QUALITATIVE HEALTH
Mercado-Martinez,
Ramos-Herrera
RESEARCH
/ DIABETES
/ July 2002
Diabetes: The Layperson’s
Theories of Causality
Francisco J. Mercado-Martinez
Igor Martin Ramos-Herrera
The authors examine laypersons’ perspectives of illness: the content of causal explanations of
diabetes and differences in explanations according to gender. Qualitative research was carried out in Guadalajara, Mexico. A nonprobabilistic sample of 20 diabetic individuals participated in interviews, and the content of the interviews was analyzed. On the origin of their
condition, participants offered explanations that match neither the biomedical model nor any
other formal causal theory. Participants attributed the onset of diabetes to socioemotional
circumstances linked to their life experiences and practices. Men attributed causality to
work and social circumstances outside the home; women attributed it to family life and
domestic circumstances. The authors discuss how lay theories can be useful for the reorganization of health services.
I
t is widely recognized that some patients’ responses to their maladies and disabilities are greatly influenced by their beliefs, attitudes, and experiences. Furthermore, their value systems can have a profound effect on the course and outcome
of disease and can be used to justify decisions about subsequent behavior, which
can vary from total indifference, to the use of home remedies, to the search for medical care (Furnham, 1988).
Individuals who feel ill react to symptoms based not only on objective data but
also, frequently, on their own theories and representations of illness, its causes, progression, and management. According to Finkler (1991), a person’s etiologic explanations shape his or her expressions and behaviors toward disease symptoms.
Beliefs, ideology, lay concepts, or cultural worldviews about certain conditions constitute not only valuable tools for understanding how individuals respond to disease but also methods for the improvement of health care systems. Comprehension
of such concepts can enable researchers and health professionals to predict more
accurately behaviors and practices of patients, and to collaborate in the development of effective policy and management programs (Glasgow et al., 2001).
Although laypeople’s beliefs about chronic diseases have been the focus of
many studies, relatively few researchers have explored the individual’s explanation of the factors that give rise to particular illnesses. Research on lay perspectives
AUTHORS’ NOTE: Carlos Calderon made valuable comments and suggestions on an earlier version of
this article, translated by Grady Miller and Ma. Luisa Arias. Marilu Carter, Editorial Consultant, substantially improved the manuscript. The National Council of Science and Technology (Mexico) supported the
study.
QUALITATIVE HEALTH RESEARCH, Vol. 12 No. 6, July 2002 792-806
© 2002 Sage Publications
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is relevant, not only because it will permit the understanding of how social and cultural elements shape chronic conditions, but also because it will permit the better
understanding of the main health problems in numerous countries, including
underdeveloped ones (Schoenberg, Amey, & Coward, 1998). Research on this topic
will also help to explain why a significant percentage of the population rejects the
use of health services or abandons professional recommendations.
In this study, we examined the layperson’s perspectives on the origin of a
chronic illness, with the central aim of presenting the content of the theories used by
lower-income inhabitants of an urban neighborhood to explain the causes of diabetes. We also examined these differences in explanations according to the gender of
participants. Three central questions guided our research: (a) What explanatory
models do sick individuals use regarding the origin of a chronic illness? (b) In disadvantaged socioeconomic sectors of an urban population, what causal theories do
persons with diabetes use? (c) Are there gender differences in causal explanations of
diabetes?
BACKGROUND
Health care and social science professionals use various academic models to explain
the origin of disease. Many researchers, nevertheless, have little or no interest in
exploring the perspectives of lay individuals on such an origin. This lack of interest
is exemplified in several well-known models, such as those based on (a) biomedical,
(b) socio-psychological, and (c) structural orientations.
Representing the academic approach par excellence, researchers most often use
the biomedical model to study disease. In the case of chronic conditions, such as diabetes, two interconnected assumptions are related to a patient’s knowledge of etiology. First, the biomedical model is useful in accounting for and assessing the degree
or amount of scientific knowledge a patient has about etiologic factors. Second, this
model presupposes that patient belief systems are erroneous because they emanate
from familial traditions, ethnic folklore, and/or common sense. According to the
biomedical model, these nonsystematic or nonscientific belief systems should be
replaced with scientific knowledge through educational or social programs (Weller
et al., 1999).
