and restoring their own health. These activities are under­
taken without professional assistance, although individuals are informed by
technical knowledge and skills derived from the pool of both professional
and lay experience. This broad definition is consistent with definitions com­
monly applied to the term self-care [(C. Smith, unpublished paper; P.
Crawshaw and B. Wong, unpublished paper; (1-3)]. The generic attribute
of self-care is its nonprofessional, nonbureaucratic, nonindustrial character;
its natural place in social life (4). Operational definitions of self-care have
more narrowly reflected various emphases on the spiritual aspect of health
and health care, wellness behavior, self-medication, healing potential, self­
administered primary medical care, management of chronic disease, and
protection in use of professional services (5-18). The concept of self-care
also remains within the traditional health education literature as focused on
risk reduction and disease prevention at the level of personal action (19).
Self-care as a political concept involving individual skills in collective action
on structural issues had its early expression in the consumer health move­
ment of the last two decades. Currently, the collective action perspective on
self-care is found largely within the broader frame of lay initiatives in
health, particularly through neighborhood voluntary organizations (15)
and mutual aid groups.

181
0163-7525/83/0510-0181$02.00
 182 LEVIN & IDLER

A typology of well-formed concepts of self-care is not to be found. Social

research has yet to catch up to the varied social expressions of lay health
care. The most useful contribution to be made by this review at this point,
midstream in the growth of our awareness of self-care as a factor in health
and health care, is (a) to synthesize the modest understanding we now have
of self-care, recognizing the theoretical and methodological limits of avail­
able data; and (b) to identify what appear to be productive directions for
research and public health policies and programs.
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SELF-CARE IN RECENT HISTORY

Before we begin to think about the subject of self-care in strictly contempo­

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rary terms, it would be well to emphasize its historical roots. Because it is

a private, largely noneconomic activity, it has gone unnoticed by most
students of the family and public health alike. Thus, its recent rediscovery
could give the somewhat false impression that it is a new practice. But
actually, the current popular interest in self-care and self-help is in many
ways similar to what it was in mid-nineteenth century America, both politi­
cally and economically.
Popular interest in self-provided health care in the nineteenth century
was closely tied to the other social and political movements that began
during the Jacksonian period. It was rooted in the traditional American
values of self-reliant individualism, anti-elitism, popular democracy, com­
mon sense, and even nationalism (20-22). But it also sprang from funda­
mentally optimistic beliefs about health and the causes of disease. With the
proper diet, fresh air, and exercise, the health reformers and some of the
domestic manuals counseled, men and women could prevent disease from
occurring in the first place. Historians have argued that nineteenth century
interest in health reform was a clear response to the social uncertainties of
the time, chief among which were changes in women's work role within the
family (23). Thus the confluence of changing women's roles, feminism, and
a general interest in health matters in the nineteenth century, and similar
configurations today suggest that these are socially logical responses to
common problems.
In any case, the 1970s and 1980s have been another period of public
interest in health, and self-reliance in health care matters has again been a
major theme in the debate.

THE EXTENT OF SELF-CARE TODAY

A surge of development in health care in Western Europe and North

America following World War II was in response to substantial deficits in
professional resources. The establishment of the National Health Service in
 SELF-CARE IN HEALTH 183

Britain in 1948 and rising concern in North America regarding issues of

access to medical care and improving quality of services served to reinforce
the perception that professional health care was synonymous with health
care generally. But access to a broad data base made possible systematic
studies of utilization patterns, and these in tum began to define the several
components of the health care resource, both lay and professional.
In an effort to define the role of the general practitioner in primary and
secondary prevention, 1. M. Last (24) documented the extent of untreated
morbidity in England and Wales. His study made clear that for virtually
every category of disease,what the medical practitioner saw was only "the
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tip of the iceberg." This conclusion agreed with an earlier study by Horder
& Horder (25) undertaken on a London population. Here it was found that
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less than one third of illnesses experienced were cared for by health profes­
sionals. In an international comparison study of medical care utilization,
White et al (26) found a similar distribution of symptoms involving lay and
professional care. From interview data, it was found that an average of
82.7% of all conditions causing "great discomfort" over a two week recall
·
period did not involve consultation with physicians.
The above studies,as powerful as they are in revealing the vast proportion
of all illness episodes cared for exclusively by the layperson, very likely are
substantial underestimates of lay self-care. The interview method used in
these studies relied on respondent recall, which has been observed to be
increasingly unreliable as a source of morbidity data after a two week
period. Even within that period it can be expected that the more serious,
painful, or disabling conditions would dominate in memory. Minor upsets,
like tension headache,indigestion,cold, backache and other commonplace,
short duration discomfort may not be remembered and thus not reported.
A more sensitive method for collecting illness experience is the home health
diary (27-29). Typically, respondents are asked to record on a daily basis
for several weeks anything "wrong" with them and what, if anything, they
did about it: such as self-treatment, or seeing a doctor.
Using the health diary method, Demers et al (30) analyzed all health
problems recorded by study participants over a three week period. Results
indicated that nearly 95% of the problems recorded did not involve profes­
sional medical care. Banks et al (31) incorporated a health diary as one of
several sources for data on factors influencing demand for primary medical
care in a group of British women between the ages of 20 and 44 years. The
results showed that only 1 in every 37 symptom episodes was brought
forward, solely on the patient's initiative, for medical consultation. The
authors of this study identified clear differences between self-eared-for
symptoms (headache, changes in energy) and those brought to the general
practitioner (bladder, skin, genital). Some symptoms were more evenly
divided in terms of self-care and professional care (emotional, abdominal,
 184 LEVIN & IDLER

