Older people in the field of medication
Address for correspondence: Kirsi Lumme-Sandt, School of Public Health, University of Tampere, FIN-33014 Finland e-mail: kirsi.lumme-sandt@uta.ﬁ
This paper focuses on how older people construct themselves as users of medical drugs, and on what factors are important in medication from the user’s point of view. The data of the study consist of focus group discussions about medication with people aged over 65 years. The analysis was based upon Pierre Bourdieu’s concepts of social ﬁeld and habitus. The main actors appearing in the discussions were users and doctors. Pharmacists had only a marginal role as suppliers of medical drugs. It was clearly important for the participants to express their appreciation towards doctors, the dominant actors in the ﬁeld of medication. The most important theme in the discussions, however, was the independence of the users themselves. By assuming responsibility for the use of their medication and by applying their own initiative, these older people were able to gain a meaningful position in the ﬁeld of medication. The habitus of a patient in the health care setting is a compliant patient. The habitus outside health care, on the other hand, requires that people are active and reasonable users. In individual practices it is possible to detect logics of both sides of habitus.
Older people use a great many medical drugs; this is a well-known fact. We also know from statistics that older people consume more drugs, in proportion to their number, compared with other sections of the population (see e.g.Cartwright 1990, Hunter et al. 1996, Finnish Statistics on Medicines 2000). The lay interpretation of this is that older people tend to use more drugs than is good for them. On the other hand, there are also large numbers of older people who do not use all the medication they are prescribed (Monane et al. 1996, Hunter et al. 1996). For many older people themselves, the ‘fact’ is that proper medication is crucially important to their wellbeing.
The medication of older people consists in large part of prescription drugs, for which doctors provide detailed instructions on usage. The assumption is that when drugs are prescribed for a medically deﬁned problem, they are used according to the instructions. If the patient fails to comply with doctor’s orders, that is constructed as a problem for medicine (Trostle 1988, Lerner 1997). Much research has been inspired by the worry that patients are not using their medication as advised. Age is often considered a risk factor for poor compliance, and older people in particular have been seen as at risk of difﬁculties in managing their medication (see Owens et al. 1991, Claesson et al. 1999).
The relationship between lay people and medical experts has been changing in recent decades; it is nowadays sometimes described as a meeting between experts (see Tuckett et al. 1985). In the context of everyday health care medical expertise is seldom questioned where indications for treatment or surgical techniques are concerned. On the other hand, the patient’s own decision-making and activity are required in matters of prevention, health promotion and rehabilitation; for instance, in non-pharmacological interventions in diabetes, hypertension, or musculoskeletal complaints. Medication is considered to be an area where people can exercise some autonomy. If, however, they go too far, their behaviour will easily be regarded as a product of ignorance and irrationality (see Lerner 1997). Yet users do not perceive taking drugs simply in terms of obeying doctor’s orders. Most drugs are used in everyday contexts where the decision on whether or not to take a drug is not made purely on medical grounds (Donovan and Blake 1992, Williams and Popay 1994). People tend to be quite suspicious about drugs (Fallsberg 1991, Lumme-Sandt et al. 2000), yet they value doctors very highly (Pound et al. 1998) – even though these are the very same doctors who prescribe those ‘suspicious’ drugs. This article tries to make sense of this paradox by using the concepts of social ﬁeld and habitus as introduced by Pierre Bourdieu.
There are more and more old people today who are living independently in the community and taking care of their own medication, both prescription and over-the-counter (OTC) drugs. In this study we are interested in how these older people talk about themselves as users of medical drugs and about the reasons for their use of medication. What is important in medication from the user’s point of view? What kind of image of themselves do older people construct as users of medical drugs in everyday life? What do lay people think about drugs, what kind of experiences of drug use do people have?
The data for our study are drawn from focus group discussions about medication. The decision to use the focus group method for data collection was based on its dynamics and on its relevance to the everyday form of communication in which dominant cultures are constructed. The focus group discussions were used to identify group norms about medication among older people, and to uncover their own rationale. The aim was not to reveal accurate facts about medication, but rather to view the interviewees as informants on their reference group (Kitzinger 1994, 1995, Kitzinger and Barbour 1999).
Five focus group discussions were conducted in Spring 2000 with 34 participants aged from 65 to 85 and living in an urban area in southern Finland. Most were women (n = 30), but two groups included a few men (n = 4). Three of the ﬁve groups were recruited from senior citizens’ hobby groups. The lay leaders of these groups were asked to recruit ﬁve to six volunteers from their group. The inclusion criteria covered age (65–85), community-dwelling, no former health care professionals and no hearing problems. These criteria were met except that each group came to include seven to nine people. At this stage no questions were asked about the extent of drugs use. The discussions with these groups took place at the places where the hobby groups normally met.