Other researchers emphasize the need to incorporate sociological and psychological concerns to understand disease. The Health Belief Model has existed for several decades and is among the most widely used models in sociology and psychology. This model is constructed on the belief that the likelihood of understanding any
behavior regarding health is a function of the individual’s belief in the perceived
level of personal susceptibility to a particular condition, the perceived severity, the
estimation of potential benefits or efficacy in preventing or reducing susceptibility
and/or severity, and the views of possible psychological and other costs or barriers
related to the proposed action (Maiman & Becker, 1977). This model has been chosen as a theoretical framework in measuring beliefs of diabetics (Schwab, Meyer, &
Merrell, 1994), although it has been criticized for its indeterminate usefulness in
predicting certain health-promoting behaviors and because it does not address
patients’ beliefs about the causes of disease.
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QUALITATIVE HEALTH RESEARCH / July 2002
Some scholars use a structural framework to explain the origin, course, and
management of disease. One orientation of this model emphasizes macro social and
economic determinants of health and disease, such as the mode of production,
social class, and process of work—among other widely used categories. Latin
American social medicine, for example, usually emphasizes the structural determinants of disease but at the same time neglects the individuals’ points of view about
their conditions, such as the causes of their epidemiological profile or of a disease in
particular (Minayo, 1997).
In contrast to these three models, interpretative, phenomenological, and
anthropological studies have contributed significantly to the understanding of the
way nonprofessionals perceive, evaluate, and behave regarding illness. These studies take into account a population’s beliefs, theories, or representations of illness—
its causes, course, and management—as objects of important and valid research.
Beliefs about the origin of illness, for example, have been understood as part of a
wider interpretative process, that is, as a way of making sense out of the events of
daily life (Nettleton, 1995). The concept of health and disease, according to Helman
(1990), forms part of a broader conceptual model, which is used by the population to
explain misfortune in general. Consequently, illness is seen as a specialized form of
adversity that shares psychological, moral, and social dimensions with other forms
of adversity (Herzlich & Pierret, 1988). Moreover, concepts regarding illness held by
individuals who feel sick are deeply grounded in social reality. According to
Kleinman (1978), explanatory models can be elicited from practitioners, patients,
and family members for a particular sickness. Each model contains explanations of
etiology, onset of symptoms, pathophysiology, course of sickness, and treatment.
Like the aforementioned authors, our aim in this study is to explore the causal
theories held by chronically ill individuals. According to Kuhn (1991), all participants hold causal theories about social phenomena. The term theory is understood
as a continuum ranging from rudimentary beliefs to the most complex and formalized system. Theories can account for features such as consistency and make statements about the world. Such statements are subject to evaluation by appealing to
evidence and argument. Furthermore, theories can involve one or more causal
themes or combinations of themes.
According to Kuhn (1991), structural theories of causality are characterized by
argumentation, that is, the numbers of different causal lines included in the theory,
the relationships that lines produce in one another, and the numbers of elements
within a causal line. These theories take three major forms: single causal, multiple
causal, and multiple alternative causal lines. These forms suggest important differences in how causal phenomena are conceived. Theories are not homogeneous,
however. Group differences occur as a function of age, class, gender, and other
social and cultural variables.
Although most of the population lives in cities, few studies have been conducted on the causal theories of diabetes sufferers in urban areas of developing
countries. Reports of causal explanations, including those of Latinos (Hunt,
Valenzuela, & Pugh, 1998), yield contradictory information. Some studies report
causes that match the biomedical model (Cabrera, Novoa, & Centeno, 1991),
whereas others highlight the emotional or social factors (Rojo, 1985; Torres, 1999).
We found no reports on gender differences in the urban population regarding
causal theories.
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METHOD
We employed an ethnographic design for this study, which is part of a broader
research project exploring participant perspectives on living with chronic illnesses
(Mercado, Ramos, & Valdez, 2000). A qualitative methodology was chosen because
it allowed us to analyze the experiences of laypeople, their theories, and their practices about a particular illness.
Study Setting
The research site was Oblatos, a neighborhood of Guadalajara, in the state of Jalisco,
Mexico. The city, ranked second in the country in terms of its population, has grown
exponentially in the last five decades, mainly because of migration from rural areas.
In 1940, Guadalajara’s population was 400,000 inhabitants. By 1990, it had reached
3.5 million (Arroyo & Velazquez, 1992).