pain in lower limb). Overall there is the strong impression that the women
in this study were in agreement on what was appropriate to self-treat and
what was not.
In addition to retrospective interview surveys and prospective health
diary studies using nonpatient populations, there are two studies that de­
scribe the self-care behavior of patients prior to seeking professional help.
Elliott-Binns (32) in Britain and Pedersen (33) in Denmark interviewed
samples of patients registered on their general practice rosters. The Elliott­
Binns study found that 96% of the patients interviewed said they had
received advice or treatment for the condition prior to contacting the doc­
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tor. This finding suggests the point that the range of self-care practice must
include, in addition to specific self-treatment behavior,those activities asso­
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ciated with seeking and evaluating information. Further, these two studies
help clarify self-care as not always or necessarily sufficient, but as a factor
in nearly all illness episodes,including those that ultimately receive profes­
sional care.
In any event, research on self-care in both the US and abroad has mush­
roomed. There are a number of bibliographies available (34-36; WHO,Div.
Fam. H. 1982, unpublished report; G. H. DeFriese, 1982, unpublished
draft) and the Index Medicus now lists self-care as a separate category,
complete with subheadings.

What Kinds of Illness-Related Actions Constitute Self-Care?

Initial descriptive self-care research has concerned the kinds of action un­
dertaken in response to illness, including self-diagnosis and options for
treatment or no treatment. Wadsworth et al in England looked specifically
at who made the diagnoses for the complaints in their sample. They found
that for the ten most frequent complaints, accounting for 98% of all com­
plaints, the majority of respondents said they had diagnosed the condition
themselves (37). In this country, a national survey of health beliefs and
practices found that 12% of their total sample relied heavily on self-diagno­
sis, and that over 25% who said they suffered from arthritis, rheumatism,
or a similar chronic ailment had never had it diagnosed by a doctor (38).
One might think that self-diagnosis would lead to further self-treatment
only in the case in which the individual felt himself to have a minor or
self-limiting illness. But, even in the case of some fairly serious chronic
diseases, people do not necessarily seek medical diagnosis or treatment. J.
M. Last estimates that for every case of tuberculosis, cancer, anemia, dia­
betes, urinary infection, glaucoma, hypertension, bronchitis, arthritis, .epi­
lepsy, and psychiatric disorder known to a physician in general practice,
there are 50 to 100% more in the population at large. Although some of
these diseases are probably undetected by sufferer as well, the author notes,
 SELF-CARE IN HEALTH 1 85

"Some of these potential patients [sic] may be people living with a disability
which has been recognized, and for which they have not sought treatment
in the year of the inquiry" (24).
Following self-diagnosis, the first available self-treatment option is to do
nothing. In the Wadsworth et al study, only 5% of the people interviewed
reported no complaints at all for the previous two weeks. Of the remaining
95% who did report at least one complaint, 19% had taken no action (37) .
Dunnell & Cartwright's study, which was primarily concerned with medi­
cine-taking, found that no medicine, either prescribed or nonprescribed,
was taken for 47% of the complaints reported, though this does not take into
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account other actions (39). Knapp & Knapp found, in their study of
self-medication, that only 7% of the illness situations received no doctor
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contacts or self-medication remedy of any kind, though 63% received a

