Lyfestyles and health behaviour

Monday, September 18, 2006

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Friday, September 01, 2006

Determinants of health-enhancing behaviours


Might it not be the case that our personalities play a very significant role in determining our adoption, or otherwise, of health-enhancing behaviours? Certainly there seem to be many psychologists who believe this is the case, as evidenced by the amount of research conducted in this area. Probably the most popular explanation offered has concerned the so-called Type A and B personalities.

The concept of the Type A personality was introduced by Friedman and Rosenman (1974) to describe psychological characteristics which they believed to be associated with proneness to coronary heart disease (CHD). The Type A personality is: highly competitive and achievement oriented, does not suffer fools gladly, always in a hurry and unable to bear delays and queues, hostile and aggressive, it also reads, eats and drives very fast, and is constantly thinking what to do next, even when supposedly listening to someone else. In contrast to this the Type B personality is relaxed, laid back, lethargic, even-tempered, amiable and philosophical about life, relatively slow in speech and action, and generally has enough time for everyone and everything.

The classification of individuals as Type A or B has traditionally been made on the basis of a structured interview (Rosenman, 1978) in which people are not only asked questions about their Type A/B modes of behaviour but also provoked into directly manifesting such behaviour by being subjected to pauses and delays in the interview, deliberately interrupted and challenged about their answers to questions. Their responses to these provocations enable the interviewers to refine their ratings of Type A/B characteristics. The structured interview (SI) is generally considered to be the best method for assessing the Type A/B personality but many researchers have adopted the less time consuming approach of using standardized self-report questionnaires of which the Jenkins Activity Survey has been most commonly used. This simply asks questions about B modes of behaviour.

Early research tended to lend strong support to these ideas. For example, the Western Collaborative Group Study (WCGS) in which over 3/000 Califomian men, aged from 39 to 59 at entry, were assessed as Type A or B using the SI and followed up initially over a period of eight and a half years, and later extending over 22 years. In an influential report on the results at the eight nd a half year follow-up, Rosenman et al. (1975) found that Type As were twice as likely as Type Bs to suffer from subsequent CHD. Of the sample 7% developed some signs of CHD and two-thirds of these were Type As. This increased risk was apparent even when other risk factors assessed at entry, such as blood pressure and cigarette smoking, were statistically controlled for.

However more recent research has not found this level of relationship, so instead researchers have now tended to focus on more specific aspects of the Type A personality that may determine illness (Adler & Matthews, 1994). One component that has generated a decent amount of research has been hostility. As in the case of the Type A/B personality, research on hostility and health is divided between studies using SI methods to assess hostility and those using questionnaires, usually the Cook-Medley Ho Scale. For example, Barefoot, Dahlstrom, and Williams (1983) found that high hostility increased the risk for CHD. They used the Ho scale to analyze the hostility scores of a group of physicians during medical school and followed up 25 years later. The results indicated that hostility was associated with more than a fourfold increase in the chances for CHD.

Unconscious Processes

From a Freudian perspective there may be many unconscious processes involved in determining health behaviours. Freud consistently argued that what was in the unconscious would often become manifested in behavioural ways, thus given that health behaviours are in no way different to other behaviours why could we not become well or ill due to unconscious factors? One psychoanalyst who to this idea to its more extreme conclusions was Georg Groddeck.

Georg Groddeck propounded a somewhat bizarre and largely intuitive theory based upon his experiences in analysing cases of heart disease, cancer, and other serious organic illnesses. The individual according to this theory does not live his own life and has little to do with his fate. He is, in fact, lived by the 'It' which seems to be conceived as a compound of the Freudian 'Id' with the wisdom of the Jungian collective unconscious. It was the 'It' which decided when the individual would be born, and it also decides when he will die, whether or not he will succeed, and when and how he becomes ill. Every disease, from a wart to a cancer, is an expression of the omnipresent and omnipotent 'It'. For example, a woman with a small wart on the inner aspect of her thigh was told by Groddeck that she wished to become a man and had therefore produced (or, rather, her 'It' had produced) a miniature penis. A woman with a tumour of the uterus had obviously developed the tumour because, lacking a child, the 'It' had caused this deadly substitute 'child' to grow within her. A fracture case would be asked: 'Why did you break your arm?' and a case of laryngitis: 'Why did you wish to be unable to speak?' (Brown, 1964, pp.89-90).