Oblatos was founded in the 1960s, and 40 years later, the number of residents
has increased to more than 30,000. Most are immigrant people from the poor rural
areas of the inner state or nearby states, or descendants of working-class families of
the city, who endured by buying low-priced pieces of land on which to build their
homes. According to the county classification, Oblatos is a lower-income neighborhood, but in reality, it is a heterogeneous community of extreme poverty, salaried
workers, and some middle-class families.
Selection of Participants
People with diabetes were selected to participate in the study. After a regional
research committee approved the technical and ethical standard for research, the
selection process was accomplished in two steps. In a previous survey, we had
located in the neighborhood 780 people with diabetes (Mercado et al., 2000). From
this list, we selected a nonprobabilistic sample of 20 participants (Kuzel, 1992). Individuals who met the following inclusion criteria were recruited: those who identified themselves as diabetics, were age 20 years or more, and had no major impairments to prevent them from being interviewed.
Those selected were visited at their homes and invited to participate voluntarily in the study. After we had explained the goals and procedures of the research
and their rights as research participants, we asked for their verbal consent because it
is not culturally acceptable to sign a written consent for this kind of task. Some
refused to participate, and they were substituted with others who had similar characteristics. All participants received a card with our address and phone numbers,
and we invited them to contact us in the case of problems or doubts.
Sociodemographic Characteristics of Participants
Participants ranged in age from 35 to 71 years, with a mean of 57 years; half were
women. They had suffered diabetes for 11.8 years on average. Eleven had diabetes
alone, but the rest (9) also had hypertension, arthritis, or another chronic illness.
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Eighteen were married, and the average number of household members was six.
Most participants had highly variable and/or limited incomes. Six had formal jobs,
four as fruit or food sellers in local markets, one as a private police officer, and one as
a nurse. Five participants owned small businesses; another three were street sellers,
and three more were retired. Most of the women did not work outside the home.
Data Collection and Analysis
These two activities proceeded simultaneously. Between September 1997 and
March 2000, two researchers, consistently one male and one female, conducted all
interviews at the homes of the participants to allow them to feel more confident.
Over this period, 8 persons were interviewed 4 times, 4 persons 3 times, 6 persons
twice, and 2 persons only once. Although we intended to conduct the same interviews for all participants, it was not possible because of their particular circumstances. For example, one participant died during the period, several months after
we conducted the first interview.
The interview format was based on open-ended questions because we wanted
to encourage extended responses. Investigators usually started interviews with
general questions about the lives of participants, asking, for example, how life was
before and after the onset of illness, or causes and effects of these chronic conditions.
No further guidelines were provided, so participants could comment freely about
their experiences, theories, and practices. This strategy encouraged participants to
tell their own stories.
Interviews lasted between 1 and 2 hours each. All were recorded and transcribed verbatim to a computer format using the Ethnograph’s text editor and following Waitzkin’s (1986) recommendations on standardizing the input of the transcriber. Observations of the context of the interview, as well as information on the
Oblatos neighborhood, described in field notes, also were transcribed.
Data were analyzed using the following steps. One investigator (FJM) carried
out a content analysis (Weber, 1990). The process of content analysis started when
categories were defined, corresponding codes created, and themes selected as text
units. After reading and rereading every interview and all the field notes, segments
were identified related to predetermined categories. Selected segments were coded
and imported into the computer program. Interviews containing specific topics
were printed, and one investigator (FJM) proceeded to a second reading. Simultaneously, notes about emerging ideas were written as analytic or methodological
notes (Bernard et al., 1990). Printed materials were organized according to categories and participants. This strategy allowed us to analyze all information contained
in every single case and to perform an intercase analysis. In addition, segments that
seemed important to illustrate particular issues were selected and quoted. All data
related to each participant were read before the subsequent interviews.
Names of participants were changed to ensure privacy. Between parentheses,
immediately after their fictitious names, symbols are used to maintain participant
identification. Symbols at the beginning of quotations indicate a participant’s age
(e.g., a, 20) and years living with diabetes (e.g., y, 8).
