SOC. Set. d Med.. Vol. II. pp. 683 to 689. Pcrgamon

Press

1977. Rioted

in Great

Britain.

SPACE, TIME AND ILLNESS

BEHAVIOR

GARYW. SHANNON Research Fellow, National Center for Health Services Research, 3700 East-West Highway, Hyattsville, MD 20782, U.S.A. Abstract-This paper explores the organization of space and time, posits associatio s between them and illness behavior, and presents a framework for comprehensive medical geograph $a1 investigation. Components of a mode1 of illness behavior are examined as they relate to the ecoiogical/functional and ecological/behavioral aspects of territoriality. Identity with one’s surroundings and spatial and temporal organization are discussed for pertinence to dil%rential perception, evaluatian, and treatmeut of ilhress. The implications of these are subsequently related to confounding factors in medical sampling and observed pa&ns of disease.

“Let there be space in our togetherness.” Kahlil Gibran, 1923.

Space has value to life as a continuum which contains resources and provides experiences. The process of developing an identity with our surroundings initiates the formation of a space within which we spend our lives Cl]. In this sense, whether by nature or convention, humans, like other animals, are territorial. The concept and components of organized space or territoriality,* derived primarily from ethology, may be of value as an organizational scheme for the study of illness behavior. This behavior does not take place in a frictionless world, upon an isotropic plain, or within a uniform physical setting, nor is it likely that illness behavior patterns will be randomly distributed in occupied space. Thus, both the ecological/fim~tional and behavioral/descriptive aspects of territoriality may bear upon patterns of illness behavior. Both deal with the spatial organization and arrangement of members of a society, but the former emphasizes local populations and fixed space and the latter the individual’s engendered space. This paper explores the organization of space and illness behavior, posits possible associations between them, and argues for the extension of illness behavior research to include a comprehensive spatial perspective. SPACEANDTERRlTORlALITY

No simplified elemental definition or explanation of territoriality has yet been advanced which can cover all of the related kinds of spatial behavior, and it is perhaps unnecessary, some say naive, to look for one [2,3]. Definitions of territoriality such as “any defensed area” [4] or “an open space . . . which an animal or group of animals defends as an exclusive preserve” [S] derived from studies of animal behavior

* The term territoriality is used throughout this paper as a generic term for spatial and temporal organization of human activity. There is considerable discussion in the literature that suggests “home range” may be appropriate for designation of everyday human activities in space and that “territory” is a subset of the home range. Yet the distinction appears to be one of location along a continuum with no clear points of demarcation. 683

have been found wanting when applied to human behavior. Research reveals, on the one hand, little evidence that territory itself is tbe object of aggressive behavior, and, on the other hand, numerous cases of spatially and socially oriented behavior with territorial ramifications [6]. For humans, territoriality serves as an important organizer of behavior on several level-the community, the small group, and the individual. At each level the primary gains are reduced randomness and added or&r. The resulting organization reduces the stresses of life and promotes efRciency in interaction and adaptation to the environment Among the conditions essential for organizing space or patterning are (1) a stable set of physical objects or milieu which does not fluctuate randomly itself. (2) behaviors which can become patterned, and (3) one or a number of factors which cause patterning in behaviors (these can be physical constraints from the milieu itself, efficiency, leairnin& etc.) [7J. The phenomenologists ascribe to each individual a “natural place”, a place to which he belongs which provides a ?ero point” of his reference system- It is from this reference point, or locus, that an individual through distance and direction of travel organizes a spatial world or territory [MO]. Humans exhibit and reflect a nested hierarchical range of territorial expression which viewed horizontally is organized into a network of roughly concentric bands or sectors that circumscribe the orbits of daily, weekly, and occasional circulation. Each band or “layer”, however, is experienced differentially by the individual. At the lowest level of the territorial hierarchy an individual occupies a space that can be organized within arm’s reach from a fixed place. A second level of space may be defined by the domestic level of social interaction-the “familial space” which is organized at the level of the home [ll]. Of particular interest here is what has been variously labeled the “home range”, “neighborhood”, “community”, or “social space”-a third or macro-level of organ&d space. This level is perhaps of greatest conceptual value in the combined study of human use of space and illness behavior. Home range is that spatial and temporal part of the life-path determined reciprocally by the daily and weekly patterning of human activi-