The two other groups were recruited by a local GP from amongst her patients. One group consisted of people who were receiving medication for hypertension, but who had no other regular prescription drugs. The other group consisted of people taking at least three regular prescription drugs. Otherwise the informants in these groups met the same criteria as those in the three other groups. The people in these groups had never met one another before. The discussions took place in the local health centre’s meeting room.
A brief questionnaire was used after the discussions to gather information about the participants’ age, former occupation, regularly and irregularly used drugs. All the participants were native Finns and were retired from working class occupations; in this respect the groups were culturally homogenous. There was only one person who took no prescription drug. Eleven people reported no OTC drugs. The number of drugs used daily ranged from zero to eight. The groups did not differ very much from one another in terms of the topics covered or in the amount of talk.
In each discussion there were two facilitators, the ﬁrst author and another researcher, both medical sociologists. They were introduced to the participants simply as researchers from the School of Public Health. The participants were told that the study was part of a research project on older people’s use of medication. The researchers were not asked any further questions concerning the study. All discussions were tape-recorded with the participants’ informed consent and later transcribed by the ﬁrst author. The discussions lasted 55–70 minutes. The topics covered were the availability and prices of drugs, what drug was used and when, older people as users of drugs, experiences and information about drugs.
The discussions were conducted in a relaxed atmosphere with minimal intervention from the facilitators, who sought instead to encourage free-ﬂowing interaction. The facilitator (ﬁrst author) did launch new themes to keep the ﬂow of the discussion moving, but whenever possible priority was given to the participants. The facilitators did not take an entirely passive role, but nor did they impose their own views and opinions. Instead, they tried to maximise interaction, drawing the more passive participants into the discussion, and encouraging them to elaborate upon topics and to challenge taken-for-granted opinions (see Kitzinger 1994).
The image of medication was constructed in the groups, of which the facilitators were also members. In the analysis, special attention was paid to the question of what kind of accounts met with a positive response from other participants, and what kind of accounts were ignored. The participants were seen as active constructors of meanings. As Holstein and Gubrium (1995: 8) have put it, ‘the subject behind the respondent not only holds facts and details of experience but, in the very process of offering them up for response, constructively adds to, takes away from, and transforms the facts and details’.
Social ﬁeld and habitus
Pierre Bourdieu’s (1984) theoretical ideas have been widely applied in many different ﬁelds of study, but less frequently in medical sociology (see Virtanen et al. 2000, Williams 1995). It has, however, been said that Bourdieu’s thoughts can be applied to any social object to analyse forms of social practice (Marlière 1998).
Bourdieu advocates the primacy of relations over individuals. A ﬁeld, according to Bourdieu, consists of a set of objective, historical relations between positions. A ﬁeld is a dynamic social space. It is simultaneously a space of conﬂict and competition, where to alter the distribution and relative weight of forms of capital is tantamount to modifying the structure of the ﬁeld. Its occupants constantly negotiate forms of authority. A ﬁeld is a space of play, which exists as such only to the extent that the players (agents) who enter into it believe in it and actively pursue the prizes it offers. The most important stake in social ﬁelds is the establishment of proper or legitimate forms of social authority (Wacquant 1992).
The resources applied in the struggles taking place in a ﬁeld are deﬁned as four types of capital: economic, cultural, social and symbolic. Economic capital corresponds to material wealth and power, cultural capital consists of social knowledge, education and cultural goods, social capital refers to social networks and group membership, and symbolic capital is the form assumed by all types of capital when their possession is perceived as legitimate (Bourdieu 1984). Each ﬁeld follows its own speciﬁc logic, and the hierarchy of the different types of capital varies across the various ﬁelds. Belonging to a ﬁeld means by deﬁnition that one is capable of producing effects on it. Positions are deﬁned in relation to the distribution of various forms of capital (Bourdieu and Wacquant 1992).
In our study medication is seen and approached as an activity which takes place in a kind of social ﬁeld, and an individual’s drug-using practices are seen to reﬂect their collective habitus, or culturally conditioned system of dispositions and distinctions, moral principles and perceptions of propriety.
Rooted in the ﬁeld considered, habitus is a set of practices shared by a group of individuals acting in the ﬁeld. Habitus is integrated with their way of living, they ‘know without knowing’ the rules structured in it, and it gives them guidelines as to what is relevant behaviour in everyday situations. Although medical drugs are objective substances and instrumental industrial products, they are not independent of the interests of those who perceive them. The habitus which is created among a certain class of people acting in the ﬁeld of medication generates a strategy for them by which they can deal with drugs in a way that takes into account their interests without explicating – and even ‘without knowing’– these interests. It is the task of sociological analysis to reveal the logics and habitus behind the everyday reality of drug taking practices.