Mercado-Martinez, Ramos-Herrera / DIABETES
TABLE 1:
797
Argumentative Lines of Disease Causality, According to Participants With Diabetes
Accident of a relative or family member (or death of a person, or threat of leg amputation, or street
vending → accident) → fright → diabetes (7)
Social activity → conflict → anger and rage → diabetes (6)
Social activity → rage and/or fright → drinking liquids → diabetes (3)
Street vending → consuming too many soft drinks → diabetes (2)
Family conflicts → problems/difficulty → diabetes (2)
Witchcraft → diabetes (1)
Medical intervention → pancreatic damage → diabetes (1)
No explanation (3)
NOTE: Numbers in parentheses refer to the number of participants who use the argument.
RESULTS
Participants describe the onset of diabetes in multiple ways. “It appeared from one
moment to the next,” “I got sick, ” or “It developed” are common expressions used
to refer to the process of becoming sick. The use of the terms “to become sick”
(enfermarse) and “to start doing poorly” (ponerse malo) is usually substantial enough
to make a distinction between two different phenomena. The first serves to make an
account of the beginning of illness; the second is used to describe the presence of
changes, complications, or worsening of the illness. Following our investigative
goals, we will proceed to describe, according to the participants themselves, why
they became sick.
Content of Theories
Here, we present a broad picture of the content of participants’ theories regarding
the cause of their diabetes. We will begin by analyzing multiple causal themes or
lines of causality used by participants. We will then proceed to show how these elements employed are combined along such lines of causality.
Seven causal lines were expressed by the participants. Each causal line in Table 1
represents a sufficient cause of the outcome—the illness—and the number in parentheses at the end of each causal line indicates its overall prevalence. This number is
arbitrary, because a larger number could be achieved by further subdivision. Some
participants, moreover, combine different causal themes, explaining why the total
number of lines is greater than the number of participants.
The most frequent causal explanation used by participants includes a series of
economic, social, or relational factors that produce fright in participants and
together “cause” diabetes. Participants mentioned three or four specific situations
that produced this great fright: an accident injurious to a relative, the death of a person, the threat of a physician to amputate a leg, and the observation of a tragic accident while working on the streets.
The second most frequent causal line of reasoning used to explain the onset of
diabetes is that attributed to anger and rage because of conflict occurring during the
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QUALITATIVE HEALTH RESEARCH / July 2002
performance of economic and/or social activities, mostly work and recreation. The
causality underlining this argument is that social and emotional processes are interconnected in such a way that when they are combined with anger and rage, they
give rise to diabetes. The situation and its circumstances are described in multiple
ways, but in essence, they are similar to that presented by Daniel (a, 47; y, 1), a fruit
street-vendor in towns and ranches near the city. He explained the appearance one
day of his condition with the following words:
One time . . . a guy made me angry . . . We [he and his family] were on the road, coming from the town celebration. In the ravine, a car got abruptly in my way . . .
Because it was night, I put on the high beams so he would pay attention, but he got
angry. He stopped in front of me and got out aggressively and drew a pistol . . . he
wanted me to get out [of the car] . . . So I got mad and said, “Look, let’s not argue so
much, if I’d had a pistol myself, I assure you that you and I would not be talking. You
are showing off because you have a pistol.” . . . I still didn’t have the problem [diabetes] . . . probably this [incident] harmed me.
Another causal explanation used by three participants refers to a process in
which a combination of social and emotional phenomena, provoked by an additional physical cause, produces this chronic condition. According to these participants, the illness appeared when a conflict in their daily activities triggered intense
fear and/or anger, which, in turn, produced a feeling of dryness in the mouth and
incited them to drink liquids, mainly water, coffee, or soft drinks. Among those who
presented this argument, Mario (a, 53; y, 12) expressed it in a particularly clear way:
I began one Saturday in the morning . . . I got upset [because of conflicts with job
partners] and drank a cup of coffee. From that moment on, I had a tremendous thirst
that nothing could get rid of . . . and I only drank a cup of coffee. The next day I went
to have some tests done; it showed 270 [blood sugar], and from this they told me I
was diabetic.
According to Table 1, other explanations of causality attribute the etiology of
diabetes to different reasons. Only two of the explanations given exclude emotional
causes, but they do include causes of a social, economic, or organic nature. This was
the case of a man and a woman who attribute their diabetes to frequent consumption of soft drinks because of the demands of their work, as both are dedicated to
street vending. Two women believe that diabetes originated because of problems
and difficulties they faced with their families: one because of her spouse’s alcoholism, the other because of her son’s imprisonment. Only one participant attributed
causality to a physical nature, asserting that a physician damaged his pancreas. One
man argued that his condition began because someone wanted to harm him.