684

GARY

W.

ties [ 12,133 and by the “fixed-feature” characteristics of the spatial milieu [14]. It is the area occupied and traversed by an individual in pursuit of routine activities during a given period of time [15,16,17] and is comprised of the behavior setting the locus of activity, and linkages between them. AlTRIBUTES OF ORGANIZED SPACE

Without territoriality life would be severely disorganized, strenuous, and primarily oriented to moment to moment survival. There would be literally no place for persons to settle. Social existence would be a huge grand central station experience; people would be endlessly milling around at random; disruptions and interruptions would be routine [18]. Territoriality, in associating an individual with the same place for sustained periods, promotes the organization of discrete everyday responses into integrated chains By a process of continued conditioning an environmental stimulus that occurs in recurrent combination with an individual’s internal events, or with other environmental events, can become a significant part of a stimulus pattern which supports that organism’s chain of behavior. While supporting a sense of continuity and stability, territoriality also separates the “holy” or “sacred’ space from the “profane” [19] ; the secure, familiar inner space from the “strangeness~ of the amorphous outer space--that space beyond the limits of an activity field delined through repeated contact [20]. The boundary between the security of the immediate territory and the insecurity of the supra-territory is delineated by the established patterns of routine interaction. In daily activities one rarely is separated from a familiar environment and if separated becomes “distressed” and makes an effort to reinstate the familiar stimulus cotiguration [21,22]. It is possible, for example, to calculate thresholds in space beyond which certain groups cannot travel without experiencing frustrations, tensions, and feelings of anomie [23]. Thus, establishment of a territory sufRcient to provide for the necessities of life, while providing for organization and efhciency of routine activities, may at the same time operate as a constraint to exploration, discovery, and use of extant or new opportunities. It would be an exaggeration to say that apprehension of outlying space is the only deterrent to limitations of activity there. It is not true, for example, that when an individual leaves the protection of the home, neighborhood, or community, he immediately steps into hostile worlds. Rather, with a concern for constraints on the individual, it is important to examine what it means for a location to have not only spatial coordinates but time coordinates as well [24]. The conceptual weakness of exclusive focus on space and the need to incorporate considerations of time and finitude have been recognized [25-271. Rather than a two-dimensional model of territoriality, for example, a personal ,daily behavioral model of a four-dimensional grid has been posited joining space, time and other “domain” constraints. Space is represented on a two-dimensional plane (the usual dimensional characteristic of territoriality), and time on a vertical one. In time-space the individual describes a path, a life-path, composed of day paths, week

SHANNON

paths, and so forth. The development of this timespace volume establishes for each individual a maximum time-space “prism” within which all activities must take place. Depending upon where the stops are located and their duration, the walls of the prism might change from day to day. As with the notion of territoriality, however, routinized daily and weekly activities serve to establish a regularity and impose a rigidity to the tim+space volume of an individual. In the daily routine of interaction an individual must join or “couple” with other individuals, tools, and materials in order to produce, consume, and transact. Each individual or item to be contacted may be thought of as having its own unique “path”. The trace inside the prism is ruled to a pronounced degree by “coupling constraints.” The spatial location and the temporal location and duration-the where, when, and for how long-of contacts imposes constraints upon an individual’s movement. While bundles or groups of several paths are formed according to various principles, many follow predetermined timetables, often the same, weekday after weekday. An individual, bound to a home base, can participate only in those daily activity bundles which have both ends inside a personal daily prism and which are so located in space that there is time to move from the end of one to the beginning of the following. An additional set of constraints exists, “domain constraints”, under the control of a given individual or group. The purpose of domain establishment seems to be to protect resourceq natural as well as artificial, and to form containers which protect an efficient arrangement of bundles (seen from the inside point of view of the principal). The domains are either not accessible at all or accessible only upon invitation or by payment Viewed in a time-space perspective, then, we have two systems in interaction. One is the predominantly time-directed way of individual life paths, characteristic of the population of an area, and the concomitant capability constraints. The other is the more space-oriented set of imposed constraints of domains and bundles to which the individual may or may not have access according to his needs and wants [28]. In this perspective, access involves much more than the simple juxtaposition of supplies in regions of arbitrary size. It involves a time-space location that really allows the life-path to make the required adjustments. Most often the roles an individual plays are exclusive, they must be carried out within a given duration, at given times and places, and in conjunction with given groups of individuals and pieces of equipment. In many instances they must be lined up in nonpermutable sequences. An individual who enters into an established society will find at once that the set of potentially possible actions is severely restricted by the presence of other people and by a maze of societal, cultural, and legal rules. These forces operate within and in part are formed by the organization of physical and temporal space. This is not to say the individual has no private world of his own, but that his world is largely circumscribed by the world of those around him [29]. It must be recognized that once a particular spatial and temporal form is created. it tends to institution-