The evidence offered by Groddeck is purely anecdotal and most people would regard his views on the causes of physical illness as absurd, but is it necessarily ridiculous to propose that a real physical illness can sometimes come about as the result of an unconscious impulse? To take a fairly extreme example, if we accept that, in the case of an hysterical pregnancy, many of the physical symptoms of a real pregnancy can be brought about by an unconscious wish, is it not conceivable that, on some occasions, a real heart attack can occur in someone who has an unconscious wish to commit suicide?

Rather than propose that the symptoms of organic disease always have a symbolic meaning for the sufferer, an alternative and more influential approach from the psychosomatic schools has been based on the concept of unrelieved tension. When certain problematic emotions, such as anxiety, depression, aggression and sexual impulses, cannot be effectively discharged or rechannelled, they can have physiological consequences which predispose the individual to develop specific organic diseases. One area that gained a great deal of attention during the 1940-50's was trying to why some people developed cancer. Leshan and Worthington (1956), reviewing research in this area for the British Journal of Medical Psychology, drew the following inclusions:

There appear to be four separate threads which run through the literature in this area. These are (1) the patient's loss of an important relationship prior to the development of the tumour; (2) the cancer patient's inability successfully to express hostile feelings and emotions; (3) the cancer patient's unresolved tension concerning a parental figure; (4) sexual disturbance. (Lesham and Worthington, 1956, p. 54)

Whilst some of these ideas may seem somewhat bizzare, the notion that we are responsible for our own health and that we may or may not engage in health-enhancing behaviours for reasons that we are not aware of, is still an assumption that seems plausible today. For example it is still used in attempting to explain why some people experience eating disorders and others do not.

Mental State

Whilst we may assume that mental health states (e.g. being very happy or sad) will contribute to determining health behaviours, we may be wrong. For example, Adler & Matthews (1994) reviewed findings linking positive and negative dispositions to illness and they report a fairly perplexing set of contrasting findings. For example, Peterson et al (1988), in a 35-year follow-up of 99 graduates of the Harvard University classes of 1942-44, found that pessimistic explanatory style, as assessed in tests taken by the participants while undergraduates, were predictive of poor physical health in later life as assessed by physicians. Yet in stark contrast to this, Friedman et al. (1993) found that children who had been rated by their parents and teachers as having a good sense of humour and being optimistic and cheerful were more likely than other children to die early in adulthood.

Another somewhat counter-intuitive finding is that of Reed et al (1994) who investigated the relationship between realistic acceptance and survival time of men suffering from AIDS. They found that those who were assessed as showing a realistic acceptance of their deteriorating condition and eventual death had a mean survival time which was nine months less than those who were assessed as being unduly optimistic. In an earlier review of research concerning mental health Taylor and Brown (1988) concluded that overly positive self-evaluations, exaggerated perceptions of control and mastery and unrealistic optimism, far from being associated with psychological difficulties, were actually associated with good mental health. Reed et al. appear to have shown that this surprising result extends even into the field of physical health. Thus it does not appear to be too clear what mental states are relates to health behaviours and well-being.

Finally, another mental state which has been of interest to health psychologists over the last 20 years is the notion of locus of control. Originally formulated by Rotter (1954), this concept was applied to health beliefs by Wallston et al (1978) who developed the Multidimensional Health Locus of Control (MHLC) Scale. This questionnaire has three subscales measuring the extent to which people attribute their state of health to their own behaviour (internal locus), and/or external factors including both powerful others, especially medical professionals, and chance or fate. In a detailed review of research on the topic, Norman and Bennett (1996) found that the results were mixed and they concluded that the relationship between locus of control and health behaviour is a weak one, a conclusion which was recently confirmed by a large-scale study of a representative sample of 11,632 people who completed the MHLC in Wales (Norman et , 1998).