Finally, three participants initially did not explain the causes of their diabetes,
although when asked to do so, they used answers similar to those given by other
participants.
In addition to the outcome—the illness—each line of causality consists of one or
more elements. According to lines of causality in Table 1, the nature of these elements is not exclusively organic, physical, or fear-induced. With the exception of
four cases, explanations of causality combine social, economic, and emotional factors linked to daily circumstances of everyday life.
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Simple and Multiple Patterns: Isolated and Recurrent Factors
How many lines of causality are included in a participant’s theory about diabetes?
What relationship do these lines have to one another? In this section, we will answer
these questions. In other words, we will explore the structural features of the participants’ theories, that is, their lines of argumentation.
Participants in this study are far from having a homogeneous etiological view
of diabetes. Some have very detailed theories that incorporate multiple elements,
whereas others’ theories are less complex, with few elements. We found three major
forms that these theories take: single causal lines, multiple causal lines, and multiple parallel causal lines. We found examples of single, multiple causal lines and
multiple alternative causal lines.
A simple pattern of causality is indicated by participants who use a single
causal line to explain the origin of the illness. According to Table 1, only one of seven
reasons of causality is considered unique in explaining the appearance of diabetes.
The example of Horacio (a, 33; y, 1), like several others, involves only causal line
number 1, in Table 1, which is identified clearly when he relates,
This [cause] all goes back to . . . September 25th last year, when my child [his son]
was run over, and I stopped the person who did it. I mean the fear and anger of not
being able to do anything to him at that moment; I only stopped him. But no! One
has pent-up rage of wanting to punch him, of doing something physically, but no!
And then . . . the disease appears, you know.
In contrast, some participants used a pattern of multiple causal lines, referring
to single-cause theories that include different causal lines converging to produce
the outcome. Elsa (a, 57; y, 15) refers to causal lines 1 and 5 when she emphasizes in
her account,
I had a very big problem. My son was in prison . . . that is really hard! And later, right
after this, I saw a man die in the street, but I don’t know if it was because I felt sorry
for him, or because of the fright I had, I began to feel depressed or as if carrying great
sadness.
Other participants employ a pattern of multiple parallel causal lines to explain
the origin of their illness. This pattern consists of two or more lines presented independently. Carlos (a, 66; y, 6), for example, uses the most complex model, including
numerous factors in his theory. When asked about the causes of his diabetes, he
begins by saying that he knows nothing about the matter, although later he
comments,
[One day] I visited a friend . . . we were chatting there a while . . . and he left and
brought two soft drinks . . . only he brought them uncapped, and I drank one cautiously . . . then I noticed something odd in this person, right? You know, people
imagine things . . . I had a hunch I was gonna get sick.
During another interview, however, he mentions another factor:
I used to play soccer, I had a team. I went in the morning and didn’t come back until
the afternoon . . . filthy and angry because sometimes we lost, I came back angrier. I
believe that was it where I developed diabetes more, I believe, with the angry fits.
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In another conversation, he introduced another argument whose origin comes from
an earlier time:
I have always told [the doctors] that they made me diabetic . . . when I was there [in
the hospital] I had a gallstone . . . they put a catheter in me . . . in my penis . . . I think
that they did damage to the pancreas or something.
Thus, according to the data gathered in diverse interviews, causal lines 2, 6, and 7
are involved, but this person gives no indication that they are integrated into a single causal structure.
The causal model used to explain the origins of diabetes can be simple or complex, but participants usually make a distinction between a single, isolated factor
and repetitive ones. The first includes beliefs in which a factor is presented on a single occasion but with such force that it unleashes diabetes. Hilda (a, 61; y, 15) refers
to this by saying, “My disease began the day one of my children died; it was an accident . . . it did not begin gradually, no, . . . all of a sudden!”
In contrast to this explanation of an isolated nature, a repetitive causal factor is
one that is presented intermittently over long periods until diabetes is said to have
fully appeared. Monica (a, 42; y, 15) illustrates this belief when she comments about
the onset of her disease:
My husband used to drink [alcohol] a lot—oh, what a miserable life! And I think
from this comes everything, from there comes many things. Because I argued a lot
with him, a lot, and I believe that from that time on the diabetes came. Sometimes I
say to him, it’s your fault I have this.
