Behaviour (PDF)

Human behaviour Achieving health and well-being in the population is the primary goal for public health specialists, yet the definition of these concepts is contested. Similarly, people's reaction to illness varies between cultures. Aside from providing a number of definitions of health and illness...

Human behaviour Achieving health and well-being in the population is the primary goal for public health specialists, yet the definition of these concepts is contested. Similarly, people's reaction to illness varies between cultures. Aside from providing a number of definitions of health and illness, this chapter also discusses some pre- conceptions of health and illness including the norms and behaviours that are tacitly expected of people who are ill (the sick role and the social role of illness) as well as society's treatment of people that do not conform to those expectations (deviance and stigma). Finally, the chapter considers how personal characteristics and a person's position in society affect whether and how they seek help for their symptoms. The social sciences aim to understand the attitudes, motivations, and behaviours of human social behaviour and why these change over time. Society is a group of interacting people who share a geographical region, a sense of common identity or a common culture. As such, it is more than an aggregate of individuals. These disciplines are of importance to public health because they can help explain: Individual behaviour Behaviour of groups within a population Behaviour of healthcare organisations Data from social research may be quantitative (numerical data) or qualitative (textual or pictorial data), although in practice, most social research considers both types. Classically, there are three major theoretical perspectives in sociology: Structural functionalism Social conflict Interpretivism (or 'symbolic interactionism') Structural functionalism This approach views society as an objective reality in which the different components are inter- dependent and work together to promote stability. There are individual roles that adapt to the needs of society. Important sociologists who adopted this Behaviour Page 1 promote stability. There are individual roles that adapt to the needs of society. Important sociologists who adopted this perspective include Talcott Parsons and Emile Durkheim. Functionalism is closely linked to positivism, which was founded by the French sociologist Auguste Comte (1978-1857). Social scientists who advocate positivism tend to value the scientific method. They believe that the social world can be studied in the same way as the material world in that hypotheses can be tested according to observable facts. Positivists often employ a quantitative approach. Social conflict Founded by Karl Marx, this perspective (also called Marxist) focuses on the competition for resources and material production to generate wealth as the major goal of society. This perspective leads to industrialisation and the establishment of different social classes. Industrialisation may affect health in a number of ways (e.g. occupational health, environmental pollution, the effects of industrial products on health) and may have a profound impact on health inequalities." Interpretivism This perspective focuses on individual or small- scale social interactions, including behaviours and communication, and how this influences the way that people interpret society subjectively. Labelling is an important aspect of this perspective. For example, a person's identity may be influenced by a label such as a diagnosis, and certain labels can lead to stigmatisation. A related epistemological stance is constructivism. This philosophy rejects the idea that there is one knowable truth waiting to be discovered. Instead, it is based on the premise that our understanding of the world is constructed by reflecting on our experiences. Each of us generates our own 'rules' and 'mental models' which we use to make sense of our experiences. Methods Studies of human behaviour may involve the use of quantitative or qualitative methods. Quantitative methods These methods are used to answer questions such as 'How many?' and 'What proportion?' Examples are questionnaires, surveys (face-to-face or telephone) and routine data sources (e.g. mortality data). As with all quantitative research, three potential causes of error should always be considered, namely chance, bias and confounding. Qualitative research Qualitative methods are used to answer questions about 'How?' and 'Why?' Methods include ethnography, interviews, focus groups, and case studies. Example: Participant observation of euthanasia To understand patients' decisions regarding euthanasia, the anthropologist Robert Pool conducted a participant observation study of a clinic in the Netherlands. While he initially felt 'invisible' in clinic meetings, he noticed that his name began appearing in patients' notes and sometimes his opinion was sought because he had spent significant time with patients. Therefore, through observation, Pool had affected his environment (reflexivity). Several months after he left the clinic, Pool returned to interview some key members of staff. When he asked them about the number of patients considering euthanasia, towards the start of the interviews, the clinicians could remember few cases. Over the course of the interview, however, the clinicians remembered more cases. From Pool's reflections on his research, it is possible to identify how different epistemological stances might have led to different methods and conclusions. A positivist perspective might have focused on quantifying the number of euthanasia cases, leading to the use of quantitative methods (e.g. administering a questionnaire). In contrast, a constructivist perspective would have explicitly considered how the estimate of cases was a reflection partly of the clinicians' recall, but also of