Health Belief Models

The Health Belief Model (HBM) was originally developed by Rosenstock (1966). According to the model (see above image), a person's readiness to take a h action is determined by four main factors:

• the perceived susceptibility of the disease;

• the perceived severity or seriousness of the disease;

• the perceived benefits of the health action;

• the perceived barriers to performing the action.

More recent revisions of the theory (Becker and Rosenstock, 1984) have also included three further factors in the HBM. These supplementary factors are demographic variables, psychosocial variables and structural variables, in particular knowledge of the disease and contact with the disease. More recently 'cues to action' has been added as an additional explanatory variable (Figure 10.1) This proliferation of variables led Oliver and Berger (1979) to describe the HBM as 'more a collection of variables than a formal theory or model' (p. 113).

The model works like this; the likelihood of me altering my health lifetsyle, lets say to stop smoking, is affected by my reasoning about such a change. I will need to be aware of how susceptible I am to illness coming from smoking and how severe this could be. These factors are more than likely to be effected by demographic variables, such as my age, sex and where I live. Then I weigh up the benefits but also the barriers to me stopping smoking. This will be affected by psychological variables, such as my personality, peer group pressure, etc. Finally having done all of this I will still need some kind of cue to action to get me started on any change to my health lifestyle (cutting down or quiting smoking).

Here is an example; I want to stop smoking because I could get lung cancer (susceptible) and this would be very bad (severity), given my age (33) and that I am male this is now a very real risk. The benefits are that I get to live a long and healthy life but the barriers are that I have smoked for so long that I am addicted. However I believe I can beat my addiction and I have the support of my family (psychological and social factors). Now all I need is a cue to doing something about it, this may be not being able to cycle as fast as my son, or that my wife and son complain that I cough alot in the morning. These spur me on to quitting smoking!

Here is a different example; I want to stop smoking because I could get lung cancer (susceptible) and this would be very bad (severity), but given my age (15) and that I am female I don't see this as a great risk (only OLD people get cancer from smoking, don't they?). The benefits would be that I get to live a long and healthy life but the barriers are that if I stop smoking I may put on weight and not seem so mature. Given the fact that I am currently highly neurotic about my weight and appearance and that I must be seen as mature and most of my fiends smoke, means I am unlikely to view the long term benefits of quitting smoking in a favourable way. I do not seem to be getting ill or unfit because I smoke, nor does anyone complain to me about smoking (except my boyfriend, but I can ignore him), so there is no cue for action. Thus I choose to continue smoking even though I do know that on some levels I should not do so.

Research evidence does lend support to this model, though usually only parts of it rather than the whole thing. For example, The Canadian Health Promotion Survey found that two-thirds of Canadians believed that exercise would benefit their health (Canada mess Survey, 1984). Further, it was apparent that those who reported increasing their exercise level did so mainly because of their increased knowledge of the risks of remaining sedentary. The Canada Fitness Survey found that the most frequently cited barriers for lack of participation in exercise were lack of time, injury, illness, poor weather and inconvenience. Lee (1993) suggested that the identification of these external barriers may act as a means of avoiding personal responsibility for lack of exercise.

Theory of Reasoned Action

The theorv of reasoned action (TRA) was developed by Ajzen and Fishbein (1980) and argues that intention is the best predictor of behavior. An intention toward a behavior is influenced by our attitude toward that behavior. This attitude is influenced by the strength of belief that the behavior will result in a certain outcome and the evaluation of the outcome. Say, you intend to start exercising to lose weight. You will have a strong intention to exercise, if you believe exercise (behavior) will result in losing weight (outcome) and losing weight is important to you (evaluation). Intention is also determined by what we believe other people think about our ability to obtain a certain outcome and how they evaluate that outcome. This is called the subjective norm. For example, if your family and friends think it unlikely that you can stick with an exercise program or that weight lose for you is not desirable, your intention to exercise may be weakened. It depends, in part, on how much you care about what they think. Intention, then, is determined by the individual's attitude toward the behavior and subjective norms.

This theory was then further altered by Ajzen to include and extra dimension; the individuals belief that they can control their behaviour enough to allow any change to occur. With this addition the model became known as the Theory of Planned Behaviour.