response within four hours of onset. Thus, a sizeable proportion of people,
30%, adopted a "wait and see" attitude before deciding that the situation
was serious enough to warrant a response, be it self-medication or other
treatment (40). Dean (K. Dean, 1980, University of Copenhagen, unpub­
lished manuscript), in an interview study of self-care for common illnesses
among a Danish population, found that "taking no action" was unevenly
distributed among various presenting symptoms. Chest pains most often
invoked no action, whereas symptoms of depression and influenza were
nearly always treated with home remedies, other forms of medication, or a
medical consultation. Differences in the rate of nonresponse to recognized
symptoms in these studies may be attributable to differences in study
design, goals, and methods. Knapp & Knapp, whose stated goal was to
study self-medication behavior, commented that this goal may have influ­
enced their respondents: "Perhaps drug use itself helped define incidents for
diary recording" (40).
Of the possible forms of self-treatment, self-medication has been by far
the most frequently studied. Wadsworth et al found that 38% of their
sample had taken an analgesic in the two weeks prior to the interview; this
was the most frequently used medicine. Twenty percent had used a skin
medicine, 13% had used lower-respiratory medicines, and 12% had used
antacids. Uses of nonprescribed medicines outnumbered prescribed medi­
cines by two to one (37).
Dunnell & Cartwright found self-medication to be the most frequently
reported response to symptoms, surpassing consulting a physician, doing
nothing, and using other treatment methods. More than half of the adults
in their sample, 55%, had used some medicine during the twenty-four hours
prior to the interview. The people with the most symptoms tended to take
the most medicine: adults who reported one symptom had taken an average
of 1. 1 medicines, whereas those who had had six or more symptoms took
 186 LEVIN & IDLER

an average of 4. Some symptoms were more likely to be responded to with

medication than others: 94% of fevers, 83% of headaches, 81% of cases of
indigestion, and 78% of sore throats were treated with medication. By
comparing the use of prescription and nonprescription medicines with the
number of symptoms present,they argue that self-medication does serve as
an alternative to consultation with the doctor. Adults who had taken two
or more medicines had lower consultation rates than those who had taken
one, and those who had taken one had lower rates than those taking none.
With children,however,medicines were used to supplement doctor consul­
tations. Furthermore, these medicines were taken frequently and sometimes
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for long periods of time. Two-fifths of the adults in the study had taken some
medicine every day in the weeks before the interview. Only 1% of the
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households in the sample had no medicines at all, and 10% had twenty or
more. The average number was 10.3. More households had nonprescription
than prescription medicines, and the most commonly found were analgesics
(39).
This supports the findings of an earlier study in England by Jefferys et
al. About two thirds of individuals in the study sample had taken a nonpre­
scribed medication during a four week period, in contrast to a quarter of
this sample who had taken a prescribed medication (41). Jones (42), collect­
ing data from the records of all pharmacies and physicians serving an entire
community in England over a two week period, found that nonprescribed
medications were acquired twice as often as prescribed medications. Given
that prescribed medicines at the time those studies were undertaken were
free or heavily subsidized by the British National Health Service, the evi­
dent popUlarity of nonprescribed medicines is somewhat surprising. In this
regard, Rea et al (43), studying the prevalence of skin disease and the use
of medical care, found that 21% of those observed to have skin conditions
severe enough to warrant professional care chose nonprescribed self treat­
ment. These authors speculated that the public must prefer to pay for less
effective drugs rather than "go through the time-consuming machinery of
obtaining [free] professional medical advice."
In their longitudinal study of 278 US families, Knapp & Knapp obtained
information on 3300 illnesses or injuries, and on 3800 drug purchases. At
the start of their study, the average household had 5.3 prescribed and 17.2
nonprescribed drugs, and during the period of the study, acquired 13.7
more of both. Prescribed drugs were used in 30% of the illnesses, nonpre­
scribed drugs in 70%. Eleven percent of the illnesses were treated with both
(40).
Self-medication may be the best studied, but it is not the only form of
home treatment. Home treatments may range from physical devices, such
as band-aids or canes, to herbal remedies,to electric heating pads, to certain
 SELF-CARE IN HEALTH 1 87

foods, i.e. chicken soup. Wadsworth et al found that 27% of their respon­
dents used "other medicines and means," which included herbal prepara­
tions, ear trumpets, copper bracelets, and self-cauterization (37). In Alpert
et at's study, 1 9% of the total symptoms received treatment with home
remedies, which included rest, rubbing, gargling, bandaging, etc (44). In a
third study, home remedies (noncommercial) made up 1 5 % of all advice
given about symptoms (32). But this area of self-care research has received
modest attention; discrepancies in the amount of usage could be accounted
for either by differences in study design or by real differences in the cultures
studied.
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How Well is Self-Care Performed?