The data of this study were gathered from one party in the ﬁeld of medication, i.e. the patients or users of medication. Physicians prescribing the drugs and the pharmaceutical industry and pharmacists delivering them only appear in the talk of the lay persons participating in the focus groups. This means that no description, of the whole ﬁeld or its relation to the ﬁeld of power, is provided, although this is how Bourdieu recommends that the ﬁeld should be studied (see Bourdieu and Wacquant 1992). The analysis is also restricted to the data, and the main concern of this article is with how elderly people experience the ﬁeld and themselves as users of medication.
Field of medication and habitus of medicine users
In the light of the discussions there appear to be three agents in the ﬁeld of medication: users, doctors and pharmacists. The agents with the most capital of each type are doctors: they are gatekeepers for prescription drugs and they also have considerable inﬂuence over OTC drugs. Their capital is based on legislation and education. They also have the strongest public voice and enjoy the greatest social esteem. A recent survey in the leading political magazine in Finland shows that medical doctors are the most highly esteemed profession in Finland (Lappalainen 2001).
Pharmacists are also experts in the ﬁeld of medication. In Finland, the sale of medical drugs (both prescription and OTC drugs) is restricted to pharmacies where staff have a university-level pharmaceutical education. Traditionally, a large part of all medication has been sold on prescription, but during the past decade or so many prescription drugs have been released for OTC status. At the same time, pharmacies have changed from drug distribution centres to shops with an active orientation to marketing. This has been seen as increasing consumers’ freedom of choice with respect to selecting their medication. Self-care is the catchword of consumerist health culture, and self-medication is the most visible aspect of self-care. Pharmacies have also recently been trying to raise their proﬁle, with pharmacy personnel no longer appearing simply as suppliers of medicines but increasingly as part of a primary health care team, aiming to support people in their self-care efforts (Sihvo 2000).
Users, doctors and pharmacists, however, are not the only agents in the ﬁeld. The pharmaceutical industry, for instance, is a major player, with considerable economic capital. The industry itself was not mentioned at all in the discussions, and its advertisements were only mentioned in a few short remarks. Since the main concern in this study is with users, any other possible agents have been deliberately ignored if they did not appear in the participants’ talk.
The ﬁeld of medication would not exist without medication users. Lacking signiﬁcant capital assets, however, their voice has remained relatively weak. Traditionally, they have been seen as passive objects who are expected to take the medication prescribed by doctors and delivered by pharmacies. It is only during the past few decades and with the growth of consumerist health culture that users have become increasingly recognised as active, independent agents. However, lacking inﬂuence and ofﬁcial channels through which to play a role in the ﬁeld, older drug users, especially, do not usually provoke major conﬂicts in the ﬁeld of medication. The means they use are more discreet and indirect and therefore more difﬁcult to pinpoint.
Although the focus in this study is on users and on how they see the ﬁeld, the purpose has not only been to uncover subjective meanings, but also to reveal cultural interpretative resources and practices that people use to make themselves understood. The idea was to let the participants construct the image of a good user of medication in order to characterise the habitus of an elderly Finnish user. Interview accounts are seen not only as factual reports but also as a means by which people can articulate their own position in the world (Radley and Billig 1996), providing an insight into how and why people present their accounts in the way they do (Silverman 1993). The habitus and position in the ﬁeld is taken up in a process of negotiation with others, using linguistic resources. Accordingly, the focus of the analysis is on the discourses used in the discussions.
Construction of the competent user in group discussions
The focus groups began with the facilitator (ﬁrst author) asking the participants what they thought about the Finnish pharmacy system. It is quite strictly regulated: the sale of medical drugs is restricted to licensed pharmacies and compensation is only available for purchases of prescribed drugs. Reference was made in the discussion to Spain and Estonia (both popular travel destinations among elderly people in Finland) where systems are far less regulated than in Finland, and where certain prescription drugs are available over the counter – and at a lower cost – than at home.
Although the participants were given every opportunity to criticise the present system, everyone seemed to agree that there was no need to do so: ‘I certainly think that it’s the safest way to use drugs that have been prescribed by the doctor’ (woman, group 2). Most participants had personal experience of buying drugs abroad, yet they were adamant that the Finnish system was the best of all. The doctor’s expertise on matters concerning drugs was not to be disputed: ‘You’d really need to be such an expert that you wouldn’t need a doctor in the ﬁrst place’ (woman, group 5).