Behaviour Page 2 perspective would have explicitly considered how the estimate of cases was a reflection partly of the clinicians' recall, but also of their interpretations of the conversations they had with patients, and on the impact of the researcher in prompting this recall. Behaviour Page 3 Individual behaviour change Interventions to influence health behaviour may be implemented at multiple levels, ranging from the whole population down to the individual level. Individual, or small-scale, interventions include face-to-face health promotion techniques and incentives to encourage healthy behaviour. Face-to-face methods Motivational interviewing Motivational interviewing, developed by Rollnick and Miller in the 1990s, is a style of counselling based on the stages of ch ange model. It is a patient-centred method that aims to develop an individual's motivation to change by exploring the reasons why they may be ambivalent about behaviour change. Motivational interviewing has a growing evidence base of effectiveness in a number of therapeutic areas including drug misuse, eating disorders, and smoking cessation. Its characteristics are to Use empathy with reflective listening Highlight discrepancies between patient's most deeply held values (e.g. desire to be 'good') and current ("unhealthy') behaviours 'Roll with resistance' (i.e. respond with understanding rather than confrontation) Build the patient's self-efficacy and confidence that they can effect change themselves Cognitive behavioural therapy CBT aims to interrupt habitual cycles of unhealthy behaviour by replacing them with healthy ones. CBT involves similar techniques to motivational interviewing but also incorporates cognitive exercises such as imagining the scenario of being offered a cigarette and how to behave in this scenario. Use of incentives to encourage healthy behaviour Personal financial incentives may be used to encourage behaviour change. Marteau and colleagues describe some examples of incentive schemes, such as Vouchers to encourage smoking cessation (United Kingdom) Money towards healthcare costs for adherence to diabetes treatment (United States) Financial rewards for avoiding STIS (Tanzania) Financial rewards for achieving weight loss targets (Italy) A points scheme for healthy school meals (United Kingdom) Research suggests that financial incentives do tend to be effective in the short term and they may also be effective in the l ong term if accompanied with other health promotion advice. However, such initiatives are associated with a number of moral concerns, including whether they are a form of bribery, are overly paternalistic, and are a poor use of public funds. Behaviour Page 4 Changing behaviour One of the hallmarks of health systems is that they are characterised by almost continuous change. These transformations encompass innovations in practice, structural reconfigurations, and evolution in the population and its health needs. In order to adapt to this perpetually changing environment, healthcare professionals and public health practitioners must be prepared adapt their behaviour and to embrace the opportunities that change may bring. Binney and Williams described different 'types' of attitude that people may have towards change. Adopting change Rogers developed the 'diffusion' model to explain how people generally move towards change. Altering behaviours Several theories from the behavioural and social sciences provide a basis for understanding why people engage in certain behaviours. As well as helping to explain and predict these behaviours, the insights from these theories can also help guide the design and implementation of strategies. Behaviour Page 5 Behaviour Page 6 Lifestyle In general, it is difficult to attribute causality between a single aspect of lifestyle and a health effect. However relationships can be observed. Obesity Since the 1980s, obesity has risen sharply in the United Kingdom and in many other 'Western' countries among both adults and children. For example, in 2010, around 25% of adults and 15% of children were categorised as obese (Health Survey for England) although there is some evidence that the rate of increase in obesity prevalence is now slowing, particularly among children. Obesity increases the risk of numerous chronic diseases including type 2 diabetes, CHD, hyper- tension, several cancers, liver disease, and osteoarthritis. In 2007, it was estimated that obesity cost the NHS in England £4.2 billion per year, with the costs to the wider economy as high as £15.8 billion through lost productivity. Physical activity Physical activity reduces the risk of obesity and many chronic diseases including CHD, stroke, type 2 diabetes, cancer, mental illness, and musculoskeletal disease. The NHS in England recommends that adults undertake at least 30 minutes of moderate intensity exercise five days a week and that children and young people undertake at least 60 minutes of moderate intensity exercise every day. According to the Health Survey of England (2008), only around 39% of men, 29% of women, 32% of boys, and 24% of girls achieve their physical activity recommendations. The last 20-30 years have been associated with a reduction in physical activity as part of daily routines but an increase in physical activity for leisure. Alcohol The NHS in England recommends that men should not regularly drink more than 3-4 units of alcohol a day and that women should not regularly drink more than 2-3 units a day. Pregnant women and those trying to conceive are advised to avoid alcohol; if they do drink, it should be no more than 1-2 units once or twice a week. Data from the General Lifestyle Survey and from alcohol purchasing data suggest that alcohol consumption in the United Kingdom has decreased in the decade up to 2010 following a long-term increase since the 1960s. However, given the lag effect, alcohol-related diseases are continuing to rise. Effects of