Theory of Planned Behaviour

Here is an example of how the model works: If applied to alcohol consumption, the TPB would make the following predictions; if an individual believed that reducing their alcohol intake ould make their life more productive and be beneficial to their health (attitude to the behaviour) and believed that the important people in their life wanted them to cut down (subjective norm), and in addition believed that they were capable of drinking less alcohol due to their past behaviour id evaluation of internal and external control factors (high behavioural and evaluation of internal and external control factors (high behavioural control), then this would predict high intentions to reduce alcohol intake (behavioural intentions).

The theory of planned behaviour has been used to assess a variety of health-related behaviours. For example, Brubaker and Wickersham (1990) examined the role of the theory's different components in predicting testicular self-examination and reported that attitude towards the behaviour, subjective norm and behavioural control correlated with the intention to perform the behaviour.

Developmental, Cultural and Gender differences in health behaviours

Developmental Differences

From your own experience you will be aware that the types and amount of physical exercise you undertake has changed from when you were a child at primary school, to a young person about to enter adulthood (and beyond, if the case applies). Why does this happen? How can children who seem on the whole to enjoy physical exercise turn into young people some of whom are international sports people and others who have not engaged in any physical activity (other than maybe walking to school/college, sometimes?) for many years? Below is some research evidence that leads us to believe that biological, gender and social factors all come together to alter how we engage in physical exercise, as an example of a health behaviour, during our formative years of development.

For example, Kunesh et al (1992) conducted a detailed investigation of the school play activities of a sample of 11- to 12-year-old girls in central USA. In interviews the girls reported that they found physically active games at home and at school enjoyable. However, in the school playground the girls preferred to stand in a group and talk while the boys participated in various games. When the girls did participate in games they were often criticised by the boys for their supposed inferior skill performance. To avoid this negative treatment the girls excluded themselves. The girls reported that when playing at school they felt nervous and embarrassed. These findings would suggest that while at an early age boys and girls both enjoy physical activities by the time they reach puberty the girls feel that they are being excluded.

As they enter adolescence the gender difference in participation in physical activities becomes more pronounced. From a series of interviews with young people from southeast London, Coakley and White (1992) identified five factors which help explain young people's decisions about participation in sporting activities:

  1. Consideration of the future in regards to the transition into adulthood: Certain sports are accepted and others rejected depending upon their perceived adultness. Teenagers reject those games which they perceive as childish. Young women in particular become less involved in sporting activities which they perceive as having little connection with the female role.
  2. Desire to display and extend personal competence and autonomy: Young people become involved in sporting activities to the extent to which it extends their feelinq of competence and autonomy Aaain there are qender differences with the young women being less likely to define themselves as sportspersons even if they are actively involved in physical activities. For them, sports is often perceived as a more masculine activity.
  3. Constraints related to money, parents and opposite-sex friends: Access to material resources is an important factor in explaining whether young people participate in certain sporting activities.
  4. Support and encouragement from parents, relatives, and/or peers: Young people report that they are often actively encouraged by family or friends to participate in certain physical activities. The young women in particular note the importance of having a friend to accompany them to sporting activities.
  5. Past experiences in school sports and physical education: Many young people report certain negative school experiences which colour their attitudes to physical activities. In particular, young women comment on how school physical education was associated with feelings of discomfort and embarrassment. Young men seem to have more pleasant memories of school sport.

Thus it would seem that developmental factors in regards to the move from childhood, into adolesence and then into young adulthood seem to play a significant role in how younger people engage in and relate to physical exercise. Though we can not exclude gender as an important factor in this equation.

Gender Differences

There appear to be gender differences in relation to exercise. as an example of a health-enhancing behaviour, though it is also hard to separate gender from othe variables, e.g. age and socio-economic background.

Simons-Morton et al. (1997) conducted a large survey of over 2,400 third grade (8- to 9-year-old) children in four US states. They found that not only did boys participate significantly more in moderate to vigorous physical activity but they also participated more in sedentary activities. Specifically, boys spent more time than girls watching television and playing video games.

