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This section of the chapter will consider lay perspectives on health and how these can contribute to understanding what health is. First we need to determine the meaning of the term ‘lay’ in this context. Lay perspectives (or ‘lay knowledge’, Earle, 2007a; or ‘lay expertise’ Martin, 2008) are distinguishable from theoretical or professional perspectives in that they are the perspectives of ‘ordinary’ (or non-professional) people. Essentially lay perspectives are about how non-expert people understand and experience their health and how they perceive it. Bury (2005) refers to lay understandings as ‘folk beliefs’ and argues that research into lay concepts of health has revealed complex and sophisticated understanding and ideas that go beyond the medical model outlined earlier.

Blaxter (2007) points out that it is not necessarily useful to use the term ‘lay’ because lay knowledge and understanding is informed, at least in part, by professional knowledge and understanding. So Blaxter (2007: 26) suggests that ‘lay understandings can better be defined as common-sense understandings and personal experience, imbued with professional rationalizations’. Nonetheless, since the term ‘lay perspectives’ is commonly used and understood and is, as such, reflected in much of the literature and research in this area, it will be used in this chapter. From this point on the term ‘lay perspectives’ will be used as a generic term, which is also seen to encompass the terms ‘lay beliefs’, ‘lay understandings’ and ‘lay concepts’.

Lay perspectives are central to the social model of health as discussed previously. The importance of paying attention to people’s subjective experience of health has been highlighted by many, including Lawton (2003) and Bishop and Yardley (2010). This is based on the fundamental assumption that people themselves often have the greatest insight into their own experiences of health and that it is therefore important to understand what these are (Earle, 2007a). As argued by Green et al. (2019: 11) ‘lay interpretations [of health] are complex and multi-dimensional’. Most often lay accounts or concepts of health are ‘uncovered’ through empirical research, so it is important to bear in mind the limitations that features such as study design and theoretical assumptions will have on findings and the way in which they are interpreted (see chapter 3 on researching health for further explanation of research methods). Health surveys often tend to ask how people would rate their own health (Bopp et al., 2012). When reading research in this area it is also important to make note of whether the research is focused on ‘health’ rather than illness (as is commonly the case due to the difficulties of defining ‘health’). Hughner and Kleine (2008), among others, argue that relatively few studies have actually focused on concepts of health as opposed to illness and Blaxter (2010) argues that different studies use different measures, categories and means of investigation, which is also problematic. There is also a ‘Western’ bias in the research that has been done into concepts of health; most of the studies reported have taken place in Europe and the USA (Downey and Chang, 2013). Nonetheless there is a body of knowledge that continues to evolve and grow around lay perspectives of health.

Lay perspectives are not homogenous nor are they uncomplex – they have been described as ‘reflecting health as a complex, multi-factoral construct’ (Downey and Chang, 2013: 825). They differ across individuals, communities and cultures and evolve over time. They also differ with age, levels of education, social class and gender. It is important to consider lay perspectives on health for many reasons. Not least because they tend to challenge theoretical, reductionist notions about what health is and draw on a much wider range of understandings and experiences, which inevitably adds to the debate. Indeed, much of the contemporary health-care provision agenda in Western societies is driven by public and user-involvement in which lay perspectives are inevitably key (Martin, 2008).

A study by Calnan (1987) carried out in the 1980s is often referred to in the literature on lay perceptions of health (although it actually focuses on lay understandings of health inequalities). Calnan’s summary of the findings revealed that ‘being healthy’ was viewed as such things as being able to get through the day (‘functioning’), not being ill, feeling strong, fit and energetic, getting exercise and not being overweight, being able to cope with the stress of life. Being healthy was also viewed as a state of mind. In contrast, being unhealthy was viewed as things like being unable to work, being ill or having something wrong – a serious, long-term or incurable illness, not coping with life, being depressed or unhappy, lacking energy and a poor lifestyle.

In seminal work on lay concepts of health, Blaxter (1990 in Blaxter, 2010) provided a framework of five categories (or ways) of describing health. This was based on the findings of a major UK study in which, among other things, people were asked what it was like to be healthy. The five categories of responses were as follows:

1 Health as not-ill

2 Health as physical fitness, vitality

3 Health as social relationships

4 Health as function

5 Health as psychosocial well-being

Blaxter’s findings are referred to in more detail throughout the rest of this chapter in relation to different lay understandings. Stainton-Rogers (1991) also studied lay descriptions of health and illness and offers a framework of seven different lay accounts for health as follows:

1 Body as machine (links with medical model understandings)

2 Body under siege (external factors influence health, i.e. germs)

3 Inequality of access (i.e. to medical services)

4 Cultural critique (linked with ideas about exploitation and oppression)

5 Health promotion (linked with ideas about responsibility for health as being individual and collective)

6 Robust individualism (linked with rights to a satisfying life)

7 Willpower account (linked with ideas about individual control)

Bishop and Yardley (2010: 272) analysed qualitative studies of lay definitions of health and identified three major themes in the findings across the studies. These were (1) health as the absence of illness – ‘health is something that one is’, (2) health as the ability to perform daily activities – ‘health can be something that one has’, and (3) health as experiences of vitality and balance – ‘heath can be something that one does’. In short, health is about ‘having, being and doing’ (Bishop and Yardley, 2010: 273). More recently Svalastog et al. (2017: 434) contended that the lay perspective on health is characterized by three qualities: wholeness, pragmatism, and individualism. See table 1.2 for further details.

Table 1.2 The lay perspective on health

Source: adapted from Svalastog et al. (2017: 434)

Quality	Explanation
Wholeness	This is related to health as ‘holistic’. Health is viewed as intrinsic to all other aspects of life, including work, family and community. Health is also viewed as a resource for living and as the ability to function. In addition, to be able to live according to one’s values is also important.
Pragmatism	This reflects health as a relative experience. Health is viewed and experienced according to what people might reasonably expect in the light of their personal circumstances (age, health condition/s and social situation). Other positive values in life can compensate for disability or disease.
Individualism	Health is conceptualized as a very personal phemomenon. This depends on who you are as a person; however, feeling close to others and part of a community or society is an important factor.

In trying to define health lay understandings (and indeed, professional ones) we are constrained by the use of language and for the most part, people tend to draw on mainstream discourse around health in order to articulate their understandings. Changes in knowledge and understanding over time also bring changes in understanding about health. As noted by Bishop and Yardley (2010), a full appreciation of the subjective nature of health has not yet been realized. This is due, in part, to the very changeable nature of health and health experience. Indeed, in a study on Eastern Canadian ‘baby boomer’s’ perspectives on health (and illness), Murray et al. (2003) noted several different narratives about the changing nature of health and illness.

Things such as age, class and gender influence how we think about health. In a sense, these different aspects of an individual co-exist and it is not really possible to separate them out. I, for example, am a Caucasian woman, aged 21 years (plus a bit!) and would be described as being middle class – as defined by my profession. All of these features may influence the way I think about health, in addition to my past experience, my beliefs, my culture and many other things. However, for the purposes of this discussion, lay understandings of health will be considered under some of these different aspects while the problematic nature of using this type of categorization, which is ‘very social in nature’ (Stephens, 2008: 6) is acknowledged.