alcohol on health Acute excess Injury Health effects Road traffic accidents Violence Social problems Sexually transmitted infections (STIs) Peptic ulcer Liver disease Chronic excess Liver disease Pancreatitis Hypertension Stroke CHD Behaviour Page 7  CHD Suicide Excess in pregnancy Fetal alcohol syndrome Drugs Recreational drug use has multiple health effects including Psychological effects-addiction, anxiety, depression, psychosis Mortality Blood-borne viral infections-for example, hepatitis C, HIV Poor nutrition Social effects-unemployment, homelessness, crime, antisocial behaviour In England, both illicit drug use and hospital admissions related to drug misuse have declined since the 1990s (Statistics on Drug Misuse: England, 2012-NHS Information Centre). Particularly high- risk groups include young people, prisoners, and homeless people. Smoking Smoking is the leading cause of preventable mortality worldwide. It is associated with a wide range of ill health including: Cardiovascular disease (e.g. CHD, stroke) Respiratory disease (e.g. COPD) Cancer (including lung, oesophageal, bladder, renal, pancreatic, and cervical cancers) Psychological effects (e.g. addiction) Pregnancy effects (e.g. IUGR) Furthermore, tobacco can similar adverse health effects through exposure to second-hand smoke. Smoking rates are higher in males (except teenagers) and among people in lower socio-economic circumstances. Smoking is also strongly associated with alcohol intake. Sexual behaviour Unsafe sex can lead to sexually transmitted infections (STIs) and unintended pregnancies. Both of these phenomena are of high public health importance due to the potential long-term health effects and stigma associated with them. STIs can lead to chronic diseases such as pelvic inflammatory dis- ease, HIV, and cervical cancer due to HPV infection. Certain groups are at increased risk of some STIs, such as men who have sex with men. Such individuals may be offered specific preventative interventions (e.g. hepatitis B vaccination). Sun exposure Sun exposure is associated with malignant melanoma and with non-melanomatous skin cancers such as basal cell carcinoma and squamous cell carcinoma. In the United Kingdom, as in many other countries, there has been a large increase in the incidence of malignant melanoma over the last 25 years. In response, Cancer Research UK has run a skin cancer awareness and prevention campaign (SunSmart) since 2003. Behaviour Page 8 Role of social marketing The term social marketing describes the use of techniques of commercial marketing to sell a health message in order to benefit individuals and society. Social marketing approaches involve seven steps. As with the sale of any commodity, selling a health promotion message involves a consideration of the four Ps of marketing, namely, the product, its price, placement, and promotion. Behaviour Page 9 Behaviour Page 10 Developing Personal Skills Learning outcomes Understand the potential and limitations of working with individuals to develop their personal skills Demonstrate knowledge of different theories of health change that can be applied to health behaviour Be able to compare and contrast four different health behaviour change models Key Action Area 5 of the Ottawa Charter for Health Promotion – Developing Personal Skills Working with individuals to develop their personal skills can take many shapes and forms. Personal Development For some individuals, low self-esteem or poor self-confidence may be hindering them from reaching their potential. This may derive from the individuals personality, family life, school experiences, disability, experience of abuse, or their position in society (e.g. related to their sex, ethnicity, legal status or social / caste). Working with individuals to help them build their self-confidence and / or self-esteem can be a very valuable process. Supporting Mental Health For other individuals the focus may need to be on helping them to develop resilience and coping skills to deal with the challenges that life inevitably presents. When people are empowered in these ways, they are then in a stronger position to move ahead with their lives. They can set themselves goals which are personal in nature or which may relate to their family, their community or society, or even the world at large. They can then strive to achieve those goals. Developing Personal Skills - Literacy and Numeracy For millions around the world some of the most important skills they wish for are literacy and numeracy skills. These skills can liberate, their absence often leads to poverty and can facilitate oppression and exploitation. Therefore, simple community based activities such as setting up Adult Literacy Groups, Children’s Homework Clubs or Community Libraries, can be drivers of change for individuals, families and communities, breaking (sometimes) inter-generational cycles of low literacy / numeracy and potentially breaking inter-generational cycles of poverty. Initiatives such as these benefit not only individuals and families but these also contribute to community development and can yield collective benefits. Computer Literacy Being computer literate is now close to becoming an essential skill in many parts of the world. For families or communities with low incomes / poor infrastructure, providing computer access and classes via community organisations or in collaborations with educational facilities or businesses, can be a valuable initiative for Health Promoters to establish. Health Literacy When people are literate they can become ‘Health Literate’. This term is used to describe the capacity to read, comprehend and act upon (if appropriate), health related information such as instructions for taking a prescription and health education materials. It also requires those providing the information to provide it in as clear and uncomplicated a manner as possible! In some countries literacy advocates have campaigned