Space, time and illness alize and, in some respects, to determine the future development of the social process. Illness behavior represents one aspect of the social process ILLNESS BEHAVIOR

Disease may be a medical entity, but illness behavior is a social phenomenon. Values, attitudes, and personality exert an important influence upon how one perceives, interprets, and responds to illness. Social group membership and personality affect one’s perception of pain, decision to seek (or not seek) sue+ and behavior as a patient, The sociocultural environment strongly influences the kinds of problems identified as “legitimate” health problems, types of “accep table” solutions to these problems, and rejection or acceptance of new ideas and techniques for improving health. Our behavioral reactions to what we perceive and interpret are largely channeled by social forces which indicate which behavior will be approved or disapproved [30-333. A MODEL

OF ILLNESS BEHAVIOR

Fabrega [34,35] posits a comprehensive yet general model of illness behavior to serve as a device for ordering and organizing social and cultural data tied to illness occurrences that influence the behavior of a sick person. While a review of the model origin is beyond the scope of the present discussion, it can be traced to the initial formulation of the “sick role” by Sigerist [36] and Henderson [373 restated by Parsons [38] and the conceptual development and empirical investigation of what has been variously labeled health-, illness-, and sick-(role) behavior by Suchman [39,40], Kasl and Cobb [41], Mechanic C42-441, Rosenstock [45], and Segall[46,473, among others. In Fabrega’s model nine stages in the illness behavior process are recognized. Most are based upon system combinations used in generally describing an individual. These descriptive systems include the biological (chemical and physiological processes), social (relations between a person and other persons, groups, or institutions), phenomonologic (a state of awareness and self-definition), and memory (a unique personal history)-the product of a finite number of experiences in a specific so&cultural-or as preferred here-a specific so&cultural, spatial and temporal setting. Briefly stated, the nine stages are: (1) Illness recognition and kzbeling: A reading of the phenomenologic system which indicates to a person that an undesirable deviation exists in the current biological, social, or phenomenologic system values; (2) Illness disvalues: A dimension set, each consisting of a negative component of illness-an evaluation of current system readings in light of recollections; (3) Treatment plans: Available treatment action sets that can be implemented for purposes of combatting illness; (4) Assessment of treatment plans: Ah evaluation of the probability that a disvalue dimension can be relieved by a treatment plan ; (5) Treatment benefits: An evaluation of the potential benefit of some treatment plan i in alleviation of the sum of illness disvalues;

behavior

685

(6) Treatment costs: Cost computation associated with treatment--a treatment plan evaluation; (7) Net benefits or uriliry: Cost of each treatment plan subtracted from potential benefits, a vector of residual benefits to be derived; (8) Selection of treatment plan: and (9) A recycling of (l)(S) [48]. The implementation of the model is based on illness behavior measured along five dimensions: (a) perceived severity of symptoms. (b) family response, (c) medical-physiological symptoms, (d) behavioral changes, and (e) treatment actions. In addition to the intrinsic value of the model for the study of illness behavior, it serves here as a useful vehicle for discussion of an organizational framework for medical-geographical investigation. Traditionally, though the importance of sp&ce for certain isolated dimensions of illness hehaviol has been recognized for some 130 years [49-513, thd study of illness behavior has been by and large aspatial. The emphasis has been on characteristics such as attentiveness to pain and symptomatology, examination of processes affecting how pain and symptoms are defined, accorded sign&ance, and socially labeled; and the consideration of the extent to which help is sought, change in life regimen affected, and claims made on others

WI.