It was widely stressed among the participants that they didn’t know enough about medication; they were also somewhat dubious about pharmacy personnel. As far as users were concerned the pharmacist’s status in the system was quite marginal, conﬁned to the provision of drugs:
Well it would certainly put these chemists under a great burden of responsibility. I’m sure they’d need more training so that they could cope. I mean the doctors they have a very long training, so I mean it must be like, at least for these more difﬁcult things, like heart disease (woman, group 4).
It was also pointed out that the system effectively prevents misuse:
Well of course the people at the pharmacy they give you advice, but at least I myself wouldn’t like to see them being sold freely. You may get people using too much medicine or anything (woman, group 3).
Doctors carry greater authority than pharmacists, and advice from pharmacy staff does not have the same status as advice by medical doctors. In this study, reference to the economic or business aspect of the ﬁeld was made only in passing, and always from the user’s point of view: prices were high and compensation was not available for OTC drugs. Proper drugs were deﬁned as medicine that had been clinically tested and that was state funded under the social security system. A pill was seen as a proper drug, whereas ointments were regarded as less effective and therefore less harmful. So sweeping was the consensus of opinion on the superiority of the present system that there was very little discussion on the subject at all. None of the participants questioned the signiﬁcance of biomedical drugs as such.
As the discussion about the pharmacy system soon dried up in all groups, the facilitator moved on to ask how the participants dealt with minor ailments such as ﬂu and common colds: the purpose here was to ﬁnd out whether the preference was for OTC drugs or prescription drugs. It turned out that prescription drugs were used for minor ailments only occasionally (e.g. people with bad allergies). However, it later became clear that the distinction between different types of drugs was of no consequence to the participants in this context. Even though the question speciﬁcally concerned minor ailments, in the responses, headaches and coughs were all mixed up with heart trouble and other serious conditions. In any case all groups went on to assert that they did not need very much medication in the ﬁrst place: ‘All my life I’ve hardly had any, no more than a dozen or so aspirins when I was younger, perhaps sometimes, but nothing now really’ (woman, group 2). And if they did use medication, they saw themselves as nonetheless being in good health:
I mean I don’t, I have to touch wood here, I never fall ill, I’m like at the end of the line as I just listen to everyone else here is using everything. Except of course what the doctor’s, this defective thyroid function, so these pills and then for the pain I have with rheumatism, but that’s all I take. I’m really the old-fashioned hardened type (woman, group 2).
It was very common to try and avoid medication as far as possible: ‘Very little indeed, only when I have to. You shouldn’t take drugs like sweets’ (man, group 4). The participants expressed the cultural norm that is common among older people to avoid medication for as long as possible (Cartwright and Smith 1988, Williams 1990, Lumme-Sandt et al. 2000). ‘No matter how you think it would help to take them, when the pain starts you try to keep going for as long as possible without them’ (woman, group 5). A phrase often repeated was: ‘best way to get rid of a cough is to cough, to get over ﬂu is to blow your nose’ (women, groups 1, 3, 4).
People with chronic illness have a difﬁcult task to strike a balance between being active and inactive (Radley and Billig 1996). In this early phase of the discussions it seemed to be important for the participants to construct an image of their being healthy, capable persons who used very little medical drugs in spite of possible chronic illness. In most cases, prescription drugs were indispensable to maintaining good health, so the accent had to be on the minimal use of OTC drugs. Prescription drugs did not play a role in constructing the image of minimal use: ‘I use very few drugs, I do have this thyroid function problem and have medication for that condition and then high blood pressure. And they’re on prescription’ (woman, group 1). OTC drugs were used as a means of constructing one’s image as a medication user because this was an area in which people could exercise their freedom of choice. There is of course a difference between drugs that help to keep one’s condition stable and those that alleviate a speciﬁc symptom. This, however, was not the issue here. The eagerness shown by the participants to emphasise their minimal drug use at the beginning of the discussions was an indication of something more: something that we would interpret as reﬂecting the habitus of a competent user of medication.
Another means in the construction of oneself as a noteworthy agent in the ﬁeld and as a person who can cope with one’s own medication was to make comparisons with other older people: ‘There are many older people who use a bit too much because they’ve also got their prescription drugs there on top of everything else. That’s my opinion at least’ (woman, group 1). One type of ‘other’ older person in these accounts was one who used too many drugs and who was not in proper control of her/his medication. These people were seen as not being responsible for their medication and therefore no longer reasonable agents in the ﬁeld. A second type of ‘other’ older person was one who was a heavy user of alternative medication, which was not considered part of the ﬁeld of medication at all. Alternative medicines were not mentioned in the questionnaires by the participants. When they were mentioned in discussions, in most cases a few words of caution were in order:
There are pensioners who use an awful lot of all sorts of natural products, I know people who have huge piles of them on their kitchen table, separate little bottles they take them from. I mean they use lots and lots (woman, group 2).
