Lifestyles and health behaviour determinants of health-enhancing behaviours
What are health behaviours? • Kasl and Cobb (1966) defined three types of health related behaviours. They suggested that; • a health behaviour is a behaviour aimed at preventing disease (e.g. eating a healthy diet); • an illness behaviour is a behaviour aimed at seeking a remedy (e.g. going to the doctor); • a sick role behaviour is an activity aimed at getting well (e.g. taking prescribed medication or resting).
What are health behaviours? • Health behaviours have also being defined by Matarazzo (1984) in terms of either: • Health impairing habits, which he called "behavioural pathogens" (for example smoking, eating a high fat diet), or • Health protective behaviours, which he defined as "behavioural immunogens" (e.g. attending a health check).
Behaviour and mortality • 50% of mortality from the 10 leading causes of death is due to behaviour. • Doll and Peto (1981) estimated that 75% of cancer deaths were related to behaviour. 90% of all lung cancer mortality is attributable to cigarette smoking, which is also linked to other illnesses such as cancers of the bladder, pancreas, mouth, and oesophagus and coronary heart disease. Bowel cancer is linked to behaviours such as a diet high in total fat, high in meat and low in fibre.
Lifestyle and health About 50% of premature deaths in western countries can be attributed to lifestyle (Hamburg et al., 1982). Smokers, on average, reduce their life expectancy by five years and individuals who lead a sedentary (i.e. none active) lifestyle by two to three years (Bennett and Murphy, 1997).
Holy Four • Four behaviours in particular are associated with disease: smoking, alcohol misuse, poor nutrition and lower levels of exercise; these are called the “holy four”. • Conversely, rarely eating between meals, sleeping for seven to eight hours each night, and eating breakfast nearly every day have been associated with good health and longevity (Breslow and Enstrom 1980). Recently high-risk sexual activity has been added to the risk factor list.
Belloc and Breslow (1972) • Belloc and Breslow (1972) conducted an epidemiological study asking a representative sample of 6928 residents of Almeida County, California whether they engaged in the following seven health practises:
Belloc and Breslow (1972) • sleeping seven to eight hours daily • eating breakfast almost every day • never or rarely eating between meals • currently being at or near prescribed height adjusted weight • never smoking cigarettes • moderate or no use of alcohol • regular physical activity.
Positive attitude • Having a positive attitude towards life has been found to increase longevity (Levy et al, 2002).The team used data gathered in 1975 in Oxford, Ohio, where almost everybody over 50 was questioned about their life and health. By tracing the deaths of participants over 23 years, the team was able to match lifespan against attitudes towards ageing expressed at the start.
Positive attitude • Participants had been asked to agree or disagree with statements such as: “Things keep getting worse as I get older” or “I have as much pep as I did last year” or “I am as happy now as I was when I was younger.” The participants were scored on a scale of zero to five, in which five represented the most positive attitude towards growing older and zero the most negative.
Positive attitude • In the Journal of Personality and Social Psychology, the team says that the median survival for the most negative thinkers was 15 years, while for the most positive it was 22.5 years. • Controlling for age, sex, wealth, health and loneliness did not alter the finding.
Evaluation • There are several methodological criticisms that can be made of the original study by Belloc and Breslow and the follow-up studies. First, the sample is not particularly representative as all the participants came from the same area in the USA. • Second, the study establishes a correlation between seven specific health preventive behaviours and longevity, but does not prove that these behaviours actually caused some of the participants to live longer. It is possible, although unlikely, that some other factor — personality, for example — affected both behaviour and lifespan.
Evaluation • The ‘behavioural change’ approach to promoting health raises a couple of ethical issues. First, it can lead to ‘victim-blaming’. If we believe too strongly that individuals can prevent themselves from falling ill by choosing to carry out health preventive behaviours, then we may go on to blame those individuals for failing to protect their own health if they do fall ill.
Evaluation • There have been cases where doctors have refused to treat certain patients because they felt that they had brought their illnesses on themselves. The greatest contributions to health have been through developments in medical science and through public health initiatives such as improved sanitation, and not through individual behavioural change.
Evaluation • The second problem with the behavioural change approach is the narrow line that exists between persuading someone to change his or her behaviour and coercion. Do we have a right to assume that we know better than someone else what is best for their own health, and to force them to change their behaviour?
Genetic theories • Is it possible, however, for a person’s genetic inheritance to directly affect their health-related behaviour? It may be, for example, that alcoholism is partly hereditary. In his book on this topic, Sher (1991) describes evidence that the children of alcoholics are more likely to become alcoholic themselves.