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Research in the "quality of self-care" is fraught with at least as many

problems as is research in the quality of medical care. However, whereas
the latter may at times ignore the patient's criteria for the evaluation of care,
this would be impossible to do in evaluating self-care. Dunnell & Cartwright
note that self-medication may have symbolic functions as well as pharmaco­
logical ones; that the experience of asserting control over the situation may
have self-fulfilling healing effects. Two-thirds of the medicines taken by the
adults were said to have helped. Further, the nonprescribed drugs were felt
to be at least as efficacious as the prescribed ones. Only 4% said the
medicines did not help them at all, and less than one in 1 5 reported side
effects (39). Another attempt to evaluate self-care was that of Elliott-Binns,
a British physician who asked patients coming to his practice to describe
and evaluate the lay advice that had been given to them about .their ailment.
Ninety-five percent of this advice was judged by the author to be either
helpful or harmless (32).

Who Uses Self-Care?

Are there some people or groups in society more likely to undertake self­
care behaviors than others?
The variable of age is strongly related to health status. The older the
people, the more likely they are to have a chronic illness, and hence more
complaints. Wadsworth et al found that for each type of complaint the
proportions of people consulting the doctor rose with patient age, implying
that younger people with the same complaint were more likely to treat
themselves (37). Dunnell & Cartwright found that the proportion of people
taking medicine rose with age. However, when the source of the medicine
is accounted for, the proportion of people using nonprescribed medicines
remains constant with age; the increase is composed solely of increases in
the use of prescription drugs (39). It appears that self-medication behaviors
do not change drastically as adults become older. Elliott-Binns found that
 188 LEVIN & IDLER

the soundness of advice given did not vary among advice givers aged 21-60,
but that advice given by people younger and older than that tended not to
be as good (32). The US survey of health beliefs and practices found no
difference in age between those who practice self-diagnosis and self-medica­
tion and those who do not (38).
The available data on sex are contradictory. According to Wadsworth et
at, significantly more women than men had consulted a doctor for a diagno­
sis of mental, digestive, and rheumatic disorders, suggesting that men were
less likely to have the problem, or more likely to diagnose these complaints
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themselves. But women had more total complaints than men, which could
explain this difference. At the same time, women took more medicines than
men, not only because they had more complaints, but also because they
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were more likely to take medicine for any given complaint (37). In the
Dunnell & Cartwright study as well, women reported more complaints than
men and took more medkine at all age groups. They took more of both
prescribed and nonprescribed medicines than men did. The authors suggest
that this may be because women do the family shopping, including buying
medicines, and they also spend more time at home where the drugs are kept
(39). Elliott-Binns found that women were more likely to offer practical
advice on health matters than men, who most often suggested going to the
doctor. However, the quality of women's advice varied: wives were thought
to give the best advice, mothers-in-law the worst (32). Knapp & Knapp also
found that wives were most likely to purchase drugs: only 20% of the
husbands in their sample considered themselves the primary drug purchaser
(40). Finally, the national US survey found that more women than men took
vitamins, but that "questionable" self-medication was more likely to be
done by men (38).
It is difficult to draw any safe conclusions from these findings. Although
it looks as though women, by and large, are more likely to practice self­
medication and to advise others to do so, women may also be more willing
to see a physician for their complaints. And both of these differences may
ultimately be due to women's higher complaint levels. However, these
higher rates may be an artifact of the research design. In all of the studies
that used health diaries, health events were recorded by the wife or mother
for every member of the family, the likely effect of which would be an
over-reporting of these women's complaints. Elliott-Binns suggests that
although times may be changing, medical care in the family has always been
"the prerogative of women" and, for the time being at least, it apparently
still is (45). Although one goal of the women's movement has been to
equalize role responsibilities within the family, the women's movement also
has focused considerable interest in issues relating to women's health, with
a strong self-help, self-care orientation. These two potentially conflicting
 SELF-CARE IN HEALTH 1 89

trends might cancel out each other's effect, with women continuing to play
a more important role in self-care than men.
Marital status and family size and structure are also important variables
in describing self-care activity, though once again, the available research
does not allow us to draw any strong conclusions (46). Wadsworth et al
found that for certain disorders, divorcees and widows were more likely
to consult a physician than were married women (37). In Elliott-Binns'
study, married patients were significantly more likely to use self-treatment
than single people (32). And in Dunnell & Cartwright's study, the num­
ber 3f medicines found in the home rose with increasing family size, al­
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though the number of items per person fell steadily. They interpret their
findings to mean that as the number of people in a family increases,so does
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the sharing of medicines. In fact they found that 20% of nonprescribed