Making the distinction was crucially important. Many of the participants said they were annoyed if others regarded them as incapable of looking after their own medication:
At least I have the same thing, that like sometimes I get really angry when they explain this over and over again as if you wouldn’t remember it. Ordinary people do notice it. I mean obviously older people, when their memory begins to fail them, with all this explaining going on and everything (woman, group 1).
Comparisons were also made with younger people: ‘Yes well the older generation they did have more patience and they put up with pain better, now it’s nothing’ (woman, group 5). Making this distinction was one way of constructing the interviewees as morally responsible users of medication. When people are giving accounts about health-related matters, they are also making claims about themselves as worthy individuals (Radley and Billig 1996, Baruch 1981). In principle, every aspect of health is fundamentally a moral issue; for instance, use in the health services (Neal et al. 2000) and sickness absences (Lumme-Sandt 1995, Virtanen 2000). One’s own practices are commonly legitimated by using examples of individuals or groups with suspicious practices.
The further the discussion proceeded in the focus groups, the more the users applied their social and symbolic capital to deﬁne their own space in the ﬁeld of medication. One key element in the process of constructing themselves as meaningful actors was the telling of stories. Accounts were deﬁned as stories when they contained some sort of prologue, action and evaluation. Stories are useful devices of communication because they allow the individual to hide any potentially controversial opinions within the story itself. In telling stories, people give explanations and assign meanings to them. Stories also serve as a means of keeping a distance from controversial issues and of presenting conﬂicts in indirect terms. They are a way of transmitting a message without making any explicit claims or arguments, and it is difﬁcult to argue against stories. Culturally valued activities are highlighted for oneself and for others by narratives, and the events of the stories are presumed to have signiﬁcance in the lives of those who tell and hear the story (Gergen 1988). According to Linde (1993), an individual needs to feel a sense of being a good, socially proper and stable person. ‘We use life stories to claim or negotiate group membership and to demonstrate that we are in fact worthy members of those groups, understanding and properly following their moral standards’ (Linde 1993: 3). Although Linde is writing about life stories, her arguments could also be applied to the stories in these discussions.
As long as the discussion remained in the realm of deﬁning the ﬁeld and constructing images of competent users, there were no stories at all. During the ﬁrst 20 minutes of the discussions there were no more than two stories, neither of which concerned medication. However, later on in the discussion the frequency of stories began to increase. Some themes inspired more stories than others; most typically, they concerned information and experience of medical drugs. In telling stories about medication, people were negotiating group membership (i.e. a position in the ﬁeld) and demonstrating that they were following the ﬁeld’s moral standards. Issues that were important to the participants were told and strengthened in stories. Since cultural concepts of medication among the participants seem to be crystallised in their stories, they are used as a key source in analysing older people’s action in the ﬁeld of medication. A total of 44 stories were identiﬁed in the ﬁve interviews. Half of the participants told stories. Most of the stories were received approvingly by nodding and other encouraging remarks. Those who did not tell stories gave accounts similar to stories.
Action in the ﬁeld of medication
How did the users act in the ﬁeld of medication? What was important to them? The theme of a competent and morally acceptable user was a feature of all the discussions, but towards the end the participants talked more about their own activity and expressed controversial views about medication.
Although it was agreed at the beginning of the discussions that it was good that the ﬁeld of medication was dominated by medical doctors, the most common theme in the stories was people’s own activity. The idea of the sick role did not emerge in these stories. Instead, the importance of the issue of patients’ control over their lives (see Conrad 1985, Dolinsky 1989, Williams 1993, Fogarty 1997) was important even when they were sick.
There were three different kinds of stories concerning independent activity. In the ﬁrst category, the accent was on attentiveness; in the second, the story-teller was concerned with her/his own decision-making regarding med-ication; and in the third, the emphasis was on people’s own responsibility.
Well, then I got asthma / a year ago. I was given two pipes because I was choking. That cleared my lungs and the next time the doctor gave me some sort of cortisone pills and / I came home and started to read the label. And there it was, people with glaucoma, you shouldn’t use the drug. It causes the pressure to increase. I didn’t even open it. I called the doctor straightaway, I said, listen, I’m not going to take these pills. She said that of course she should have known, but it’s impossible to think of everything. I said: I’m not accusing you, but it’s good that at least someone read the label. And she said, don’t take it. And I didn’t (woman, group 5)1.