Genetic theories • Although it is notoriously difficult to determine whether a correlation such as this is due to genetic factors or arises as a result of social learning, some psychologists argue that, although there probably is no such thing as an ‘alcoholism gene’, certain genetically inherited personality traits may pre-dispose an individual towards alcohol abuse.
Family genetics and history of dietary risk factors. • Several studies have provided evidence that family history of dietary risk factors may be related to adolescents’ food preferences. Fischer and Dyer (1981) reported that family history of obesity was related to increased intake of sweets, dairy products, and fatty foods in a sample of 116 high school girls. Their results also indicated that having a family history of heart problems was related to decreased consumption of milk, eggs, and salty foods.
Family genetics and history of dietary risk factors. • Levine, Lewy, and New (1976) found a family history of hypertension to be associated with a greater prevalence of obesity among African American adolescents. Some investigators have also analyzed dietary intake among twin populations as evidence of a genetic variance for nutrient intake. In one of these studies, De Castro (1993) found significant heritabilities for identical and fraternal twins with regard to the amount of food energy and macronutrients eaten daily.
Family genetics and history of dietary risk factors. • In contrast, Fabsitz, Garrison, Feinleib, and Hjortland (1978) demonstrated that, in addition to a genetic variance, environmental effects (e.g., how frequently twins saw each other) were important in accounting for similarities in twins’ nutrient intakes. These results suggest that there may be an interaction between genetic and environmental factors that influence eating behaviors among adolescents.
Genetic theories • Genetic theoriessuggest that there may be a genetic predisposition to becoming an alcoholic or a smoker. To examine the influences of genetics, researchers have examined either identical twins reared apart or the relationship between adoptees and their biological parents. These methodologies tease apart the separate effects of environment and genetics.
Genetic theories • In an early study on genetics and smoking, Sheilds (1962) reported that of 42 twins reared apart, only 9 were discordant (showed different smoking behaviour). He reported that 18 pairs were both non-smokers and 15 pairs were both smokers. This is a much higher rate of concordance than predicted by chance. Evidence for a genetic factor in smoking has also been reported by Eysenck (1990) and in an Australian study examining the role of genetics in both the uptake of smoking (initiation) and committed smoking (maintenance) (Murray et al. 1985).
Genetic theories • Research into the role of genetics in alcoholism has been more extensive and reviews of this literature can be found elsewhere (Peele 1984; Schuckit 1985). However, it has been estimated that a male child may be up to four times more likely to develop alcoholism if he has a biological parent who is an alcoholic.
Behaviourist learning theories • Classical conditioning is a process in which the individual associates an automatic response with a neutral stimulus. Ivan Pavlov (1849—1936) described this process after he noticed that laboratory dogs would salivate when he turned a light on because they had learnt to associate the light with the presence of food.
Behaviourist learning theories • Classical conditioning could explain certain health-related behaviours such as ‘comfort eating’, for example. If a parent regularly offers a child sweets or chocolate at the same time as physical and emotional affection, then the child may learn to associate sweet foods with the reassuring feelings that arise out of parental love. In later life, the child may try to recreate these pleasant feelings by eating chocolate when he or she is stressed or depressed.
Operant conditioning • Operant conditioning is when people respond to reward or punishment by either repeating a particular behaviour, or else stopping it. If an individual carries out a behaviour that clearly seems to be bad for his or her health, such as smoking cigarettes, a deeper look may well reveal benefits for the individual, such as social approval, the nicotine buzz and so on.
Operant conditioning • A striking example of how operant conditioning can affect health behaviour is the study by Gil et al (1988). They conducted research on children suffering from a chronic skin disorder that causes severe itching. They videotaped the children with their parents in the hospital and observed that when parents tried to stop their children scratching (in order to prevent peeling and infection) this actually increased the scratching behaviour by rewarding it with attention.
Operant conditioning • When they asked parents to ignore their children when they scratched and give them positive attention when they did not scratch, the amount of scratching was significantly reduced. • Drinking, eating, smoking, drug and sexual addictions all have the ‘irrational’ characteristic that the total amount of pleasure gained from the addiction seems much less than the suffering caused by it. According to learning theorists, the reason for this lies in the nature of the gradient of reinforcement.
Operant conditioning • Addictive behaviours are typically those in which pleasurable effects occur rapidly after the addictive behaviour while unpleasant consequences occur after a delay. The simple mechanism of operant conditioning and the gradient of reinforcement is able, as it were, to overpower the mind’s capacity for rational calculation.
Social learning • Social learning occurs when an individual observes and imitates another person’s behaviour, either because the individual looks up to that person as a role model or else through vicarious reinforcement — that is, .the individual sees the person being rewarded for his or her actions.