for this and in Ireland for example, the National Adult Literacy Agency (NALA) has provided guidelines on the use of ‘Plain English’ and lobbied for their use by all agencies providing information to the public. Homework Clubs These provide students with a structured environment to complete homework. Homework Clubs support young people at risk by improving their academic ability, as well as their work habits, emotional adjustment and peer relationships. Assist pupils and parents or guardians by providing homework support to pupils. Address issues of in-school conflict between teachers and pupils over homework. Help raise pupil achievement through increased understanding of school subjects. Improve behaviour and social skills. Help young people to unwind in a relaxed setting. Allow participants to acquire new skills. Improve young people’s attitude to school and teachers. Improve attendance in school. Improves self-esteem. Improve literacy and numeracy Developing Personal Skills – Understanding & Changing Behaviour Public Health and Health Promotion interventions sometimes seek to encourage and support people to change their current behaviour to that which is better for their health. It is known that interventions which are based on social and behavioural science theories are more effective than those lacking a theoretical model. Behaviour change theories can help to - Identify specific health behaviours that people may wish to change. Describe the most salient personal factors in predicting whether people will/will not change their behaviour. Five Personal Factors known to influence health behaviour: 1. Personality Behaviour Page 11  1. Personality 2. Attitude 3. Self-efficacy 4. Locus of Control 5. Unrealistic Optimism 1. Personality ‘The Big Five’ McCrae and Costa 1987 (acronym OCEAN) Openness (inventive/curious vs consistent/cautious) Appreciation for art, emotion, adventure, unusual ideas and variety of experience. Conscientiousness (efficient/organised vs easy-going/careless) Tendency to show self-discipline, act dutifully, aim for achievement, planned rather than spontaneous. Extraversion (outgoing/energetic vs solitary/reserved) Energy, positive emotions, tendency to seek stimulation in the company of others. Agreeableness (friendly/compassionate vs cold/unkind) Tendency to be co-operative and compassionate as opposed to suspicious and antagonistic. Neuroticism (sensitive/nervous vs secure/confident) Individuals high in this trait tend to experience emotional instability, anxiety, moodiness, sadness, irritability Behaviour involves an interaction between a person’s personality and situational variables. In most cases people offer responses consistent with their personality traits. Behaviour Page 12 2. Attitude There are three components which form an attitude: Thought (Cognition), Feeling, Behaviour Cognitive beliefs about the attitude object e.g. cigarette smoking reduces stress/cigarette smoking is a sign of weakness. Emotional feelings about the attitude object, e.g. smoking is disgusting/pleasurable. Behavioural intended action towards the attitude object, e.g. I am not going to smoke. 3. Self-efficacy Theory Self-efficacy is the belief that one is capable to of performing the behaviours required to produce a desired outcome(Bandura 1986). People with high self-efficacy have high assurance in their capabilities People with low self-efficacy doubt their capabilities 4. Locus of Control (LOC), Rotter (1966) An individual's locus of control describes the extent to which they perceive that their experiences are within/outside their control. Internal locus of control: Individuals believe that they are the prime determinant of their health state External locus of control: Individuals believe that luck, fate, chance, other people are the prime determinant of their health state. 5. Unrealistic Optimism Weinstein (1897) defined 4 associated factors: 1. A lack of personal experience with the behaviour/problem concerned. 2. A belief that their individual actions can prevent the problem. 3. The belief that if the problem has not already emerged, then it is unlikely to do so in the future. 4. The belief that the problem is quite rare. Four Theories and Models of Individual Behaviour Change. 1. The Health Belief Model (HBM) 2. The Transtheoretical Model (TTM) 3. The Theory of Reasoned Action (TRA) / Theory of Planned Behaviour (TPB) 4. Social Ecology Model (SEM) The above models are the best known and most widely used theories and models of behaviour change. However, it must be acknowledged the theories were developed in the context of western societies and may not be generalisable to other regions of the world. The first three have an individual focus while the fourth incorporates the wider determinants of health. 1. The Health Belief Model (HBM) The HBM proposes that people will not seek health measures unless they: Possess minimal levels of health motivation and knowledge. View themselves as potentially vulnerable. View the condition as threatening Are convinced of the efficacy of the ‘treatment’ Behaviour Page 13  Are convinced of the efficacy of the ‘treatment’ See few difficulties in undertaking the action. The above factors can be modified by socio-economic, demographic or media influences or encountering illness (e.g. in a friend or relative) HBM: Threat & Evaluation Perception of Threat I believe that coronary heart disease (CHD) is a serious illness contributed to by being overweight Perceived Severity I believe that I am overweight Perceived Benefits of Change If I lose weight, my health will improve Perceived Barriers to Change Changing my cooking and dietary habits when I also have a family to feed will be difficult and possibly more expensive HBM: External and Internal Factors People may identify ‘cues’ to action which could be external or internal in nature. Cues to action (Becker & Maiman 1977): 1. That recent TV programme on the health risks of obesity worried me (external). 