INTRODUCTION

Health and illness can be difficult concepts to define. Personal, cultural and social factors influence a person’s ideas about the nature and meaning of health and illness so that definitions of health and illness vary from person to person. Cultural differences also affect how societies classify what is health and what is illness. Individual and cultural differences affect perceptions of how an illness is caused and treated. A person’s perception of health and illness is socially constructed. For example, a person’s social group may help that person recognise that they have a potential illness, and encourage them to seek health care. Long before there is a perception of illness, however, a person’s family and cultural heritage will, among other things, have had a significant influence on the conduct and experience of various health issues: pregnancy and childbirth, the understanding of the role that food plays in the promotion of health, and the appropriate management of stressful situations¹. What may be classed as an illness in one society may be viewed as quite normal in another society. For instance, until recent times, homosexuality was stigmatised by many people as a mental illness, requiring significant medical intervention². Homosexuality is still considered unlawful in some societies².

In Australian Aboriginal and Torres Strait Island cultures, illness is a manifestation of spiritual, emotional and physical factors. Spiritual connections to the land and ancestors, as well as community relationships, particularly those with elders, have traditionally been central to health issues in Aboriginal and Torres Strait Islander peoples³. A recent qualitative study of health perceptions of an Aboriginal community in Australia confirmed that traditional Aboriginal beliefs regarding the concept of health and well-being still prevail³. The study found that well-being involved an interplay of identity, family and community kinship, culture and spirituality, and land. In 1999, the National Aboriginal Health Strategy defined Aboriginal people’s perception of health in the following way:

It is argued that the fundamental cause of poor health among Aboriginal people is disempowerment, partly due to dispossession from land³. Thus, a multi-faceted approach to improving the health of Aboriginal people is needed that goes beyond treatment of physical symptoms of illness.

Similarly, the Māori people of New Zealand have poorer health compared with other New Zealanders⁵. The process of colonisation and the introduction of Western scientific medicine resulted in a suppression of traditional Māori medicine. The Māori philosophy towards health is based on a holistic approach, which encompasses spiritual, psychological, emotional, cultural, social, environmental, family aspects, and physical health. It has a long history and is characterised by oral transmission of knowledge, diversity of practice, and emphasis on the spiritual dimension of health⁵. For many Māori, the major deficiency in modern health services is taha wairua (spiritual dimension)⁶. Many Māori people are increasingly turning to their own traditional healers for health services, as they are more consistent with the way many Māori people view health and illness than is Western scientific medicine⁵.

Educational differences, as well as class, gender and the structures within society, can influence an individual’s perception of what constitutes illness and healthy behaviours⁷. In addition, personal perceptions can change over time: a child’s definition of illness may alter by the time they reach adolescence, then again as an adult⁸. Health professionals may also have differing views of health and illness, with some regarding the concepts from a dualistic, biomedical perspective only (i.e., the mind and body are separate, with physical diseases located solely in the body)⁹, while others take into account the social determinants of health and illness¹⁰.

Although there are inherent difficulties in defining health and illness, it is important that nurses understand both these concepts because it influences their practice. For example, nurses need to be able to describe health and health problems when deciding if they can effectively manage an issue problem⁸. The practice of nursing is improved when nurses understand that their ideas of illness may differ from those of some of their clients. An appreciation of the reasons for a client’s behaviour when ill allows nurses to appropriately accommodate the behaviour when implementing care⁸. A holistic understanding will better assist clients and their families in achieving optimal health. Enhancing wellness can improve quality of life, especially for those clients living with chronic illnesses or disabilities⁸. Being able to define illness also helps nurses to define our scope of practice and describe it to others⁸. Contemporary nursing practice involves provision of complex, holistic care in an environment where there is access to highly technological equipment and services. Consequently, it is important for the profession to develop and articulate its own perception of the meaning of health and illness^11,12.

This chapter, therefore, will also review concepts that are central to the meaning of health and illness:

WHAT IS HEALTH?

A number of concepts of health co-exist within current Western society and inform quite different approaches in the provision of health care. Early theories about health and illness proposed that the mind and body were connected. However, Descartes challenged this theory with the notion of dualism, where health was thought to exist only in the absence of disease, or where there has been medical cure of illness¹³. This medical model of health has existed for some time, but as this perspective does not begin to address the health inequities that exist throughout the world, the World Health Organization has advocated a holistic, social model of health as an alternative¹⁴. This model defines health as a multidimensional concept that is individually and socially constructed by the connection that exists between people’s health choices, their ‘social world’ and the environment¹⁵. It is described as a fundamental human right that can only exist ‘for all’ in a socially just society. Health is not only the absence of disease but rather is

With reference to these definitions of health, consider the following examples from Wass¹⁵ and think through who, in the following list, could be regarded as healthy. Would it be a person who

Nurses who view health from a holistic perspective are more likely to work with clients in a collaborative way, encouraging active participation in decision-making about how best to promote their client’s health. This is a care rather than cure focus that also necessitates the inclusion of a client’s social and family network^14,17.

WHAT IS ILLNESS?

Put simply, illness may be defined as a state of bad health or sickness¹⁸ or a condition marked by deviation from the normal healthy state¹⁹. However, one of the limitations of defining an illness as a state identified by measurable deviations from the norm, is that a person with an amputated leg would be an example of someone who deviates from the norm. However, this person may adapt successfully to having a prosthesis, and there-fore not be regarded as ill or disabled. According to Besson²⁰, there are six circumstances in which a person’s health status does not easily fall under the category of ‘healthy’ or ‘ill’:

A more complex definition that considers more than the physical component, is that of illness as a process in which the functioning of a person is diminished or impaired in one or more dimensions (physical, emotional, intellectual, social, developmental, spiritual), when compared with the person’s previous condition²¹. Central to this interpretation of illness is the meaning the person and their significant others give to living and coping with impairment or disablement⁷.