Yet, illness behavior does not occur in a vacuum, and it is likely that illness behavior is not uniformly distributed throughout diverse populations The former is obvious; the latter is supported by the numerous findings that an iqdividual’s, and in the aggregate, a group’s illness hhavior patterns in a large part are so&culturally Uetermined.

ECOLOGICAL F’UNCITOl’#L TERRITORLUITV-jIiE

ASPECIS OF FIXED-

FEATURE SPACE OF b@DICAL

CARE

Fixed-feature space is one of the basic ways of organizing the locations and activities of individuals and groups It includes mataxial manifestations as well as the hidden, internal&l designs that govern locational and movement behavior. The grouping of buildings and land use activitib, the morphology of a community or region, and the hierarchy and spacing of communities and their +ctivities, are not haphazard but evolve with changes in culture over time. associated) economic Similarly, the spatial (and oft clustering of various so&cult ce ral groups constitute a dimension of fixed-feature spice at least as real and important as the distribution d the natural and artificial landscape. The importapt point about flxedfeature space is that it is the mold into which a great deal of behavior is cast [63]. The coincidence of social and spatial identification, the feeling of topophilia [54], within a region was exemplified particularly in early 20th Century studies of French districts [SS]. Allihough physiographic boundaries were emphasized, the pattern of living (genre de vie) shaped and was shaped by the sense of place. Later studies identif$d groups tending to have their own social space determined by spatial patterns of social networks [56]. The social space refle-cted a group’s particular values, preferences, and aspi-

686

GARY W. SHANNON -

rations. Social area analysis [54] and more recently numerous factoral ecological investigations have repeatedly demonstrated the spatial clustering of sociocultural groups over the wide spectrum of regional analysis. To the extent that illness behavior may be differentiated by so&cultural variables and the concomitant spatial clustering of sociocultural groups, we may expect that differences in this behavior will be reflected in spatial patterns. We may expect differences, for example, between rural and urban populations, among populations from one rural or urban area to another, as well as on an intra-urban and intraregional basis. Zborowski’s [SS] classic study of reactions to pain showed that Jewish, Italian, Irish, and “old American” patients responded differently. other more recent data rellect the extent of folk remedies among certain population groups in a modem urban community [59]. The prevalence and persistence of certain illness be havior patterns in particular populations may also be associated with the fixed-feature space of distributed medical care opportunities [60]. The location of population groups relative to the existing and evolving distribution of health care opportunities may serve to initiate or reinforce alternate medical care systems and resulting ilhtess behavior. The manner in which medical facilities are distributed uis-his the population distribution has a demonstrated effect upon illness behavior [61]. Generally, the distribution of medical care opportunities may a&t the recognition of illness, the evaluation of treatment plans, and the tinal selection of a treatment plan. Separation from a medical care “bundle,” other things being equal, may tend to increase sensitivity to signals from and readings of the social, biological, and phenomenological systems such that illness behavior may be altered according to the distribution of a population relative to the medical care opportunities. Gn the other hand, it has been frequently observed that distance from medical care (whether measured on a physical or functional basis) is often associated with a delay in seeking treatment for recognized ilhmss. This “desensitiz3tion” to medical care may be the result of the necessary adjustments on the part of the individual to alter the every&y constraints upon his time-space volume to accommodate costs associated with the travel and time necessary to obtain medical care. The amount of travel and time required to obtain medical care therefore acts as an important variable in the assessment of treatment plans, evaluation of treatment benefits, and treatment plan selection--each an important segment of the illness behavior process. It should be pointed out that the “t&d-feature” space of medical care is not etched in stone but rather, locationally evolving. This is the result of both the movement of so&cultural groups as well as medical care opportunities. As regards the former, this reflects the “natural” process of residential relocation related to socioeconomic mobility. Particularly since the mid-20th Century, however, the relocation of medical opportunities has been sign&ant. Certain population groups retain their accessibility to medical care while others are left effectively remote from medical services C62-641.