2. I am regularly feeling breathless on exertion so maybe I could think about dieting (internal) 3. I feel very tired all the time so maybe if I took some exercise it would energise me (internal) Health Motivation (Becker, Haifner & Maiman 1977): It is important to me to maintain my health, and I will make a concerted effort to do so. Limitations of the Health Belief Model Most HBM based research has incorporated selected components of model, thus not testing it as a whole. It does not take into consideration factors such as environment or economics. It does not incorporate the influence of social norms and peer influences‘ on decisions regarding health behaviours. 2. The Transtheoretical Model There are four key elements of the Transtheoretical Model of Change (Reed 1999) A set of distinct categories that describe the stages of behaviour change that people go through (SOC’s). A set of ten processes which people use as they change behaviour. Self-efficacy underpins different stages. The recognition that weighing up of pros and cons of changing behaviour will influence progress e.g. Smoking cigarettes / flossing teeth / physical activity Behaviour Page 14 The Transtheoretical Model applied to Physical Activity Pre-contemplation No intention to become more active in the next six months. Contemplation Thinking about becoming active within the next six months and considering the costs and benefits. For example ‘I think I need to take up some exercise but not quite yet, maybe after my summer holidays’ Preparation Intending on action in next 30 days or so. Defined by an actual change For example a person might start to take a walk on weekends or take out a gym membership but not enough to meet minimum criteria for active living. Action People have become regular exercisers but only within the previous six months. They are feeling the benefits but prone to relapse. Maintenance Regular exercise has been maintained for over six months. The behaviour is conditioned and less prone to relapse. Relapse People who relapse can fall back to any stage, and may begin the cycle of change again from any of the prior stages. : Some Limitations of the Transtheoretical Model The model is primarily a self-change / help model A person may be asked to think of reasons why s/he might want to quit smoking and to consider health risks of smoking. No sense of how much time is reasonable within each stage. Smokers hospitalised for a myocardial infarction may quit smoking so go directly from pre-contemplation to action. Intention to change (decisional balance) is a good predictor of change, BUT past behaviour is a better predictor of future behaviour. 3. The Theory of Reasoned Action The Theory of Reasoned Action (TRA) suggests that a person’s behaviour is determined by their intention to perform the behaviour and that this intention is, in turn, a function of their attitude toward the behaviour and subjective norms (Fishbein & Ajzen, 1975). The best predictor of behaviour is intention or instrumentality (belief that the behaviour will lead to the intended outcome). Instrumentality is determined by three things: 1. The individual’s attitude, or personal opinion, on whether a specific behaviour is good or bad, positive or negative, favourable or otherwise. 2. The prevailing subjective norms, or the social pressure arising from other people’s expectations, as seen from the individual’s point of view. This, in turn, has two components: ○ The individual’s normative beliefs, or what he perceives to be what other people want or expect; and ○ The individual’s motivation, or need, to comply with what other people want or expect. 3. The perceived behavioural control of the individual, or his perception of his ability to perform a specific behaviour. The more favourable the attitude and the subjective norms and the greater the perceived control, the stronger the person’s intention to perform the behaviour. The less favourable the attitude, subjective norm and sense of perceived behavioural control the weaker the intention to perform the behaviour (Azjen 2002). Behaviour Page 15 Theory of Planned Behaviour The Theory of Planned Behavior (TPB) is viewed as an improvement to the Theory of Reasoned Action. The two theories are often mentioned and discussed together. The Theory of Planned Behaviour reinforces and adds to the assumptions in the Theory of Reasoned Action. This theory suggests that Human Behaviour is guided by three types of beliefs. 1. Behavioural beliefs (beliefs about the outcomes of a behaviour and evaluation of same: produce favourable/unfavourable attitudes). 2. Normative beliefs (expectations of others and compliance with same: produce perceived social pressure, subjective norm). 3. Control beliefs (presence of factors that may facilitate or impede behaviour; perceived behavioural control). Limitations of the Theory of Planned Behaviour ‘Moral norms’ – some intentions and behaviours may be partially motivated by moral norms not just social norms. Anticipatory regret – anticipating that regret would result if a certain behavioural decision was made/not made influences future behavioural intentions and behaviour. Self-identity – how one perceives and labels oneself may influence intention above and beyond the effect of core TBP variables. Implementation intention – forming an implementation intention is thought to be part of the process involved in turning an intention into action, i.e., filling the intention behaviour gap highlighted by limitations in behavioural prediction by TPB studies. Self-efficacy beliefs – shown to be more strongly associated with behaviour than perceived control over the behaviour. 