Gottlieb and Chen (1985) considered the character of physical activity among a sample of 2,695 seventh and eight grade students (12-14 year olds) in Texas. They found that the female students were more likely than the males to participate in running, swimming, dancing, skipping, tennis, roller skating and volleyball. These activities were largely classified by sporting experts as individual, non-competitive and potentially aerobic activities. The male students preferred team, competitive, non-aerobic activities. The male students preferred team, competitive, non-aerobic activities. Gottlieb and Chen concluded that this evidence of sex typing in sporting activities reflected 'the importance of socialization within the family unit and later through the peer group for gender differences'.

Hasbrook (1986) found that gender differences in sporting participation interacted with socio-economic status. Among girls, those from poorer d backgrounds were less likely to participate in physical activity "eas among boys there was no relationship with social position. Oygard and Anderssen (1998) also found that teenage girls with higher levels of education were more physically active whereas again among boys lere was less evidence of a relationship with level of education.

Cultural Differences

By most any gauge of well-being, health correlates with social class (Marmot, Kogevinas, & Elston, 1987). According to Sarafino (1994) individuals from lower classes are more likely than those from from lower classes are more likely than those from higher classes to :

  • Be bom with very low birth weight.
  • Die in infancy or in childhood.
  • Die in adulthood before age 65.
  • Develop a long-standing illness in adulthood.
  • Experience days of restricted activity because of illness.

Not coincidentally, people from the lower classes have poorer health habits and attitudes than those from higher classes; for instance, they smoke more, participate less in active sports, and are less likely to feel that individuals can actively promote their own health (Marmot, Kogevinas, & Elston, 1987). Research has also shown that people from lower classes have less knowledge about risk factors for disease. They are less likely than individuals from upper classes to know, for example, that people can reduce their cardiovascular risk by controlling their blood pressure, stopping smoking, and eating a low-cholesterol diet (Hossack & Leff, 1987).

Unfortunately these factors seem to be compounded by ethnicity differences. For example, the rate of infant mortality in the USA is twice as high for Blacks as it is for Whites. Among babies who survive the first year, the life expectancy for an African American baby is about 6 years shorter than that for a White baby in the USA (USBC, 1991). Moreover, regardless of that African American baby's gender, he or she is far more likely than a same-sex white baby to develop a major chronic disease in its lifetime, and to die of that disease. Thus the Empirical evidence suggests that the health of minority ethnic groups is generally poorer than that of the majority of the population, and that this pattern has been consistently observed in the USA between African-Americans (or Blacks) and Whites for at least 150 years (Krieger, 1987).

Why are the ethnicity differences? Marks et al (2000) offer these factors as possible explanations -

First, the social practice of racism means that minority ethnic groups are the subject of discrimination at a number of different levels. Such discrimination could lead directly or indirectly to health problems additional to any effects related to socioeconomic status, poverty, unemployment and education. Discrimination in the health care system exacerbates the impacts of social discrimination through reduced access to the system and poorer levels of communication resulting from language differences.

Second, ethnocentrism in health services and health promotion favours the needs of majority over minority groups. The health needs of members of minority ethnic groups are less likely to be appropriately addressed in health promotion which in turn leads to lower adherence and response rates in comparison to the majority population. These problems are compounded by cultural, lifestyle and language differences. For example, if interpreters are unavailable, the treatment process is likely to be improperly understood or even impaired and patient anxiety levels will be raised. The lack of permanent addresses for minority ethnic group families created by their high mobility makes communication difficult so that screening invitations and appointment letters are unlikely to be received.

Third, health status differences related to race and culture are to a large extent mediated by differences in SES (social and economic status). Studies of race and health generally control for SES and race-related differences frequently disappear after adjustment for SES. Race is strongly correlated with SES and is even sometimes used as an indicator of SES (Williams and Collins, 1995). Thus ethnicity may not be the issue, rather social and economic factors are.

Fourth, differences in health-protective behaviour may occur because of different cultural or social norms and expectations.

Fifth, differences in readiness to recognize symptoms may occur also as a result of different iral norms and expectations.

Sixth, differences could occur in access to srvices. There is evidence that differential access to optimal treatment cause poorer survival outcomes in African-Americans who have cancer in comparison to other ethnic groups (Meyerowitz et al., 1998).