THE HOLY, THE PROFANE, AND THE UNKNOWN-ACTIVITY SPACES, lNFORMATlON FIFLDS, AND ILLNESS BEHAVIOR

Population distributions, medical care opportunities, and travel for medical care are not themselves isolated but are a part of a fabric of an interconnected network of locations, activities, and related travel-a social space. The utilized set of medical care facilities are part of and rellect the general nature of an individual’s daily activity space and associated information field [65]. Two information field types may be identified. The direct information field, or direct awareness space (the “holy space” of ethology) refers to that location set directly contacted by an individual in day-to-day activities such as working, shopping, visiting friends and relatives, and attending voluntary association meetings. A household’s direct awareness space is comprised of the nodes and edges representing the contact locations and associated paths used by household members. It is generally this space and these locations for which the most accurate information is available. The direct awareness space is generally much smaller in extent than the indirect awareness (or profane) space. The latter is defined by the location set with which the individual family member is familiar through indirect information sources, i.e. other than through direct contact. This space then is an extension of the direct activity or information field but reflects and is determined to a certain extent by, the distribution of locations defining the direct contact field. The medical care resource opportunity set practically available to any household reflects that known to it through the combined direct and indirect information fields Again, as with illness behavior patterns, we may expect information field patterns differentiated by various locational and sociocultural population characteristics Beyond this awareness space, comprised of both the holy and part of the profane, lies, of course, the unknown. This is the space and opportunity set contained therein about which an individual has no information. In practical terms medical care opportunities in this unknown territory do not exist for the individual, and it takes extraordinary circumstances for an individual to seek care here. It should also be mentioned that unless special circumstances prevail, there is little likelihood that any member of the household will travel much beyond the “traditional” limits or alter the spatial “equilibrium” of their direct awareness space to obtain medical care. Based upon the combination of so&cultural group distribution and associated activity and awareness spaces (territories), we may expect a distribution of ecological “containers” [66] for selected population groups, and as a result perhaps different experiences and expectations pertaining to availability, type, and quality of medical care resources. These expectations and experiences may in turn be directly related to treatment plan set composition and treatment plan selection. An additional consideration, of course, must be that of the memory of an individual or group of individuals possessing a common so&cultural as well

Space, time and illness behavior as activity space. Through such shared characteristics we may be able to differentiate the population with pertinence to illness behavior [67]. MENTALMAPS-THE SURJEClTVE REALITY OF SPACE The shared characteristics must not and cannot, however, be understood only within the framework of objective measures of time and space. While it is true that the organization of space and time and its influence upon behavior may be directly measured we must also be alert to the subjective reality of these dimensions. It is not sufIicient to draft an opaque “objective” map of medical phenomena in space, but, rather, investigation should be directed toward understanding the impact of social and cultural variations upon the silent language of time and space. The organization of space and associated illness behavior patterns are not the result of objective interpretation of external stimuli. The individual does not passively react or adapt to the environmental forces impinging on him but brings a variety of cognitive activities to bear-expectancies, attitudes, even symbolic elaboration and transformation of the world of reality, which come to mediate and modulate the impact of the environment [68]. While there may be considerable overlap among subcultural groups, people occupy and live in Upsycho-space” which differs from person to person. The information which leads to the individual’s interaction with the environment is dependent upon the individual’s cognitive map of the spatial environment. Cognitive maps are the convenient sets of shorthand symbols that we all subscribe to, recognixe, and employ [69,70]. This mapping process is comprised of a series of psychological transformations by which an individual acquires, codes, stores, recalls, and decodes information about the relative locations and attributes of phenomena in the everyday spatial environment. We must distinguish in our investigations of illness behavior the objective geographical-temporal environment (absolute space) and the behavioral enviromnent (relative space). The cognitive map has been postulated as a basis for deciding upon and implementing any strategy of spatial behavior and as such is effectively linked to the evaluation and implementation of treatment actions in the illness behavior process It is the subjective knowledge which largely governs behavior. As it pertains to the memory system, environmental cognition need not be linked with immediate behavior and, therefore, need not be directly related to anything in the proximate environment Consequently, it may be connected with what has passed (or is past) or what is going to happen in the future in either experienced or unknown space. The many observed linkages between objective measures of time, space, and certain phases of illness behavior might be made even clearer if measured upon the more sensitive and retlective mental map. Medical behavioral geographers should be concerned about the methodological problems of relating, first, models of the mind; second, procedures for recovering and measuring perceptions and preferences; and, third overt spatial choice behavior [71].