4. Social Ecology Model (SEM) A model which can be used to examine the multiple effects and interrelatedness of social elements in an environment (Bronfenbrenner 1977, 1979). The SEM offers a framework for programme planners to determine how to focus prevention activities. Each level in the SEM can be thought of as a level of influence and a key point for prevention. It is important to implement programmes and policies that can reduce risk factors and increase protective factors at each of the different model levels (CDC, 2002). Microsystems Individual and interpersonal features, aspects of the social identity Mesosystems Organisational or institutional factors that shape or structure the environment Exosystems Community level influence, including fairly established norms, standards and social networks. Macrosystems The cultural contexts, not solely geographically or physically but emotionally and ideologically. Behaviour Page 16 Top down effects Environmental effects shape individual behaviour Bottom up effects Individuals or community affect higher levels Interactive effects Occur simultaneously at multiple levels Limitations Challenging to design comprehensive interventions. Requires integration of knowledge from several different disciplines. Incorporation of multi-level, multi-method assessments of programme outcomes over extended periods can be quite expensive and logistically complex. Can be cumbersome and impractical to implement. Summary: Developing Personal Skills Facilitating individuals to develop their personal skills can be interesting and rewarding as you see them make progress. Theories and models of Behaviour Change offer guidance in the planning and development of initiatives which seek to work with individuals specifically on behaviour change. They have strengths and limitations but research has shown that initiatives are more effective when based on a theory / model than not. If you are using a Theory / Model in the planning and development of a HP initiative with individuals, try to ensure you chose the most appropriate one for the issue / people / context – i.e. try to get a good ‘fit’. NOTE: From a Health Promotion perspective the most effective way to promote health and address health inequalities and inequities is through the creation of policies and environments which support health, through strengthening communities and developing primary health care. These approaches are collective in nature and produce outcomes for many. Working with individuals is resource intensive and relative to this, the benefits are small. Behaviour Page 17 Psychology of decision-making in health behaviour In order to improve health outcomes through greater concordance with treatment, clinicians need to understand the issues that may influence a patient's decision about whether or not to follow therapeutic recommendations. There are a number of models and theories that attempt to offer explanations for why people behave as they do with regard to health. Zola proposed five 'triggers' for help seeking. Beliefs about medication: reasons for variable adherence among patients It is estimated that 30%-50% of medications are not taken as prescribed. Non-adherent behaviour is sometimes regarded by prescribing clinicians as the preserve of certain recalcitrant patients, or due to patients' forgetfulness, confusion, or a lack of understanding. Research into adherence (i.e. the extent to which the patient's behaviour matches agreed recommendations from the prescriber) suggests a more nuanced picture. There does not appear to be a clear pattern of non-adherence among different socio- demographic groups or diseases. However, patients' beliefs about medicines do provide some insights: while many patients believe that their medication is necessary, they may also have concerns about the risks of side effects and dependence. High levels of concerns about the risks of medicines often correlate with self-reported non-adherence. This finding has led some researchers to conclude that 'viewed from the patient's perspective, [non-adherence] often represents a logical response to the illness and treatment in terms of their own perceptions, experiences and priorities, including concerns about side effects and other unwelcome effects of medicines'. Behaviour Page 18 Occupation and health The effects of occupation on health vary according to the Type of occupation Personal risk factors Levels of social support In general, there are substantial health benefits to being in work, but certain occupations can expose employees to particular risks. Unemployment Being out of work is associated with adverse physical, mental, and social effects. These phenomena are related partly to the length of time spent unemployed. Although being out of work may cause morbidity, the causal relationship also works the other way around (i.e. people who are physically or mentally unwell may be more likely to leave jobs or have difficulty working). Studies indicate that ill health and healthcare use are also associated with job insecurity, especially the anticipation of job losses. There are consequences from unemployment on the individual, on families, and on society at large. Behaviour Page 19 Complex interventions Combating complex problems using a wide range off and broader cultural interventions. Several methods have been adopted to tackle complex issues such as poor diet. They include the so-called medical, behavioural, and socioenvironmental approaches: Medical approach This approach focuses on disease, with a narrow conception of the causes of disease and the determinants of health. Illness is considered in micro- biological or physiological terms. Prevention focuses on known risk factors (e.g. high cholesterol and hypertension as risk factors for cardiovascular disease). Risk reduction focuses on pharmacological interventions (e.g. statins or anti-hypertensives), and health is equated with the absence of disease and the provision of health services. Socioenvironmental approach This approach seeks to improve health by means of strategies that modify the social, political, and economic environment through government and community actions. Health