3 Individual lifestyle factors
As you have seen above, emphasis on individual lifestyle as a determinant of health can be seen in most policies and strategies. In recent years the concept of a ‘healthy lifestyle’ has achieved considerable popular currency but, like many such concepts, the term can be widely used in many different contexts and can come to mean different things. Davison et al. provide a useful definition of ‘lifestyle’ which they describe as: ‘the aspects of health related behaviours and conditions which entail an element of personal action at the individual level ... strongly associated with the possibility of individual choice and the triumph of self control over self indulgence’ (Davison et al., 1992, p. 675).
The main issues addressed usually include diet and physical activity, tobacco and alcohol use, drug intake and sexual activity, although, at various times, other issues have also fallen within this rubric, for example, exposure to the sun and use of seat belt or child car seat.
Many attempts to promote public health have focused on the individual and their lifestyle, and this seems to be a fairly common-sense approach. After all, it could be argued that if individuals ate a little less and took more exercise, then they would be less likely to become obese. If they smoked less and drank less alcohol they would be at a reduced risk of long-term conditions such as heart disease or cirrhosis, and if individuals engaged in safe sex, then they would be less likely to become infected with HIV or other sexually transmitted infections. Individual behaviour can play an important part in health and illness, so maintaining a healthy lifestyle could well be simply a matter of self-control. However, as outlined below, lifestyle accounts have been challenged on several counts.
Thinking point: how far is maintaining a healthy lifestyle simply a matter of self-control?
At a practical level, research has shown that it is very difficult to change individual behaviour. Although there have been some instances of success (e.g. the national HEA campaign to prevent cot deaths in the 1990s), there is still considerable debate about how far health can be improved through targeting individual behaviour. For example, although smoking has declined over time, a recent Omnibus Survey (Lader and Goddard, 2004) of smoking behaviour found that nearly 80 per cent of current smokers had tried (unsuccessfully) to give up smoking; and of these, 46 per cent had received advice on smoking cessation.
Many theories and models have been developed to help explain individual health behaviours. However, one of the key problems facing those promoting public health is the failure of many individuals to follow healthy lifestyle advice. Two key explanations have been put forward to explain this. The first rests on the notion that the public are ‘victims of their own ignorance’ (Davison et al., 1992) and that with increased health education and advice, they will begin to embrace healthier lifestyles. This was the notion underpinning the government’s HIV/AIDS prevention campaign in the late 1980s (see Figure 3).
The second explanation draws on the idea that individuals can believe that health is largely determined by external factors, therefore denying the relevance of individual behavioural change. Psychologists draw on the health ‘locus of control’ (Rotter, 1954) to describe the general expectancy that behaviour either is or is not directly related to health outcomes. An internal locus of control relates to the individual’s feeling of control over health, whereas an external locus of control relates to factors outside of the individual’s control. For example, a study of stress among mothers caring for children with intellectual impairments found an internal locus of control to be a protective factor (Hassall et al., 2005). A study of perceived risk for breast cancer also noted that women with an internal locus of control were more likely to engage in protective health behaviours such as attending screening (Rowe et al., 2005). The significance of this internal locus of control underpins the ‘Take Control Campaign’ launched by Epilepsy Action, which seeks to encourage all those with epilepsy to take control so as to achieve better management of their condition. ‘Take Control’ wrist bands formed part of the campaign (Figure 4).
The notion of taking control underpins many contemporary attempts within the public, private and voluntary sectors to promote public health. However, taking control is subject to the ability to take responsibility for health and to make choices, both of which are governed by power relations. In other words, not everyone is free to make decisions and choices, since individual choice and control can be constrained both by other people and by the factors that influence health.
While targeting individual behaviour might seem to be common sense, it is important to recognise that distinct patterns of behaviour can be found among different social groups. For example, Table 1 shows that people in routine and manual occupations are more likely to smoke than people with non-manual occupations. Figure 5 shows changing patterns of excessive alcohol consumption, demonstrating that younger people are more likely to drink to excess and that women are now more likely to drink excessively in comparison to previous years.
Lifestyle accounts draw on notions of individual choice. However, if patterns of behaviour are considered – for example, those identified above – it is easy to see that ‘choice’ is not just an individual matter, but a social one. It is important to ask why young women are drinking to excess and why men in manual occupations are twice as likely to smoke as men in managerial or professional occupations. The rhetoric of choice and the ‘right to choose’ have become embedded in policy and practice. Writing specifically about reproductive choice, for example, Petchesky (1980) argues that, to be meaningful, the right to choose must carry with it the enabling conditions that will make that right concretely realisable and universally available:
The ‘right to choose’ means very little when women are powerless ... women make their own reproductive choices, but they do not make them just as they please; they do not make them under conditions which they themselves create but under social conditions and constraints which they, as mere individuals, are powerless to change.
Table 1 Prevalence of cigarette smoking, by sex and socio-economic classification, 2001–2004
|Percentage Smoking cigarettes||Bases = 100 per cent|
|Managerial and professional occupations||17||17||16||16||586||647||625||637|
|Routine and manual occupations||33||34||36||30||651||675||606||630|
|Never worked and long-term unemployed||26||22||30||29||68||135||142||114|
|Managerial and professional occupations||20||16||15||18||544||574||564||527|
|Routine and manual occupations||27||30||34||29||802||799||686||734|
|Never worked and long-term unemployed||14||24||20||20||131||203||207||197|
|Managerial and professional occupations||18||16||16||17||1132||1221||1189||1165|
|Routine and manual occupations||30||32||34||29||1452||1474||1291||1365|
|Never worked and long-term unemployed||19||23||24||23||199||338||349||311|
So, although lifestyle might be a factor that influences health, it is also important to focus on wider influences and the context within which individual ‘choice’ takes place.