drugs and 6% of prescribed drugs had been used by a family member
other than the one for whom they had originally been obtained (39). One
might take these data to indicate that self-care activities will increase with
family size, not only in frequency, but also proportionately, and that
those who live alone will be more likely to consult a physician than to
treat themselves. Clearly, coping styles and their effectiveness may vary
by culture, family demographics, family decision-making, the nature
of the illness (and its perceived implications), the persona of the ill mem­
ber, the family's previous illness experience, family access to technical
knowledge, and the availability of extended kin and friendship support re­
sources (13-14, 47-52). This is another area for future research, and
it is somewhat surprising that these correlations have not already been
more fully explored.
Finally, the variable of social class should be mentioned. After sex and
age, social class has been the most frequently measured variable with regard
to self-care behaviors, and the results, both in Britain and America, have
been remarkably consistent. Wadsworth et a1 and Dunnell & Cartwright
both found social class to be of little value in explaining their findings with
regard to physician consultation rates. Wadsworth et al conclude, "Sound
explanations of this difference are not to be found in simple and readily
available descriptive variables concerning social position, but are most
likely to lie in the more complex areas of social interaction and role." They
argue that marital and employment status are much better predictors of
physician consultation (37). The National Analysts survey found self-diag­
nosis and self-medication not to be related to any demographic variables,
a finding they report with evident dismay: "It appears that those who
engage in self-diagnosis, as examined in this study, are not very different
from people in general." One might even say, they are people in general
(38).
 190 LEVIN & IDLER

Public Interest in Self-Care

We can only speculate with regard to factors and forces that may be related
to growing public interest in self-care. Given the cultural and social specifi­
city of the factors proposed, the discussion is limited to those factors rele­
vant to North America and, in some respects, to Western Europe.

EPIDEMIOLOGICAL FACTORS The shift in disease patterns from acute

to chronic disease makes self-care both a logistical necessity and an appro­
priate strategy (1).
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PERSONAL RESPONSIBILITY FOR HEALTH Research on the associa­

tion of life-style factors with both morbidity (53) and mortality (54) has
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focused public interest on personal initiatives to prevent disease and pro­

mote health.

NEW HEALTH WORKERS AND CONSUMERS The bureaucratization of

medicine has opened prospects for a variety of medical tasks to be per­
formed by persons with less professional training and suggests the feasibility
and legitimacy of extending the lay medical role. Consciousness of the limits
and hazards of professional care (4, 55-61) also has grown.

ALTERNATIVE THERAPIES Non-allopathic systems of health care have

become readily accessible and are attractive from the standpoint of their
compatibility with a wide range of cultural values and ideologies (62-64).

AVAILABILITY OF SELF-CARE INFORMATION AND TECHNOLOGY

There is a substantial and growing self-care literature, both allopathic and
non-allopathic (62). Also available are texts on medical consumerism, par­
ticularly focusing on how to seek and use health professional resources in
a productive and self-protective way ( 16-17, 65, 66). Pursuing self-care
interests has been enhanced further by medical technology designed for lay
use, including health monitoring for bladder infection, strep throat, preg­
nancy, bowel cancer, and high blood pressure (67). Home computers, termi­
nals, and cable television programming presage a new complex of resources
for lay self-care development.,

IMPACT OF BROAD SOCIAL MOVEMENTS The consumer participation,

civil rights, and women's health movements have contributed to the democ­
ratization of employment, housing, education, and health care. The latter
presents a difficult challenge because of its tradition of elite professional
control (68). The women's health movement, in challenging the medical
 SELF-CARE IN HEALTH 191

autocracy by seeking women's control over their own bodies, left a legacy
of individual and collective programs designed to promote self-care among
all groups of people, particularly those at high risk for illness or at high risk
for the negative effects of professional care.
With regard to economic factors, studies in Western Europe and North
America report comparable levels of self-care practice among countries
with diverse health care systems and payment mechanisms. Financial fac­
tors are apparently not as important in motivating self-care as are a person's
belief in the efficacy of self-treatment, convenience, and desire to self-man­
age. However, the cumulative economic impact of increased levels of self­
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care is of interest to economists (69) and health service planners (70). There
is a link between lay self-care competence and the viability of primary
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professional care (71). Even modest shifts in the overall level of self-care can
have powerful health economic effects (72).