Social learning • Social learning can clearly be very influential in encouraging people to do things that are bad for their health (for example, a teenager may take up smoking because he or she has an admired elder brother who smokes, or may try illegal drugs because he or she sees other people taking them and having a good time).
Social learning • Another example of how vicarious reinforcement can lead to unhealthy behaviour concerns young women with eating disorders, who see images of very thin models in magazines being rewarded with success, money, glamour and fame. On the other hand, many health promotion campaigns use positive role models to try to get people to lead healthier lifestyles. The advertising industry, whose reason for existing is to persuade people to change their behaviour, often depicts successful, good-looking and happy people using a certain product in the hope that this will make others want to use the product as well.
self-efficacy • Bandura (1977) has been particularly influential in emphasising the importance of learning by imitation in linking it to his concept of self-efficacy, personality traits consisting of having confidence in one’s ability to carry out one’s plans successfully. People with lower self-efficacy are much more likely to imitate undesirable behaviours than those with higher self-efficacy.
self-efficacy • Heather and Robertson (1997) give a useful discussion of the application of these principles to drinking. Patterns of drinking by parents are observed by children who may then imitate them in later life, especially the behaviour of the same sex parents. In adolescence, the drinking behaviour of respected older peers may also be imitated, and subsequently that of higher status colleagues at work, a phenomena, which may explain the prevalence of heavy drinking in certain professions such as medicine and journalism.
Commentary • Many psychologists criticize behaviourist-learning theories on the grounds that they are too mechanistic. In other words, they assume that human beings respond automatically to specific situations. Not only does this imply a lack of freewill, but also it also ignores the effect on behaviour of cognitive factors.
Social and environmental factors • There are many different social and environmental factors contributing to people’s health behaviour. For example, a common explanation for young people taking drugs or smoking cigarettes is ‘peer pressure’. It may be that people imitate their peers because of the explanation given above — that is, vicarious reinforcement; they see others getting a reward for a certain behaviour, so they copy it.
Social and environmental factors • Social factors such as culture influence dietary behaviour. Culture affects an individual’s food selection, preparation, and eating patterns. Certain tastes or food are associated with specific feelings and meanings within a culture (for example, soul food may denote fried and barbecue meats within the African American community).
Social and environmental factors • Mexican American women often feel uncomfortable with focusing on themselves as individuals therefore a successful approach to losing weight would target the whole family rather than the individual woman (Foreyt et al, 1991).
Social and environmental factors • Television advertising also exerts a larger influence over dietary behaviour. Advertisers often target adolescents by promoting fast foods high in fat, cholesterol, sodium, and sugar. It has been found that children’s television viewing positively correlates with smoking behaviour and attempts to influence parents shopping selections (Dietz and Gortmaker, 1985). Television viewing is also highly correlated with obesity in children (Bowen et al, 1991).
Commentary • • Conformity does not exert an equally strong influence in all situations and with all individuals, It is likely to be more powerful in ambiguous situations, when others are perceived as having more expertise, or when the individual has low self-confidence, poor self-esteem and a weak sense of self-efficacy.
High-risk sexual behaviour • Hawkins et al. (1995) reported that the most frequent safer sex behaviour amongst well-educated heterosexual students was the use of the contraceptive pill. The least frequent sexual practice, reported by only 24% of the sample, was the use of condoms. An important factor is that the majority of young persons do not see themselves as at risk of HIV infection or have feelings of invulnerability towards the disease.
Exercise Those who are physically active throughout the adult life live longer than those who are sedentary. Paffenburger et al (1986) monitored leisure time activity in a cohort of 17000 Harvard graduates dating back to 1916. Using questionnaires it was found that those who were least active after graduation had a 64% increased risk of heart attack compared with their more energetic classmates. Those who expended more than 2000 calories of energy in active leisure activities per week lived, on average, two and a half years longer than those classified as inactive.
Exercise About a quarter of the UK population engage in health promoting levels of exercise, with a similar picture in the USA. In recent years these levels have dramatically increased. For example in Wales 20% of men and 2% of women took sufficient exercise in 1985 but by 1990 this had increased to 27% of the population. Those who engage in exercise are more likely to be young, male and well-educated adults, members of higher socio-economic groups, and those who have exercised in the past.
Exercise Those least likely to exercise tend to be in the lower socio-economic groups, older individuals, and those whose health is likely to be at risk as a consequence of being overweight and smoking cigarettes (Dishman 1982). Obstacles to exercise include not having enough time, lack of support from family or friends and perceived incapacity due to ageing.
five different types of exercise. • Brannon & Feist (1997) describe five different types of exercise. • Isometric exercise involves pushing the muscles hard against each other or against an immovable object. The exercise strengthens muscle groups but is not effective for overall conditioning.