THE DISTINCTION BETWEEN DISEASE AND ILLNESS

Although most people not working in health care would use the terms disease and illness interchangeably, health care professionals distinguish between the two terms. Suchman¹² suggests that disease is the medical condition defined in terms of medical and physiological functioning, while illness is a social response defined in terms of social functioning. According to the wellness-illness model²², disease is an objective process, viewed as a dysfunction or alteration in functioning. It is measured by laboratory tests and direct observation. Illness is the human experience of the disease, affected by intrapersonal (e.g., personality, past experiences), interpersonal (social support, relationships) and extrapersonal (sociocultural and economic) factors²¹.

The distinction between disease and illness is made clearer when one considers that two individuals may have the same disease, but different degrees of illness. Another example demonstrating the difference between the two is that a person may feel ill but there may be no disease identifiable, while another person may have a disease without feeling ill.

Boorse²³ views disease as an illness only if it is serious enough to be incapacitating, with social evaluations attached to it. An illness may be viewed as a subclass of diseases: a reasonably serious disease with incapacitating effects that make it undesirable. A person with a spinal injury may not feel ill, but on a physiological level, he or she has a disease/dysfunction. Another social connotation to illness is that when a disease is called an illness, the person is viewed as deserving special treatment and diminished moral accountability²³. In terms of a nursing definition of illness, Wu²⁴ suggests that illness is best described as ‘an event or happening that offers content for scientific observation and study, i.e., an experience that evokes a certain class of behaviours’ (p. 6).

Mental illnesses also highlight the individual differences in definitions of illness. Weitz²⁵ contrasts the medical and sociological models of mental illness, suggesting that in the former, mental illness is a psychological, biological condition that requires medical treatment, while in the latter, the illness is thought to be socially as well as psychologically or biologically determined and thus may or may not respond to medical treatment. Like nurses and other health care professionals, lay people attribute their own meanings to mental illness. For example, one person may view depression as having a physical basis, while someone else may see it as a character weakness.

In summary, illness is not synonymous with disease. Disease may be classed as a physical response, while illness is a subjective experience; only the person can tell you whether or not he or she feels ill. Illness may or may not be detectable in terms of a pathological process. Disease, on the other hand, is a pathological process with verifiable, observable signs and symptoms that can change over time as the body struggles to maintain its equilibrium²⁶. Disease has the potential to cause illness.

Nurses working in hospitals tend to focus on illness, which may include disease as well as its effects on functioning and all dimensions of well-being.²¹ It is important that nurses determine how the patient experiences their own health state (i.e., whether they view themselves as ill) when planning care.

BENEFITS OF ILLNESS

Craven and Hirnle²⁷ conceptualise illness as

For some people, a positive aspect of being ill is the increased attention one receives. For others, it can mean a break from usual roles and responsibilities.

A simple exercise to identify the needs being met through illness is to

ACUTE AND CHRONIC ILLNESSES

The incidence (number of cases with onset during a specific time period) and prevalence (total number of cases at any given point in time) of chronic diseases have increased since the beginning of the twentieth century. The reason is that fewer persons are dying from acute diseases. Decreases in deaths due to infectious diseases are due to improved sanitation, vaccines, and antibiotics²⁹. Decreases in deaths are also due to effective treatments for some cancers²⁹. Worldwide, the major causes of ill health and death today are heart disease, stroke, cancers and accidents²⁹.

An acute illness is one caused by a disease that produces symptoms and signs soon after exposure to the cause, that runs a short course, and from which there is usually a full recovery or an abrupt termination in death²⁹. The symptoms usually have a rapid onset, are intense, and often subside after a short time period. Influenza is an example of an acute illness. A chronic illness is one caused by a disease that produces symptoms and signs within a variable time period, that runs a long course, and from which there is only partial recovery. A chronic illness usually persists longer than six months. An example is bronchiectasis. Criteria that may be used to define chronic conditions are: 1) the conditions were first noticed 3 months or more before the date of the interview, or 2) they belong to a group of conditions (including heart disease and diabetes) that are considered chronic, regardless of when they began²⁹ (p. 72).

These criteria are in accordance with the definition of the Commission on Chronic Illness³⁰, which views chronic illness as an impairment that is characterised by one or more of the following. The illness

Chronic physical conditions may be placed into the following categories: 1) selected skin and musculoskeletal conditions, 2) impairments (visual, hearing, speech, paralysis, deformity, or orthopaedic impairment), 3) selected digestive conditions, 4) selected conditions of the genitourinary, nervous, endocrine, metabolic, and blood and blood-forming systems, 5) selected circulatory conditions, and 6) selected respiratory conditions²⁹ (p. 72).

Acute attacks in chronic illness can also occur. An example is asthma, where the person has a chronic condition, but under certain conditions (e.g., viral) an acute asthma attack can be precipitated. The person requires more intensive medical treatment at this time, while at other times they will take preventive medication to reduce the occurrences of acute attacks.

The needs of patients, in terms of treatments and nursing care, and patients’ responses to treatment recommendations, can be very different in a patient with an acute illness compared with a patient with a chronic illness.

DISEASE CATEGORIES

Diseases can be caused by disruptions to the body’s structure or function. Some diseases have no known cause, and are called idiopathic. Diseases can be caused by

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