In this story the point made by the narrator is that you should never just accept the medication you are given but always read the label ﬁrst, even if you know your doctor well and are pleased with her. The idea that you can only blame yourself if you don’t read the instructions was repeated several times in the interviews. No real horror stories about the participants’ own use of medication emerged, because their own activity had prevented them from happening. Even though it is the doctor who prescribes the drugs, the responsibility lies ultimately with the user. In this case the narrator did not want explicitly to blame the doctor for what was a clear case of prescribing the wrong medication. This was very typical of the interviewees. Any apportioning of blame was done in the most sensitive manner. Assuming responsibility for their own actions was one of the ways in which the users claimed more space in the ﬁeld of medication. It is quite a delicate task to try to be active and at the same time not to challenge the doctor’s authority.
There was this case, when I was in the university hospital, because diabetes has given me a lot of trouble. I was given something called T . . . (a drug). I read it on the slip of paper, on the prescription the doctor gave me. I said, dear me, this is a psychopharmaceutical drug. I’m not going to take these. My husband takes these, so I was positive this was a psychopharmaceutical drug. It’s something that can be used for my condition as well. But I’ve never taken it. I thought that I wouldn’t take it. I’m not that ill yet that I would take mental health drugs (woman, group 3).
Although this narrator had many illnesses, her story emphasised that in spite of her physical ailments she was still capable of making her own decisions. Her mind was perfectly clear and she wanted to keep it that way and maintain her ability to act independently. The decision-making of the narrator was based on the knowledge she had gathered as a result of her husband’s condition. The number of illnesses they have and the number of drugs they take are not central to the process in which people construct their image as users of medication. The key thing is maintaining one’s independence. The interviewees were also sometimes prepared to assume full responsibility for their decisions:
It was when I had the menopause, I was just over 50, they gave me oestrogen. I think I kept taking it for a couple of years, I didn’t have any symptoms, I don’t know whether that was because I was taking these pills. But then when I went to see my gynaecologist and she took these tests and what-have-you and she recommended that I started on oestrogen then. And so I started again, but it didn’t, it made me feel so bloated that I just gave it up.
Facilitator: You made that decision yourself?
Yes all by myself, that I’m not, there was this disc with this daily2, I thought no I’m not going to eat these, if I die sooner so what. I can just as well go now (woman, group 2).
Some of the stories unfolded sequentially from earlier ones:
Ann: So I mean it’s you and no one else who’s responsible for your medication. I remember it was in ’79 I had this facial paralysis and spent two weeks in hospital. I took my own medication along, I was taking these hypertension drugs by then. I took my own medication and took care of it. The nurses and the doctors were saying how good it was that I knew when to take my medication and that I had my own medication with me. And that was it, I didn’t use any of the hospital drugs. I felt much safer taking care of myself.
Mark: Yes, it’s much safer.
Ann: Yes, it is.
Mark: When I was in hospital there was this case where the drugs of two patients were accidentally changed. The other one had had a coronary bypass and the other one had some mental problems and something else. And then the drugs had been switched.
Mark: Even the doctors were amazed, what’s going on here, why isn’t he getting better (woman and man, group 3).
In this account Ann told a story about her own exemplary action and Mark provided veriﬁcation in the form of an example that serves as a warning. Hospitals have traditionally been places where people are more passive than in outpatient settings. But even there, you cannot let your control slip.
Any criticisms concerning medication which were levelled at doctors during the discussions were quite moderate. One might well ask whether this was due to the context of the focus groups (i.e. a study conducted by the School of Public Health) or whether the participants really were satisﬁed with their medical encounters. One possible interpretation is that this was a way of showing one’s acceptance of the rules prevailing in the ﬁeld of medication. It was understood that there could be problems with medication. The explicit criticisms that were made against doctors concerned rude and indifferent behaviour. The key factor seemed to be the interaction between doctor and patient. If patients felt that the doctor took a problem seriously, they were prepared to understand that their medication could also have certain side effects.
My brother-in-law’s wife, she saw this GP regularly, and she had medication for hypertension, they kept re-prescribing them and then eventually one day when she didn’t wake up and her husband took her to the local hospital and from there straight to the university hospital. She was unconscious for a day or two, she was examined and they found that her medication was all wrong. They discontinued her hypertension drugs. She didn’t need them at all. The drugs had caused her calcium levels or something to drop. Well she was unconscious for days and all because of having the wrong medication (woman, group 1).
Stories were a central means in the criticism of doctors. Accounts of bad experiences only appeared in stories, and even there any open criticism was rare. In this story it was not the doctor who was blamed for having prescribed the wrong medication; somewhat more circuitously, the wrong medication was blamed for the problems that had occurred.
By these examples, these older people established a solid position for users in the ﬁeld of medication, without challenging the authority of doctors. More important than criticising doctors was to emphasise the patient’s own activity. By assuming responsibility for the use of their medication and by applying their own initiative, they were able to gain a meaningful position in the ﬁeld of medication.