687

ILLNESS BEHAVIOR AND MEDICAL SAMPLING The associations among space, time, and illness behavior are inherently interesting and valuable to a comprehensive understanding of the illness behavior process. Yet the value of such investigation is multiplied when its pertinence to medical sampling is considered Mortality data are at best a poor index of incidence of disease when the fatality of a disease may be at&ted by the availability or efhciency of treatment [72]. Similarly, factors have been identified that confound reported incidence of’diseases, among them the availability and utilization of medical services which are related in part to (1) factors intrinsic to the patient such as so&economic status, educational level, and beliefs and attitudes toward health; (2) factors associated with the so&-economic environment, including the level of development and the economy of the neighborhood, region, or country; (3) factors associated with communication and transportation, as well as the distribution of resources; and (4) factors associated with hospital and clinic care, among them equal availability of facilities to all patients, which may be limited by geographic accessibility [73]. Most medical studies of etiologic processes in diseases depend primarily upon those persons who seek medical care at clinics, hospitaIs, and other facilities To the extent that these populations are not repreaentative of those persons in the population having a particular disorder, and to the extent that selection of patients occurs on some systematic baais, biases that may lead to incorrect and unwarran ted conclusions and generalizations am fntroduced. The study of those variables that affect the arrival of ill persons to medical care settings is a basic research problem since these variables come into play before medical scrutiny and may even determine whether diagnosis and treatment will begin at ah [74]. The implication of variation8 in illness behavior for mapping distributions of disease and attempting correlation analysis based on gnosis am obvious If certain groups within popu% ‘ens are not seeking medical services, then disease data based on only those who achieve medical care are not representative. Similarly, if certain population sets are delaying getting care for recognixed illness, then the etiologic outcome of the disease process may be altered and consequently spatial disease patterns a&ted.

SUMMARY An attempt has been made here to describe the many-faceted association between space, time, and illness behavior and the implications of this association for both medical geographical and medical care research. It is hoped that the preceding discussions will serve to identify the relationship of ongoing and proposed research in medical geography with the major underlying issues of illness and disease as well as describe potential contributory areas of interest and research heretofore relatively unexplored. There is undoubtedly a substantial portion of illness behavior which operates ihdependently of spatial form and spatial and temporal organization, and we need to know what portion of the activity is in-

GARY W. SHANNON

fbS8

fluenced by spatial form and which remains relatively independent [75]. Personal construct theory, semantic differential, and direct questioning are available to investigate the influence of the constructed and “natural” environment on a population. An altemative favored by behaviorists is simply to observe people’s behavior and, on the basis of their overt activity, gauge their reaction to their environment. In this case it is the overt behavior in space which provides us with the necessary clues to understand the

spatial and temporal signifkxnce and interaction with the social, cultural, and medical environment Regardless of the approach, however, it is quite apparent that the spatial and temporal consideration of epidemiology (geographic pathology) and illness behavior are intricately related and that a comprehensive approach will elaborate meaningful relationships pertinent to medical care research and health planning. REFERENCES I. Calhoun J. B. Space and the strategy of life. In Behcruior and Environmenr: The Use of Space by Animals and Men (Edited by Esser A. H.) pp. 329-387. Plenum