ORGANIZED APPROACHES
TO SELF-CARE DEVELOPMENT

Formalizing self-care education, as distinct from other forms of health

education, began with the "activated patient program" organized by Seh­
nert in 1970 (9). This program has since become a prototype for myriad
self-care education programs throughout the United States. The Course for
Activated Patients (as it is now called) is designed for adults, but is not
specific to cultural or demographic factors. Subjects covered by the course
include (among others) lifestyle behavior, self-monitoring (e.g. blood pres­
sure), use/abuse of medications, management of common illnesses and
minor injuries, patient rights, the physician-patient relationship, and nutri­
tion. Content is allopathically oriented. Instruction involves lectures, dis­
cussions, demonstrations, and role playing. More elaborate packaged
programs are now available that offer wider content options, more variety
in educational methods and evaluation techniques. The major advantages
of such packaged programs are that they are easily accessible (although
some have a one-time high purchase price); start-up time for user groups
is short, requiring little or no preparation of materials or decisions about
methods; efficient scheduling of program cycles is possible; and they have
the ability to accommodate large numbers of learner clients at once. Also,
uniform methods of evaluation allow for continuous program monitoring
and comparisons among similar programs elsewhere.
There are, however, several limitations to packaged programs (73). Per­
haps the most serious criticism is that these programs do not necessarily
reflect, in either content or methods, the preferences, values, or learning
styles of clients. The result may be more than inefficient or even inappropri-
 192 LEVIN & IDLER

ate learning; professional control of educational content is essentially dis­

cordant with a definition of health empowerment that includes problem­
posing skills as a central goal (74),relating to the clients' life situation (75),
and honoring the extent and substantial health competence of lay people
(76). Self-care education programs also have been organized with the needs
of particular groups in mind [e.g. rural populations (77), the elderly (78-
79), university students, poor and minority populations (L. S. Levin, Yale
University study,in progress),and children (80,81)]. There are,in addition,
a vast array of self-care programs for women sponsored by women's health
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groups (82).
Available literature on organized self-care education is meager. We know
little about the extent of such programs, the characteristics of sponsors,
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participants, content, methods employed, ideology, or effectiveness. No

standard nomenclature exists for them; they are not bound together as an
association; they have no central clearinghouse or official publication. As
of this writing, a national survey of self-care education programs is under­
way as the first step toward a careful delineation of self-care programs [G.
H. DeFriese, University of North Carolina, unpublished study; (83)]. This
study could provide frames of reference for inquiries that are both program
(efficacy) and policy (equity of access) productive.
There are clear philosophical differences among protagonists of or­
ganized self-care education. The kernel of the controversy is the distinction
between health education and self-care education (18). Health education
has its historical roots in medicine (84) and as a result is bound to a strategy
of diagnosing needs, filling gaps in knowledge or skill, seeking compliance,
and measuring success against professionally validated outcomes. This ap­
proach has carried over to many of the packaged courses as well as self­
study books as represented in medical self-help guides and lay oriented,
do-it-yourself texts that use clinical algorithms (e.g. 72). There also is an
opinion that self-care education,whose goal may be to improve health and
reduce costs, should focus precisely on those medical self-care practices that
would have the greatest measurable, direct potential to do so (85). Another
view of self-care education holds that achieving health is essentially a politi­
cal struggle and efforts to improve health must address a broad shift in the
locus of control from professional to layperson (2, 86). In this view, the
central tasks of self-care education are to preserve and nurture a layperson's
sense of competence in health, follow already established motivations for
learning additional skills, strengthen problem-posing skills, create a mutual
learning environment, avoid medicalizing social life, and measure the suc­
cess of the educational program against client-derived criteria. Further­
more, this perspective on self-care education encourages consideration of
structural aspects of health (environment, professionalism, politics, econ­
omy) as well as functional aspects (individual care skills).
 SELF-CARE IN HEALTH 193

SELF-CARE ISSUES AND PROSPECTS

Professional care givers and social scientists have, until quite recently,
chosen to ignore and sometimes condemn these unsanctioned health prac­
tices as useless and frequently hazardous. One federal study labeled lay
health care as "rampant empiricism" (38); and the influential work of
Parsons (87) judged the family to be largely incompetent as a health re­
source and, indeed, a prime source of pathology. But changes in the social
environment noted above forced more precise consideration of the nature
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of lay self-care practices and implications for health status,the professional

health care resource, and strategies for increasing the lay role in health.
With more precision in framing the issues, however, there is apparently no
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lessening of polemic. Lay health care has become a subject both of scientific
inquiry and political debate, often inextricably linked (88).
Self-care and self-help, as society engages these concepts and practices,
cover a wide and diverse range of values, motives, and ideologies. Among
practitioners of self-care are those seeking to avoid disease,promote health,
apply self-healing, reduce iatrogenic risks, and generally regain control over
health. Self-care is not a movement in the classical use of the term: there
is no single ideological position adhered to, no charismatic leader, no agreed
set of goals. As a result, critiques of self-care often fail to make explicit the
definition of the aspect of self-care involved. A central issue appears to be
the confusion of health promotion programs with self-care programs. Al­
though clearly these are not wholly discrete terms, the former mainly
emphasize changes in lifestyle habits (e.g. eating, exercising, smoking cessa­
tion), whereas the latter focus on developing behaviors associated with the
effective and self-practiced use of health resources (e.g. self, family, commu­
nity, professional). The "self-care debate" is, of course, more than a prob­
lem of definitional confusion; but such clarification could help move
attention to the role of self-care and self-help in improving the quality of
care and extending its benefits (89, 90). Below are several questions that
seem to dominate the literature about the role of self-care.