Not too much
As far as the participants were concerned, medication was very much their own business. Even spouses were told simply to take care of their own medication. ‘My husband died two years ago, but he took care of his own medication. I didn’t touch them at all. He just said never you mind, he’ll sort them out’ (woman, group 3). The spouse would only take over in cases where the husband or wife could no longer cope: ‘Well his memory’s gone to such an extent now that that’s why I have to do it [look after his medication]’ (woman, group 2). However, although medication is technically seen as the individual’s own business, it is not so in a moral sense.
My uncle’s widow, she took other drugs as well, she was always taking everything, if someone said it was good for this or that, she just went out and bought it. She then began to have stomach pain and went to see a doctor, took along her bag of drugs and prescriptions. The doctor sorted them out for her, these and these will have to go in the bin, and the whole bagful. And these are the ones you will need to take. That was the end of her stomach pain (woman, group 2).
Using medication is a moral issue in the sense that anyone who uses a lot of medication will be at risk of being labelled an immoral and irresponsible person. The stories here served as a way of providing warning examples. Excessive use was an indication that the individual was unable to cope with her own medication and therefore to act properly in the ﬁeld of medication. It is quite understandable that people want to convey an image of themselves as reasonable users of medication. One possible explanation is that the position of users in the ﬁeld of medication is so weak that it may be further weakened by the deviant practices of other people and be a threat to other’s position as well. On the other hand, the disapproval of other’s behaviour is one way of emphasising one’s own exemplary action.
Compliance is a concept constructed by medicine. According to Trostle (1988) talk about poor compliance is one way doctors keep their patients in a subordinate position in the ﬁeld of medication. This study shows that it is important for lay people to feel they are independent, signiﬁcant agents. However, in this data set there were three people, all with a number of chronic diseases, who presented themselves as compliant persons: virtually all their statements in the discussions expressed some kind of compliance. In a sense they can be seen as representing deviant cases in the data. While most discussions in the interviews were conducted in a spirit of mutual understanding and agreement and approval of statements was expressed by nodding, statements of compliance were received in a different manner.
Eva: I said to the doctor couldn’t we cut back on them a bit, there’ve been no ﬁts or anything. So the doctor says absolutely not. You have to have these for the rest of your life. They’re these medicines to thin the blood and that’s what they’re prescribed for, I once had this small clot pass through the brain. So it’s better to take these drugs than to have these attacks. So I’ve been sticking to doctor’s orders and been taking them.
Mary: Yes well they do say that doctors nowadays often tend to prescribe too many drugs (women, group 2).
This is an example of a typical response to a statement of compliance: it was quite simply ignored by other interviewees, who moved on to talk about a different subject. This group setting was crucial to making this discovery, which would hardly have been possible in individual interviews. It could also be compared to Radley and Billig’s (1996) notion that if people accept the sick role too readily they run the risk of being deﬁned by others as weak, and their views will not be accepted as readily. Lack of encouragement did not, however, silence the ‘compliant’ narrators; they continued to describe how they were doing what their doctors had told them to do throughout the discussions. Compliance was clearly a matter of personal pride to them. They tried to construct their social competence by emphasising their compliant behaviour, but failed to do so in this context. It seems that although compliance, for some people, is an important part of life-control, for the majority, making their own decisions appears to be an important value of life in itself.
The role of users in the ﬁeld of medication is often overlooked and ignored, and users themselves tend to be perceived as objects rather than subjects. Applying Bourdieu’s (1984) concepts, such as habitus and social ﬁeld, this study aims to show how users of medical drugs act, and how they themselves see their position. It is important to note that this is by no means a comprehensive analysis of the ﬁeld of medication, for it concentrates exclusively on lay people, trying to open up a new angle on their practices as users of medical drugs.
The focus group discussions started with the participants outlining the ﬁeld of medication. Regardless of the questions asked, the participants were keen to demonstrate that they were familiar with the rules of the ﬁeld and that they accepted them without question. An important thing in the discussions was to express one’s appreciation towards doctors, the dominant actors in the ﬁeld. The signiﬁcance of doctors and biomedical drugs was not explicitly challenged at any point in the discussions. As far as these Finnish older people were concerned, there were only two main agents in the ﬁeld of medication: users and doctors. Although the participants stressed the importance of their own position as drugs users, the doctors played a key role in their talk. It is possible to ﬁnd accounts of compliant behaviour and morally acceptable users of medication in individual interviews as well (Lumme-Sandt et al. 2000). In the group settings the accounts which legitimate a meaningful and active position for users turned out to be stronger, since encouraging comments from other participants in the group made these accounts more convincing.