The Evidence
What kind of arguments do laypeople use to support their theories? In this section,
we will present the probes that participants of this study used to support their
causal explanations about their chronic condition. Two kinds of evidence were
found: external evidence and discounting, a form of indirect evidence.
Besides their own experience, the perception of participants regarding the origins of their diabetes incorporates external evidence in the causal sequence used. In
this case, participants go beyond the elements of the causal lines to invoke additional external factors as proof. They refer to circumstances of their immediate context that reinforce their explanations about the origin of the condition, such as
beliefs of their domestic groups—relatives and neighbors whose experiences and
explanations are similar to theirs. Julia (a, 60; y, 32), like many others, refers to having knowledge of other people who got sick for reasons similar to hers: “I say that it
is due to getting angry or being frightened. I had an aunt who wasn’t [sick], nor
were her relatives . . . [but] she was frightened. The house burned down, and from
this she became diabetic.”
Similar external evidence that reinforces the participant’s perception of etiology is the knowledge system shared, at least by neighborhood residents and the
city’s poorer inhabitants. According to several authors who have studied this same
population (Mercado-Martinez, 1996; Torres, 1999), this additional factor serves as a
basic reference: A set of emotions related to the problems of everyday life is the
cause of diabetes.
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There is also indirect evidence related to the elimination of alternatives, that is,
the participant’s discounting of someone’s explanations. In this case, perceived causality of illness is constructed and strengthened when systematically opposed to
alternative theories, such as those of health care professionals. Every participant in
our study has been in contact with these professionals directly, indirectly, and
through the mass media for many years. However, they make no reference to the
causal theory commonly used by these professionals to explain the origin of the disease, a model that emphasizes factors related to diet, exercise, stress, or organic
damage. When asked specifically, all participants denied the possibility that diabetes is a contagious disease. The majority, in contrast, make explicit reference to
heredity as a causal factor, but only to refute it, asserting that this belief is part of the
doctors’ accounts. Participants commonly use as evidence to discard the heredity
factor the existence of parents or grandparents without symptoms of diabetes. For
example, Eloisa (a, 62; y, 22) reveals her position quite clearly, emphasizing her rejection of the doctors’ explanation:
The doctors tell us that one already has it, one has the disease . . . because it is hereditary. . . . But I realize, from my relatives . . . I don’t know which of them was diabetic
because, you know, all the family on my father’s side has died at 105 years old; my
great-grandfather was 110; my grandfather died at 98; my father died at 86.
Elsa (a, 57; y, 15), in the same tenor, overwhelmingly rejects this same explanation:
“This that they [doctors] say, that [diabetes] is hereditary, is not true . . . it is not true
that it’s hereditary.”
Gender Differences
Male and female participants in this study, even those who lived in the same neighborhood and in relatively similar circumstances, offer different perspectives regarding the causes of their illness. These differences were found in three areas: the context in which the diabetes appears, the disposition of the participant involved, and
the participants’ emotional state.
Participants associate the cause of diabetes as tied intimately to a specific
sociogeographic locale in which these participants perform their daily activities,
that is, in circumstances of the inhabitants of an urban neighborhood. Males place
the causes of their illness in the public sphere or arena, particularly at work and outside the home, in their immediate surroundings while engaging in recreation or in
the streets. In contrast, females place the causes of their illness in the private space,
referring primarily to those situations that occur at home and/or with their families. Specifically, these women offer the perceived cause of their disease as difficulties, conflict, and problems associated with intrafamilial violence and family accidents. Ruth (a, 50; y, 2) describes one such episode:
I had a fright [in my house]. I was frightened because someone told me my brother
was seriously ill. [He was] one of these people who doesn’t know how to give
news . . . all exaggerated, and I got frightened, and I came home, and I drank water
because my mouth was dry, and there’s where it started.
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Another difference in causal explanations according to gender is linked to the
social actors with whom the participants find themselves involved in relationships.
In the case of males, relationships are established with strangers with whom conflicts and difficulties are generated at work or on the street. Jose (a, 51; y, 16) told us
one day,
A boy knocked down my nephew [playing soccer] and I got plenty upset, and I
mean plenty! So I wanted to take him off the [soccer] field, but I controlled my rage
and all . . . and I went for the water. [That’s why I got sick].