Press, New York, 1971. 2. Altman I. Territorial behavior in humans: an analysis of the concept. In Spatirrl Behavior of Older People (Edited by Pastalan L. A. and Carson D. H.), Chap. 1, pp. l-24. The University of Michigan-Wayne State University Institute of Gerontology, Ann Arbor, Michigan, 1970. 3. Kaufmann H. Is territory definable? In Behavior and Environment: The Use of Space by Animals and Men (Edited by Esser A. H.) pp. 36-40. Plenum Press, New York, 1971. 4. Howard H. E. Territory in Bird Le. John Murray, London, 1920. 5. Ardrey R. The Territorial Imperative. Atbeneum Press, New York, 1966. 6. Peterson N. Hunter-gatherer territoriality: the perspective from Australia Am. Anthrop. 77, 53, 1975. 7. Edney J. J. Human territories: comment on functional properties. Environment & Behavior 8,31, March 1976. 8. bolinow 0. F. Lived-space. Translated by Gerlach D. from Philosophy Today, Vol. 5, pp. 31-34, 1961. In Readings in Existential Phenomenology (Edited by Lawrence N. and O’Connor D.) pp. 178-186. PrenticeHall, Englewood Cliff&, N.J., 1967. 9. Gelwicks L. E. Home range and use of suace by an aging population. In Spa&l Behavior of Older People (Edited bv Pastalan L. A. and Carson D. H.) DD. i48-155. ihe University of Michigan-Wayne ‘S&e University Institute of Gerontology, Ann Arbor, Michigan, 1970. IO. Buttimer A. Social space in interdisciplinary perspective. Geog. Rev. 49, 417, July 1969. 11. de Lauwe C. Paris er Pagglomerarion Parisienne. Vol. 1, pp. 19-26, 1952. In Buttima A. 1969. ibid. 12. Hagerstrand T. lnnovation Difision as a Spatial Process. Translated by Pred A. from Innovations forloppet ur korologisk synpunkt. Gleerup, Sweden, 1953, University of Chicagb cress, 1967. _ 13. Hagerstrand T. What about people in regional science’? Papers, Regional Sci. Ass. 24, 1, 1970. 14. Hall E. T. The Hidden Dimension, pp. 103107. Anchor Books, Garden City, N.Y., 1969. 15. Porteous J. D. Design with people: the quality of the urban environment. Environment & Behavior. .DD. . 155-178, June 1971. 16. Peterson N. op. cit.

17. Gelwicks L. E. op. cit. 18. Edney J. J. op. cit. 19. Eliade M. Saved space and making the world sacred. In The Sacred and the Profane, pp. 20-65. Harper Books, New York, 1961. 20. Bollnow 0. F. op. cit. 21. Webber M. Culture, territoriality, and the elastic mile. Papers of the Regional Sci. Ass. 13, 59, 1964.

22. Edney J. J. op. cit. 23. de Lauwe C. Paris et Pagglomeration Parisienne, 1966. Cited in Buttimer A. 1969, op. cit. 24. Hagerstrand T. 1970, op. cit. 25. Buttimer A. Grasping the dynamism of lifeworld. Annls Ass. Am. Geographers 66, 277, June 1976. 26. Cullen I. G. Space, time and the disruption of behavior in cities Environment & Planning 4, 459, 1972. 27. Haaerstrand T. 1970. OD. cit. 28. Ibid 29. Suchman E. Social patterns of illness and medical care. J. Health & hum Behav. 6, 2, Spring 1965. 30. Ibid. 31. Mechanic D. The concept of illness behavior. J. chron. Dis. 15. 189, 1962. 32. Mechanic D. Response factors of illness; the study of illness behavior. Social Psychiatry 1, 11, 1966. 33. Mechanic D. The Growth of Bureaucratic Medicine, pp. 161-176. Wiley, New York, 1976. 34. Fabrega H. Jr. Toward a model of illness behavior. Care 11,6, 1973. 35. Fabrega H. Jr. Disease and Social Behavior: An Interdisciplinary Perspective. MIT Press, Cambridge, Mass., 1974. 36. Sigerist H. The special position of the sick. In Henry E. Sigerist on the Sociolwy qf’ Medicirle (Edited by Roemer M.) pp. 9-22. M.D. Publications, New York, 1960. 37. Henderson L. J. Physician and patient as a social system. New Engl. J. Med. 212, 819, 1935. 38. Parsons T. The Social System Free Press, Glencoe, N.Y., 1951. 39. Suchman E. 1965, op. cit. 40. Suchman E. Health attitudes and behavior. Archs envir. Hlth ZJ, 105, January 1970. 41. Kasl S. and Cobb S. Health behavior, illness behavior, and sick role behavior-Part I: health and illness behavior. Archs envir. Hlth, 246-266, February 1966. 42. Mechanic D. 1962, op. cit. 43. Mechanic D. 1966, OD. cit. 44. Mechanic D. 1976; ob. cit. 45. Rosenstock I. Why people use health services. Milbank meml Fund q. 44,94,

1966.