How Safe is Self-Care and What is Its Legal Status?

Existing levels of self-care are part of social life and constitute a fabric of
beliefs and practices more profoundly cultural than medical. The bulk of
lay self-care remains within the realm of coping with common symptoms
of distress,self-limiting illnesses and injuries,and managing chronic condi­
tions. Its modalities include home remedies, nonprescribed medications,
and psychosocial support. Although the safety or value of specific self-care
procedures may be challenged, as in the case of the prophylactic use of
Vitamin C, there appears to be common acceptance of self-care contribu-
 194 LEVIN & IDLER

tions to both health and the viability of the professional care system (91).
Concern about the safety of self-care and its legality appears more likely to
arise around efforts to expand the venue of self-care practices. To date, the
safety issue has been focused mainly on the quality of published self-care
materials (92, 93) rather than on self-care education programs. From a legal
standpoint, the status of self-care practices has not been fully established
(94). Courts appear reluctant,however, to regulate intrafamily or friendly
services, despite the broad sweep of statutes governing the practice of the
healing arts. The legal status of organized self-care programs is equally
vague and would depend on the character of the appropriate state statutes.
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However, even if such programs fell within the general scope of medical
practice acts, self-care instructors could seek exceptions on statutory or
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constitutional grounds. Clearly a more fruitful solution to such possibilities

is to revise relevant state health practice acts to conform to contemporary
public expectations for access to self-care skills.

How Effective are Self-Care Practices?

As Martini (95) emphasizes, there is a dearth of evaluative research on the
effectiveness of indigenous self-care practices. However, a substantial pro­
portion of changes in morbidity and mortality experience is associated with
concurrent changes in lifestyle, such as nutrition and smoking. The effec­
tiveness of self-care for minor illnesses and injuries seems not to have
precipitated complications requiring professional interventions; on the con­
trary,such practices seem both appropriate and effective (33,91). It appears
that the question of the quality of self-care activities is actually less directed
to the activity per se, but rather: (a) can laypeople effectively perform tasks
heretofore professionally administered? and (b) how effective are various
education methodologies in teaching new self-care skills? With regard to lay
capability to learn and effectively perform heretofore professional tasks, the
number of published studies are few but are positive in their findings (96-
98). Systematic studies of the effectiveness of self-care education are being
sought (83), but there are few examples (11, 99-101).

Where Should the Lines be Drawn Between Self-Care and

Professional Care?
As the breadth of lay health initiatives becomes more apparent and un­
dergoes purposeful development,questions arise with regard to the interface
of self-care and professional health resources. An earlier period saw the rise
of consumerism affect the health care system from the standpoint of gover­
nance (102). The present self-care movement is focused on the care-giving
process itself and thereby opens issues of professional-lay jurisdiction and
fundamental changes in clinical services (what, how, and who offers them).
 SELF-CARE IN HEALTH 195

Two studies and commentaries support the conventional wisdom that lay
people (103) tend to view self-care more favorably than do physicians (104).
Placed within the context of the health care system, differences in expecta­
tions vis-a-vis self-care between patient and professional will force consider­
ation of accommodation in the interest of both lay people and service
providers. There is a common ground of interest, for example, in "humaniz­
ing" professional services (105), reducing iatrogenic effects, sensitizing insti­
tutional environments (106, 107), improving productivity of services, and
contributing to the quality of health care generally. At the same time,
institutional accommodation to public interest in nonprofessional care
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strategies and environments will respond to economic incentives, to capture

new markets for service [offering risk reduction and wellness programs
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(108)] or to hold on to old markets ("birthing" rooms which simulate

homeyness). Some aspects of professional adjustment to lay self-care inter­
ests may touch the nerve of authority and thus not be readily approved.
Patients' access to their medical records is an example in which the benefits
are apparent but professional resistance remains strong (109-111). There is,
however, some evidence that self-care interests of even institutionalized
patients can overcome substantial resistance (112). Unanswered is the ques­
tion of how and with what consequences self-care and self-help interests of
patients will be affected by professional values either in the direction of
expansion of the self-care ethic or in its control (113, 114).

Is Professional Interest in Self-Care in the Public Interest?