education involves recognition that aspects of home, workplace, and community life may be detrimental to health. Advantages Evidence of effectiveness (e.g. legislation to reduce salt in food) Potential to reduce inequalities (by tackling structural barriers to healthy choices) Disadvantages May be perceived as minimising free will (the 'nanny state') Can lead to unpopular policies Behavioural approach This approach promotes education and free choice, rather than legal or fiscal coercion. Disease prevention can be achieved through the provision of information to populations about lifestyle risk factors (e.g. smoking, drinking, or diet). In particular, many campaigns now make use of social marketing to encourage people to adopt healthier eating habits (see Section 21.3). Social marketing aims to take into account the priorities and perspectives of particular sectors of a target group for health messages. Messages and health promotion campaigns are then targeted accordingly. A limitation of the behavioural approach is that it tends to disregard sociocultural influences on behaviour, such as the way in which dietary choices are influenced by advertising and income. Dietary education may therefore have little impact on poorer families who have no access to affordable fresh fruit and vegetables. This approach has also been criticised for blaming problems on ignorance or on personal choices through the attribution of guilt. Nudge Neoclassical microeconomics assumes that individuals always make perfectly rational decisions. In contrast, behavioural economics seeks to recognise the foibles and irrationalities of human nature, including overconfidence, projection bias (blaming others), and the effects of limited attention. These irrationalities can lead to systematically irrational behaviours, such as Status quo bias (when people prefer to continue a course of action simply because it has been previ- ously pursued) Social influences (e.g. herd mentality, where people make decisions that following the opinions and choices of others even when demonstrably suboptimal) Heuristics or 'rules of thumb' (e.g. availability heuristic-perceiving the frequency of an event simply based on the ease with which an example can be brought to mind) The authors of 'Nudge' advocate the doctrine of 'libertarian paternalism'. This is where individuals are given the freedom to make their own choices, but a paternalistic organisation, such as the government, develops a 'choice architecture' that favours the healthiest option. For example, a super- market might sell a wide range of products and customers are free to purchase any of the foods on offer, including unhealthy foods. However, if healthier options are stocked on the shelves at eye level, then this will have the effect of 'nudging' shoppers into purchasing healthier foods without constraining their liberty. Equally, by making pension schemes opt-out rather than opt-in, the government provides a nudge to higher enrolment, which should help reduce poverty in old age. The Nudge approach is sometimes criticised as simply devolving responsibility for decision-making to individual citizens. In fact, however, the Nudge vision embraces a responsibility for government to encourage people into making the healthiest selection. Advantages Does not limit individual choice Low cost Simple and rapid Some evidence of effectiveness (e.g. placing fruit near checkout increases consumption) Disadvantages Behaviour Page 20 Disadvantages Relatively ill-defined concept Little evidence at a large scale May be less effective than proscriptive legislation Potential for perverse responses Might widen healthcare inequalities Behaviour Page 21 Concepts of health and wellbeing Although good health is sought almost universally by human beings and is prerequisite for well- being, the definition of health is far from being universally agreed. The way in which health is defined can be an important influence on health policy and on health promotion strategies. The WHO definition: Explicitly links health with well-being Conceptualises health as a positive aspiration, not merely the absence of disease Similarly, there is debate about what constitutes well-being. For example, the Well- Being Institute at the University of Cambridge defines well-being as the 'positive and sustain- able characteristics which enable individuals and organisations to thrive and flourish'. Other authors question whether well-being is indeed something that can be researched to uncover its essential nature, and argue that well-being is a social and cultural construct that is interesting because of what it tells us about a society and a culture. Behaviour Page 22 Concepts of primary and secondary deviance Becker first described deviance as a behaviour that is seen as being unacceptable within a particular culture. Labelling theory and deviance People who deviate from the norm are labelled as being abnormal in some way. However, note that behaviour that is seen as being perfectly acceptable in one culture may be regarded as unacceptable in another. On being recognised as such, deviant behaviour may be subject to sanctions, punishment, correction, or treatment. In medicine, deviance has implications with regard to the labelling of organic and psychiatric disease. Parsons considered illness as a form of deviance where the doctor is an agent of social control (i.e. the doctor restricts access to the sick role by labelling people as either sick or healthy). Example: Combating drug taking and deviant behaviour through drug rehabilitation requirements The use of illicit drugs is a prime example of deviant behaviour in Western societies. Drug use is often linked to a range of other deviant behaviours (such as stealing and prostitution) that can result in contact with the criminal justice system. However, drug use is also recognised in many Western cultures as an addiction and as such may be regarded as