46. Segall A. (a) The sick role concept: understanding illne& behavior. J. Hlth & sot. Behdv. 17. 163. June 1976. 47. Seaall A. (b) So&cultural variation in sick role behavioral exp&ations Sot. Sci. & Med. 10, 47, 1976. 48. Fabrega H. Jr. 1974, op. cit. 49. Shannon G. W., Bashshur R. L. and Metzner C. A. The concept of distance as a factor in accessibility and utilization of health care. Med. Care Rev. 26, 143, February 1969. 50. Donabedian A. Aspects of Medical Care Administration: Specifving Requirements for Health Care, pp. 425-485. Harvard University Press, Cambridge, Mass., 1973. 51. Shannon G. W. and Knudson G. Distance, accessibility, and the use of medical services; progress and prospects. Unpublished manuscript, 1977. 52 Mechanic D. 1976, op. cit. 53. Hall E. T. 1969, op. cit. 54. Tuan Y. Topophilia: A Study of Environmental Percep tion, Attitudes and Values. Prentice-Hall, Englewood Cliffs, N.J., 1974. 55. de la Blache P. La France de PEst. Paris, 1916.

Space, time and illness behavior 56. Sorre M. Les Migrations des Peuples: Essai sur la MobilitC Giographique. Paris, 1955. 57. Shevky E. and Bell W. Social Area Analysis. Stanford University Press, 1955. 58. Zborowski M. Cultural components in responses to pain. .I. sot. Issues 8. 16, 1956. 59. Shannon G. W.. Fischer P. J. and Bashshur R. L. Alternative health systems within the urban setting: Washington, D.C. Unpublished manuscript, 1977. 60. Shannon G. W. and Sourlock C. Urban ecological containers, environmental risk cells, and the use if medical services. &on. Geog. 52, 136, April 1976. 61. Girt J. The location of medical services and disease ecology-some conclusions on the effects of distance on medical consultations in a rural environment Canadian Geographer 17, 154, 1973. 62. Elesh D. and Schollaert P. Race and urban medicine: factors affecting the distribution of physicians in Chicago. .I. Hlth & sot. Behav. 13, 239, September 1971. 63. Roemer M. Historical development of current crises of rural medicine in the United States. In Victor Robinsol Memorial Volume: Essays in the History of Medicine (Edited by Kagan S.) pp. 333-342. Froeben Press,

1948. 64. Shannon

G. W. and Dever G. E. A. Spatial patterns of health resources. In Health Care Delivery: Spatial Perspectives, pp. 36-39. McGraw-Hill, 1974. 65. Shannon G. W. and Spurlock C. 1976. op. cit.

689

66. Medvedkov Y. Ecological approach to health hazards. A Presentation to the Director-General’s Conference, World Health Organization, July 2, 1969. Mimeo. 67. Shannon G. W. and Spurlock C. 1976, op. cit. 68. Kates R. and Wohlwill J. Man’s response to the physical environment: introduction. .I. sot. Issues 22, 15, 1966. 69. Downs R. and Stea D. image and Environment: Cognitiw Mapping and Spatial Behavior. Aldine, Chicago, 1977. 70. Tuan Y. Images and mental maps Annls Ass. Am. Geegraphers 65, 205, June 1975. 71. Burnett P. Behavioral geography and the philosophy of the mind In Spatial Cho&e -and Spat&l Behavior (Edited bv Golledpe R. and Rushton G.) DD. 23-50. Ohio S&e Univet&y Press, 1976. ’ s* 72. Doll R. Methods of Geographical Pathology: Report of the Study Group Convened by the Council /or International Organizations of Medical Sciences. BlackwellDavid, 1959. 73. Davies A. M. The Geographical Epidemiology of the Toxemias of Pregnancy. Charles C. Thomas, Springfield, IlL, 1971. 74. Mechanic D. Some implications of illness behavior for medical sampling. New Engl. J. Med. 263,244, August 1960. 75. Harvey D. Social processes and spatial form: an analysis of the conceptual problems of the urp planning. Papers, Regional Sci. Ass. 25, 47, 1970.