According to the female participants, relatives and neighbors were around them
when the diabetes appeared—primarily spouses, teenagers, or adult sons—as
female participants suffer accidents or find themselves victims or involved in violent acts by males. Significantly, no female has referred to any female (daughter,
mother, or female relative) as the cause of her diabetes.
Finally, gender-differentiated interpretations respond to the kind of emotional
phenomena implied. Intimately related to their work or activities developed in the
streets, males referred to anger or rage in situations surrounding the origin of their
condition. Females, by contrast, emphasized other kinds of emotional phenomena,
such as affliction, pain, sadness, fright, and fear associated with domestic problems
and other difficulties they confront in their homes with their families.
DISCUSSION
During investigation of this lower-income Mexican neighborhood, we focused on
the individual’s perspectives on the origins of chronic illness. We have examined
the content of their causal theories of diabetes. Various considerations, hypotheses,
and implications can be derived from the findings. One main finding is that participants’ theories of causality of diabetes remain far removed from proposed biomedical or structural models. This result does not signify, however, that participants’
causal theories are illogical or irrational.
Most participants in this study argued that the appearance of diabetes came
from a combination of personal and structural, as well as social, economic, and emotional factors. In contrast to technical interpretations of the biomedical model, participant theories of causality acquire an eminently personal connotation intimately
linked to their experiences and a constant reference to problems of daily life. Participants of this study, moreover, identify multiple external circumstances within the
context of their work, social relationships, recreation, and family life as causes of
their diabetes. Inclusion of all these factors, this far-reaching causal interpretation in
no way resembles the model offered by health professionals. Rather, our findings
agree with authors who affirm, “A popular lay belief system brings together, with
singular logical coherence, different levels and areas of reality (individual, social,
material) ostensibly unconnected, in which emotional, relational, material, magical,
and organic bases are joined in a social representation to which the cause of disease
is attributed” (Gonzalez, 1998, p. 241).
According to Garro (1995) and Kay (1979), the explanations of the origin of diabetes used by certain groups of English-speaking countries tends to emphasize
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803
those causes linked to food and/or diet, heredity, and stress. That is, their findings
incorporate core elements of a biomedical model (Helman, 1990). Our findings are
quite different because they emphasize the combination of different-nature factors,
with little or no emphasis on causes mentioned in medical discourse. Afuture line of
research focused on diabetic participants with access to health care services or social
class that are different from those described here might be useful to explore such
explanatory differences.
Participants’ combination of causal lines and of different kinds of elements is
also at variance with the interpretation broadly generalized in Latin America,
which states that patients explain diabetes as the effect of an episode of fright (susto).
Participants’ references to fright, incidentally, differ completely from the susto syndrome (Rubel, O’Nell, & Collado, 1992) because the latter has not been documented
in an urban population such as Guadalajara’s. In addition, causal explanations of
urban inhabitants usually differ from those of rural dwellers; for example, rural
inhabitants of a nearby state mention that diabetes is caused by tapeworm (Young,
1981).
No participant in our study explained the specific process by which consuming
water or food immediately after an intense emotional episode causes diabetes. Nevertheless, this explanation still prevails among certain population segments of Latin
America, especially peasants and indigenous people. Based on beliefs in a coldwarm duality, traditional interpretations assert that “warm” blood circulates
throughout the body. Under intense emotional states, the blood heats up even more,
a phenomenon referred to as “boiling blood,” or as it is said, “the blood boils.” The
consumption of cold foods or liquids, therefore, can cause illness.
In general, our participants attributed strong emotions—happiness, surprise,
fear, anger, suffering, or emotional shock—as causes of diabetes. In their own cases,
however, they cited only “negative” emotions—fear, anger, sadness—as causes of
the illness. Positive emotions—happiness, or surprise—were in no way attributed
as an etiology. This finding coincides with other reports, such as Rojo’s (1985),
whose study indicates that fear, anger, suffering, and frustration are reported by
women living in Mexico City’s poor neighborhoods as causes of their diabetes.