an illness. In England, the programme of Drug Rehabilitation Requirements (DRR) explicitly links this deviant behaviour with the sick role. People who are arrested and have a history of taking illicit drugs may be offered treatment and rehabilitation for their drug use in an attempt to break the cycle of drugs and crime. Participants' attendance is closely monitored and in certain circumstances they can be required to attend. In this way, DRRS serve as an alternative to prison, which was the traditional way of dealing with deviant behaviour." Behaviour Page 23 Illness behaviour Factors that influence illness behaviour Mechanic identified ten variables that influence illness behaviour: 1. Visibility of symptoms and signs 2. Perceived seriousness (by the patient) of the symptoms, based on perceptions of present and future probabilities of danger 3. Amount of disruption caused by the symptom to work, family, etc. 4. Frequency and persistence or recurrence of symptoms 5. Tolerance threshold of person exposed to symptoms 6. Knowledge, information, and assumptions of the evaluator 7. Basic needs leading to denial 8. Needs leading to competition with illness 9. Competing interpretations assigned to symptoms once recognised 10. Availability of treatment: access, cost (not only money but also emotional, such as stigma) Cultural differences Pilowski and Spence noted some marked cultural differences between Anglo-Saxon (stoical, withdrawn) and Mediterranean groups (emotionality) in their interpretation and response to symptoms. Similarly, Zborowski found that Americans of Irish origin had a matter-of-fact attitude toward pain, whereas people with an Italian or Jewish background tended to be more demanding and dependent on medical help. Phenomenology of symptoms Diseases that present with striking symptoms (e.g. bleeding, jaundice) are more likely to receive prompt medical attention than those that are less dramatic. Lay referral and intervention Sometimes, a lay person may intervene to initiate medical consultation, for example, on behalf of a child or by calling an ambulance for a person who is having an epileptic fit or suffering from chest pain. Behaviour Page 24 Illness as a social role People with symptoms are not automatically patients. They become patients (or are defined by health professionals as such) because they choose to seek healthcare. The terms sickness, illness, and disease are used interchangeably and may often co-occur; however, their meanings are distinct: Sickness covers both illness and disease. Illness refers to a patient's subjective experience of mental and physical sensations or states. Diseases are the abnormalities in form and function of organs and body systems that clinicians diagnose and treat. According to Cassell, 'Illness is what the patient feels when he goes to the doctor, disease is what he has on the way home'. The concept of illness as a social role introduces the notion that people who feel ill and those who care for and treat them behave in ways that are related to society's implicit ideas of what it means to be sick. The American sociologist Talcott Parsons described this as 'the sick role'. Sick role Parsons wrote that people who are ill have certain rights and responsibilities that work together in the interest of society. These rights and responsibilities are all both temporary and universal. Example: The sick role in a New Guinea village Gilbert Lewis's ethnographic descriptions of sickness in a New Guinea society highlight the variations in the ways that different cultures treat people with sickness. In his account, both Western medical approaches and local rituals were used to attempt to cure a sick man. As part of the latter approach, the source of his illness was sought from his previous behaviour (fights, disputes, etc.) and spiritual cures were attempted, including placing crucifixes around the bed and conducting a Malyi ceremony. Many of these behaviours contrasted with the Western ideas of the sick role but they emphasise how a 'sick role' is not confined to Western cultures. Doctor-patient role Doctors often face a conflict between acting in their patients' best interests and serving the wider interests of society. For example, if a doctor saw a patient who worked as a lorry driver and the patient reported having had a blackout, then the doctor would be obliged to inform the Driver and Vehicle Licensing Authority (DVLA) in Great Britain, or similar agencies in other countries, thereby jeopardising the driver's livelihood. Scambler describes the traditional doctor- patient role as being Behaviour Page 25 other countries, thereby jeopardising the driver's livelihood. Scambler describes the traditional doctor- patient role as being paternalistically doctor centred, but in recent years, there has been a shift in some countries towards more patient-centred care. It is increasingly being recognised that patients and professionals each have their own area of knowledge and expertise and that both parties benefit from working together. Behaviour Page 26 Risk behaviour A person's aversion or predilection to risky behaviour is influenced by several factors, including the following: Familiarity with the outcome of the risky behaviour. Degree of personal control over the risk factor - in contrast to environmental risks, individuals tend to downplay personal risks. This tendency is due to beliefs of personal invulnerability and that other people are at greater risk ("It won't happen to me') Demographics (age, gender, and ethnicity) - young people are more likely to take risks (partly due to greater peer pressure) and women are more likely to be risk averse. Risk interventions Interventions can be implemented at different levels: Professionals - to reorient services Patients - to receive preventive treatment, make lifestyle changes The public - to make healthy choices and protect or promote the health of society Behaviour Page 27