Discussion

This investigation focused on the meanings which the mothers attached to children’s symptoms and behaviours seen as relevant to health and illness. The strength of the qualitative method employed here lay in the researcher’s ability to elicit the respondent’s (research subject’s) viewpoint. It would have been counter productive to begin data collection with a predefined set of issues and questions: ‘appropriate or relevant questions are seen to emerge from the process of interaction that occurs between the interviewer and interviewees’.²²

The limitations of the method lie in its inability to test hypotheses, and to produce statistically significant results, and the results cannot be presented in the traditional scientific manner. However, through the use of illustrative quotes from both the health diaries and interviews, the way in which the mothers in this sample routinely negotiated health and illness within the family is demonstrated. The identification of the specific dimensions of normality, and the development of the four categories interpreting behavioural change may be useful in practice.

In common with other studies,^{23, 24} the mothers’ recognition of illness and symptoms appeared to be embedded in a commonsense knowledge about what was normal and acceptable. The mothers’ perceptions of normality underpinned negotiation of their children’s illnesses. Normality could be interpreted as a yardstick that operated in a variety of ways, as a measure of whether or not the child was ‘ill’ with the condition, for example a cough, whether the child was sickening for something, was experiencing normal illness or was experiencing illness normally. It was only through understanding the features of their concept of normality that deviation in their children’s behaviour took on any meaning. Interpreting what the women said in this way helped to provide some understanding of how they constructed illness, other than simply recognizing predefined or commonly known conditions.

As we have reported elsewhere,²¹ mothers closely monitor their children’s well-being. It is important to examine the recorded behavioural changes in detail because these are based on the mother’s unique knowledge and may not be readily perceived by the doctor. These behavioural changes, especially regarding eating and sleeping, were found to be problematical concerns for the mothers. Given the emphasis which society places on the nurturing role of the mother, and on the adequate physical and emotional development of children, it is not surprising that changes in eating and sleeping emerged as major concerns among the mothers. A concern for healthy development, and the ability to resist disease seemed implicit in their concern for good eating and sleeping behaviours. However, the relationship between these behaviours and illness was found to be varied and complex. Unlike previous investigations, ^23-25behavioural changes were not simply interpreted as clues to an underlying problem. Although they were sometimes interpreted as a symptom of illness, their relationship to health and illness was more complicated. In fact, whether or not illness was present was not necessarily the primary concern for the mother.

While some illnesses were normalized by the mothers,²⁴ deviation from normal behaviour could be recognized as a precursor, concomitant or result of illness, as illness itself, or as a problem because of its effect on the well being of the child and of other family members. Such changes in behaviour may be all of these things at different times or some of these at the same time.

Although general practitioners may make a rapid global assessment of a child’s state of health, they are searching for the presence or absence of specific signs and symptoms of high discriminative value, for example dysuria or a red eardrum. On some occasions this will allow a definite diagnosis to be made; on many others the diagnosis will remain tentative, but collaboration of whatever ‘hard’ information is available should allow the general practitioner to decide how to act. Mothers, on the other hand, recognize illness largely through behavioural change, that is, data of low discriminative value from a medical diagnostic point of view, for example, changes in eating and sleeping. This variation in the meaning of a ‘soft’ non-specific symptom is not necessarily recognized by those professionals to whom the mother goes for help.

What are the consequences of these potentially divergent needs and viewpoints‌ The doctor’s response is critically important. If he or she operates solely on the basis of signs and symptoms, he or she may be perplexed to find a mother worrying excessively over a seemingly trivial diagnosis such as a cold. If he or she is aware that the consultation has been unsatisfactory despite, in his or her terms, having done all the right things, feelings of anxiety and inadequacy may be engendered, particularly in the less experienced doctor. Alternatively, the doctor may make a judgement about the coping skills of mothers who seem to bother him with trivia, thus creating and sustaining the stereotype of the neurotic or inadequate mother. Cartwright recognized that general practitioners often respond to perceived trivia with a prescription.²⁶ Children with Upper Respiratory Tract Infections form the largest single component of general practice workload, and consume a vast quantity of prescribed medicines.¹⁹ Might this cost be reduced if general practitioners had a different understanding of the processes involved when mothers consult with young children‌ The argument that busy general practitioners must prescribe to keep going is not valid, as there is evidence that short term gains are offset by increased overall workload.²⁷ It ignores the potential within the consultation for education and for the enhancement of help seeking behaviour,²⁸ and is not compatible with aspirations for a quality service.²⁹

What are the consequences for the mother if she feels that she has been unable to communicate her concerns or that her concerns have not been acknowledged‌ If she has been made to feel that she has wasted the general practitioner’s time she may be left with doubts and anxieties about her own adequacy as a mother. The sense of rejection is likely to be felt most keenly by those whose self esteem is already vulnerable, such as the depressed or the young first-time mother, the more so if she is no nearer to resolving the anxieties about her child which caused her to consult initially. The more experienced and confident mother may feel anger that her legitimate status as the expert on her child’s behaviour is not being acknowledged. Her perception of being fobbed off may be heightened if, in addition, she receives an unlooked for prescription. In both instances, the process of deciding to seek professional help on a subsequent occasion will be much more fraught and might involve significant delay. Creditability, trust and respect will have vanished from the relationship.

It was possible to test the validity of our findings in practice, and one off us (S I) did so while working as a general practitioner. This consisted of focusing on what the mother presented as her major concerns, no matter how ‘soft’ these were from a diagnostic point of view. The method was not time consuming and is likely to be used already by doctors who are good communicators. It was in keeping with the observations of ILLINGWORTH and ILLINGWORTH, that failure to determine the cause of mother’s concern is a potent source of further anxiety.³⁰ After further direct questioning and then examination of the child, the findings, diagnosis, advice or treatment were discussed in the context of the mother’s concerns. On the basis of a subjective and informal assessment this appeared to result in successful consultations. Eating and sleeping difficulties arising during the course of a minor illness, such as a cold, were often mentioned by mothers. If concerns about these particular issues were not volunteered, but their discussion was subsequently initiated by the doctor, this also appeared to increase the chances of a mutually satisfactory consultations.

Mothers have a unique and intimate knowledge of their children, and their concept of normality in their children’s behaviour underpins their negotiation of illness. Although much illness in children is taken for granted, considered normal, and treated at home,²¹ changes in eating and sleeping were of particular concern to mothers, even when these behaviours were not overtly related to illness. These are important and emotive issues, linked to ideas of the mothers’ competence, and to their perceptions of the general health and development of their children. If health professionals can become more sensitive to these issues and recognize mothers’ concerns, their quality of communication with mothers of small children can be enhanced, resulting in more effective client-professional relationships, and greater satisfaction to both parties.