Seventh, members of minority ethnic groups are more likely to inhabit and work in unhealthy environments because of their lower SES. Eighth, there could be genetic differences between groups which lead to differing lence of disease and some diseases are inherited. There are several recognized examples, including sickle cell disorder affecting people ofAfrican-Caribbean descent, thalassaemia, another blood disorder which affects people of the Mediterranean, Middle Eastern and Asian descent, and Tay-Sachs disease which affects Jewish people.

It would seem then that one of the most important determining factors in regards to health behaviours and overall level of health, is cultural differences, wether these be social, class, economic, ethnic or all of them interacting together. Until these issues are addressed it may be that we will still little significant change in our nations patterns of health inequalities.

Evaluation Points You Should Know About Lifestyles and Health Behaviours

Point 1:Determinism

Determinism is apparent in this topic of because it is assumed that certain types of personality, for example Type A, will determine the individuals health behaviours. Also the Health Belief Model essentialy assumes that cognitive processes will determine health behaviours and lifestyle. The problem here is that a deterministic approach may not enable us to fully understand why people engage in the health behaviours and lifestyles that they do. Determinism limits our understanding because it does not allow us to grasp the complexity of this issue. For example, it is highly probable that habit, social pressure, material circumstances, past experience and modelled behaviour all influence our health behaviours and lifestyle not just cognitive processes. Further, these points are even more relevant in highlighting the problematic nature of assuming that a certain personality type will be the determining factor in shaping health behaviours. Thus we can conclude that the adoption of a deterministic approach to understanding why people do and do not engage in certain health behaviours is not a valid way of studying this phenomenon.

In addition we may end up 'blaming the victim'. this is because such approaches lead us to believe that you are healthy or otherwise because of what you did e.g. having a certain personality type or thinking about health in certain ways. Thus the poor health of others is due to something about them rather than the other numerous factors, psychological, social, material and biological, that are needed to create a lack of health within the individual. Thus the usefulness of adopting a deterministic viewpoint may not be advantageous to the people we are trying to help.

Determinism ignores other factors. We want to know this information to use it to improve health behaviours. If we adopt a deterministic approach we ignore other variables that could cause or contribute to poor health, therefore how can you rectify this problem thoroughly? How far this information will be useful may well depend on the extent of the determinism apparant within the research.

Point 2: Cognitive Psychology

For example, the Health Belief Model was developed directly from cognitive psych. It shares the same assumption that we process information on a fairly rational level. Therefore unconscious processes such as emotion and habit aren't a part of this. Are we rational, is that the only way we make decisions? You can always contrast Freud with this viewpoint, as he argued that unconscious/ non-rational processes often determine what we do, which is the opposite to Cognitive psych. The Health Belief Model assumes that we are very rational but will our health behaviours also be affected by things that we are not aware off, such as unconscious motivations e.g. smoking- a girl may smoke and give rational reasons such as she likes the taste and that it makes her 'look cool'. However a Freudian approach may argue that she has an oral fixation. Or a social psychologist may argue that she is conforming to group norms and expectations even though she is unaware of this process. Therefore this problem can never be just cognitive. Whilst it is useful to just look at one area of psychology, as it simplifies an issue, nevertheless it won't give us a complete picture of the phenomenon of study.

Point 3: Measurement

Many of the studies you may have refered to in the descriptive part of your essay will only have taken a 'snap-shot' of the Ps health behaviours and lifetstyle. However we want longitudinal designs as we need to see how maturation affects people health behaviours; if you are talking about lifestyles and behaviours surely this occurs over time and therefore need a longitudinal design? If you want to create an intervention/way to change non-healthy lifestyles, you will need to know how these lifestyles came about and you may only get this from a longitudinal design. Snap-shot studies will be limited in how far they can provide us with this type of understanding.

Point 4: Correlation

A different methodological point is that the data on personality types (Type A and B) and health behaviours is purely correlational. Meaning that we can say there is a close association between a certain personality type and certain health behaviours but this does not mean that the personality cause the behaviours, just that they are associated in some way. Association does not establish causation.