Some observers see the recent interest of academics and health professionals
in self-care as evidence of the health establishment's flexibility in response
to a perceived threat to its control. The argument is put forward that such
professional intervention, using Zola's term, medicalizes life functions and
thereby expropriates a large share of social life as falling within the expert
domain of medicine (1 1 5). This is in sharp contrast to self-care practices,
which derive from the collective experience of people and are shared with­
out domination of the expert. It is difficult to judge the overall validity of
this critique, particularly if one takes into account over 1500 non-allopathic
texts and the growing diversity of perspectives among allopathic writers
(116).

Is the Advocacy of Self-Care a Mask for the Retrenchment

of the Government's Role in Providing Medical Care?
There have been concerns expressed that for certain populations, self-care
education may be inappropriate or counterproductive. For poor popula­
tions, could efforts to raise self-care skills be viewed as a strategy to compen-
 196 LEVIN & IDLER

sate for deficiencies in available professional care (117)? Should we not

adhere to a policy of first ensuring equity of access to professional care
before promoting self-care? With regard to self-care and women, the policy
of promoting self-care skills is problematic, even paradoxical (118). It is
women who maintain kinship ties, care for the family's sick, and provide
myriad psychological support services. Would focusing on increasing or
even improving women's care giving skills further reinforce an inequitous
burden? Both of these issues are crowded with assumptions and interpreta­
tions of self-care, some expressed, many latent. They are further evidence
of the political volatility of self-care and the need for clear frames of refer­
Annu. Rev. Public Health 1983.4:181-201. Downloaded from www.annualreviews.org

ence (119).

Is Self-Care an Attempt to Individualize What Are Really

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Social, Political, and Economic Issues?

Some observers of the self-care phenomenon argue that its promotion by lay
people or professionals could divert public attention and energy from efforts
to control structural factors that negatively affect health (89). This hypothe­
sis assumes that participants in lay self-care development, presumably in­
cluding members of mutual aid groups and lay voluntary programs, are
different from people with political interests in health and health care.
There is presently insufficient data to characterize the political values and
awareness of participants in organized self-care activities; indeed, the his­
tory of mutual aid groups would suggest a contrary hypothesis (90, 120).
Data on the nascent self-care education programs are too meager to judge
the ultimate direction of their influence on participant awareness and politi­
cal action. There is no basis now to conclude that interest in seeking more
personal control over health and health care precludes, much less immu­
nizes against, sensitivity regarding social factors in health and disease or
involvement in collective political action (121).

CONCLUSION

Lay self-care appears to be the dominant form of health care in Western

Europe and North America, despite variations in cultures and the availabil­
ity and accessibility of professional resources. The contribution of lay self­
care is profound, but until recently this pervasive, commonplace resource
has been, relative to professional resources, of marginal interest to research­
ers and health planners. With changing disease patterns and increased
access to information and appropriate technology, there has been a concom­
itant rise in public expectations for more control over individuals' health
destinies. This may be merely an artifact of a larger public interest in
maintaining or reestablishing personal integrity in an impersonal world.
 SELF-CARE IN HEALTH 197

Mediating institutions such as neighborhoods and churches (122) appear to

have taken on new vitality as people seek opportunities for direct involve­
ment in problem posing and problem solving. Self-reliance is not necessarily
synonymous with the rugged individualism of the past, precipitated by a
lack of options; it seems more a choice among choices, satisfying needs that
are at least partially in excess of those met through expert channels of
service. In health, those benefits include reducing risk and promoting health
through changes in lifestyle and changes in the environment; minimizing
dependency on professional care, avoiding the iatrogenic sequelae of profes­
sional care; and, generally, establishing a social construction of health.
Annu. Rev. Public Health 1983.4:181-201. Downloaded from www.annualreviews.org

Individual and family self-care is one element in a complex of nonprofes­

sional health resources. Mutual aid groups (123-125), lay voluntary orga­
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nizations, and the church (15), and, indeed, friendships (126) make their
contribution to health and health care. Recognition of these resources raises
difficult ethical and strategic political issues, particularly as they may be
subject to medicalization and the hegemony of the health professions. The
"discovery" of the lay resource in health by planners and politicians may
be a mixed blessing for the public interest, and there seems to be a reason­
able basis for such a concern as we look at some of the expert-originated
self-care education materials and programs. But in the larger arena of
indigenous self-care practices, evidence of professional or single ideological
dominance is scant and, given the pluralism of values and practices, seems
remote. Here, the least we can do may be the most we can do (127). A
minimalist strategy would remove barriers of public access to information,
materials (128, 129), and health technology that now stand in the way of
the public demand for more effective lay participation, both personal and
political, in health and health care.

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