Representations Create a Context for Management

1.3.1 Relating Treatment and Action Plans to Illness Representations

The activation of a representation of a condition such as asthma, cancer, diabetes, or hypertension creates a framework within which individuals engage in a common-sense selection and appraisal of procedures to prevent, detect, control, and cure potential threats to health. These specific procedures can be selected from culturally prescribed nostrums, the shelf of family remedies, or be medically prescribed. Procedures are highly valued if they are perceived and believed to attack the disease at its location, address its mode of action, and/or affect a perceptible target (e.g., a subjective symptom or objective reading), and do so quickly. The match between the procedure representations and the illness representation determines the relevance of the procedure for illness control: if "heart burn" is the problem, ingesting an anti-acid makes good "common sense"; if cancer is a growth or lump, then surgical removal makes good "common sense" (radiation less so as it leaves something in the body). If asthmatic patients perceive that they have asthma only when they experience symptoms and that asthma has few negative consequences, they will doubt the necessity and will not take their inhaled corticosteroid as prescribed (i.e., Halm et al, 2006; Horne and Weinman, 2002). It is more difficult to sustain a procedure that fits this formula less well and has less distinctive and/or delayed feedback. For example, feedback will be less rapid and clear for attempts to control diabetic blood glucose levels with diet and physical activity than with medication. On the other hand, behavioral practices sustained by widely held, culturally supported beliefs could support possibly risky actions that are of little benefit biologically (e.g., the belief that natural foods enhance the body's immune system). It is important to note that in each of these examples the combination of an illness and treatment representation created the context for management, but the actual performance required the creation of an action plan.

In summary, the system is dynamic and the representations and actions are fluid. The underlying prototypes can vary from highly stable (e.g., the self) to moderately stable (e.g., lifetime experience with colds and migraine), to vague and readily changeable (e.g., SARS). Given its complexity and flexibility, the model speaks to a wide range of situations and poses challenges to our ingenuity in creating interventions and measures to test specific hypotheses.

1.3.2 The "Executive Self" and Strategies for Management

So far, our focus has been on the "nitty gritty" of the CSM - the details involved in creating structures for performance in a specific place and time. The CSM postulates a second, executive level of strategies involved in evaluating and protecting the self-system, testing and choosing among illness representations, screening and selecting procedures for management, and selecting targets for evaluating outcomes. The model mirrors gerontological views of age-related change (Baltes and Baltes, 1990) and overlaps with psychological models focusing on properties of the self, such as self-efficacy (Bandura, 1998), coping and stress management (Carver et al, 1989; Lazarus, 1993), and procedures involved in cognitive behavioral therapy (e.g., Friedman et al, 2003). The CSM has examined, in detail, the procedures involved in global self-assessments of health (e.g., Mora et al, 2008) and the "executive level" coping strategies for protecting and enhancing the self, conservation of resources (i.e., the belief that one will live longer by conserving energy) and "use it or lose it" (i.e., using competencies to avoid loss) approaches to self-management frequently expressed by older patients (Leventhal and Crouch, 1997). A longitudinal study examining the impact of a major health event on giving up activities and the factors associated with later replacement used a 3 item scale to assess belief in the need to conserve resources and found the expected negative association (high scores interfered with action) with finding a replacement (Duke et al, 2002). The CSM has not yet advanced hypotheses as to how strategies for regulating functional resources will relate to specific approaches to problem solving (i.e., the sequence in which risks and action plans are identified and put in place).

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