As it turned out, pharmacists have quite a marginal role in the ﬁeld, attracting very little respect on the part of users. It was clear they had not as yet appreciated the new role of pharmacies. Overall, as far as users are concerned, the pharmacy has no authority in the ﬁeld of medication. During the discussions no reference was made to any other possible agents in the ﬁeld, e.g. the pharmaceutical industry or advertisements.
In his study of the welfare ﬁeld Peillon (1998) observed that although welfare clients cannot mobilise resources to act effectively, and lack of capital transforms them into objects of welfare agencies, this does not necessarily mean that they comply with the procedures set up by professionals. Clients may turn to a range of strategies in dealing with these agencies. In this study the participants constructed themselves as competent agents in the ﬁeld of medication by emphasising their own control over drugs and health, in spite of the high respect they showed for doctors. Following the initial stages of the discussions, the accent shifted to the user’s own activity; this was the dominant theme of the discussions. They had various kinds of stories about their activity with respect to medication. Although older people from a working class background do not have much cultural capital in the form of education and formal knowledge, they do have a great deal of experience and they know themselves and their medication. This gives them capital resources on the strength of which they can challenge the authority of doctors and present themselves as competent and independent actors in the ﬁeld. The safest way to express user activity was to tell stories: the medical profession could not be explicitly attacked and criticised because that carried the risk of challenging the basic rules of the whole ﬁeld, which in turn would have had disastrous consequences for lay people themselves. The users saw themselves as responsible for their medication: it was they who made the ﬁnal decision about drugs in the context of their lives, regardless of what the doctors had told them to do. The use of medication is an integral part of life control. In this data set it also seemed that for many older people, it is important to have a sense of being in control of all aspects of one’s life.
Cornwell (1984) makes a distinction between public and private accounts. Public accounts are sets of meaning in common social currency that reproduce and legitimate the assumptions people take for granted. Private accounts, on the other hand, are often structured as a personal story and are normally supposed to be shared by the speaker’s own group. According to Cornwell, public accounts are replete with commonsense legitimations which render the speaker morally acceptable to others. Our study has shown that there are also two sides to taking medicine in a moral way. Through its dominant position, medicine has constructed an image of a compliant patient that is legitimated and valued by both health care professionals and lay people. However, among lay people this image does not yet sufﬁce to make them morally acceptable. There are also private accounts which, although they spring directly from personal experience, are recounted in stories and are used to legitimate oneself among other lay people and give them also a legitimated position in the ﬁeld of medication. In this sense, we could agree with Radley and Billig that ‘there is always the possibility that private stories can be used to legitimate the speaker, while public statements are more like the rehearsal of widely shared, taken-for-granted beliefs, in terms of which the speaker feels relatively secure’ (1996: 232).
The accounts that construct a reasonable person with little medication are not just private. Therefore, because they are more than private, Bourdieu’s (1984) concept of habitus could be applied to this. Cockerham and Rutten say ‘habitus provides a cognitive map of an individual’s social world and the dispositions or ‘procedures to follow’ appropriate for that person in a particular situation’ (1997: 327). And since a habitus can vary to ﬁt the situations, the habitus of a patient in the health care setting is a compliant patient. The habitus outside health care, on the other hand, requires that people are active and reasonable users. In individual practices it is possible to detect logics of both sides of habitus.
The paradox of medication among older lay people is that while they value doctors very highly, they are at the same time suspicious about drugs. Their respect for doctors is based on the dominant position of the medical profession in the ﬁeld of medication and in the ﬁeld of medicine more generally. Doctors are concerned with matters of life and death and are gatekeepers to new effective drugs. They have no serious competition, and their authority is unquestionable. This further strengthens their ownership of different types of capital.
Lay people’s suspicions are based on the fact that drugs are mainly artiﬁcial. In Protestant culture it is more valued to try and cope in life without artiﬁcial substances; in general, one should not try to make life too easy for oneself (Williams 1990). However in the case of disease and functional ability in particular, the problems are so grave that one has to ask for help. Being cautious with one’s medication, as reﬂected in both moral and activity talk, provides a better way of responding to doubts that one resorts too easily to drugs. By relying on their own activity it is possible for people to adjust the balance between valuation and suspicion. In seeking help for diseases, it is quite sensible to have a prescription from a doctor. However, to be attentive and active concerning one’s own medication mitigates excessive valuation, and guarantees controlled suspicion about medical drugs. A suitable amount of both makes for a reasonable user of medication.
1 / = a pause of 1–3 seconds.
2 Disc refers to the circular packaging of these tablets which is divided by daily dosage.