Like other researchers of populations of comparable socioeconomic characteristics (Aguado, 1998; Rojo, 1985), we identified perceived causality content with
respect to diabetes, but also observed their probes as a system integrated within the
circumstances of the participants and their social networks. Participants’ use of this
particular model, with its own evidences, is remarkable if one takes into account
that all participants have availed themselves of professional health services for
more than a decade on average, and the majority have attended health education
courses. Why do participants in this study—urban residents with access to medical
care for over a decade—reject medical explanations? Why does this traditional theory of causality persist among laypeople despite the affirmations of health care professionals that such false beliefs would disappear on contact with medical doctors?
These questions surpass the aims of this work. For now, let it suffice that our findings seem to indicate that perceived causality of illness emerges and is framed
within a set of popular values, interpretations, and meanings whose roots are found
in the world of daily life (Furnham, 1988). For this reason, contact with medical services constitutes or guarantees no change in perception and interpretation of health,
illness, and health care.
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Participants’ contact with health professionals used to be related to acute disease management, the most prevalent public health problem until recent times. Furthermore, because of the labor and economic circumstances of these participants,
access to health services has been irregular for many years (Mercado, Alcántara,
Lizardi, & Benitez, in evaluation). Finally, after our study was concluded, all participants continued to visit traditional healers for multiple reasons, including diabetes.
Studies performed in other contexts indicate that sick persons commonly do
not believe in the information given by medical doctors (Mason, 1985). This topic
could be explored along two lines of research. First, the type and time of contact
with health professionals and their effects on specific content of theories could be
analyzed. Second, in the case of cultural beliefs, such as Mexican, a worthwhile
topic is public policy and social scientific interests and how they relate to multiple
medical systems. A third area of study might be the resistance mechanisms used by
sick people against certain health practices imposed by hegemonic sectors of
society.
Added to a large volume of literature (Kuhn, 1991), our study provides evidence that men and women use dissimilar content styles and arguments to establish
causality. According to previous data, gender differences in the origin of diabetes
emerge from particular social circumstances. Males usually argue causality related
to nondomestic economic and social activities; females usually argue causality
related to domestic and familial economic activities. We noted with interest that
lines of causality and elements are relatively similar among men and women who
work in similar circumstances. Our study provides new evidence for authors who
assert there are differences in health and health behavior not only according to gender but also relating to specific phenomena such as a population’s theories of causality in chronic conditions (Emslie, Hunt, & Watt, 2001).
IMPLICATIONS AND LIMITATIONS
Our use of a small and a nonprobabilistic sample means that we cannot generalize
the findings of this qualitative research. Despite this possible limitation, some
themes provide insights that could be important for the promotion, prevention, and
management of a chronic illness such as diabetes.
In accord with a growing body of literature (Hunt et al., 1998; Reiser, 1993), the
material presented here calls for health professionals to move away from an authoritative role and search for a model that incorporates the voice of diverse social
actors, including sick individuals, to reorganize health policies and programs.
Health promotion and preventive activities could be enriched if health providers
were more sensitive to lay theories about the origin and management of diseases
and/or illnesses. Such programs could achieve their goals more efficiently if all
actors participated in the identification of the problem and became actively
involved in the generation of alternatives. Among other things, such alternatives
should consider gender perspectives and those of low-income families, who attribute causality of diabetes to their material, economic, and emotional circumstances.
In countries like Mexico, these suggestions could dramatically change the way most
of the population—that is, the urban poor—can receive health care services.
Using ethnographic strategies, we chose to obtain data through several openended interviews and observation at a site most familiar to the participant—the
Mercado-Martinez, Ramos-Herrera / DIABETES
805
home. Conducting only a single interview, even of an open-ended type, would have
generated data of a different nature and would have failed to allow us to identify
sensitive topics, such as participant rejection of a medical doctor’s causal explanation. Similarly, results would have been limited if data were gathered in health care
facilities. Despite continued care to preserve anonymity with information obtained,
ethnographic approaches in studying topics such as causality theories offer great
advantages because they remain sufficiently broad in scope to permit understanding of experiential evidence, health beliefs, and practices. Such methodology and
topics, usually overlooked, may represent valuable tools for understanding not
only laypeople’s explanations but also the transformation of the health care sector.
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Francisco J. Mercado-Martinez, M.D, Ph.D., is a researcher at the Public Health Department, University of Guadalajara Health Sciences Center, Mexico.
Igor Martin Ramos-Herrera, M.D., M.Sc., is a researcher at the Public Health Department, University of Guadalajara Health Sciences Center, Mexico.