1.4 Influences on health and illness behaviour
Activity 2: Experiencing health and illness
Drawing on your own experiences of health and illness, answer the following questions.
When do you decide you might be ill and need advice?
Who do you turn to for health information, advice or treatment?
Different people react in different ways to illness. One person who did this activity said, first, she consults someone close to her – a family member or a friend – wondering whether she should be concerned about the problem. She might also look on the internet – initially she would be concerned about the diagnosis. If this concern persisted, she would consult a doctor; however, if she thought she knew what the problem was, she might do any of the following: treat it herself; go to a pharmacist or doctor; go to another ‘conventional’ therapist (for example, dentist, chiropodist, optician); or go to an ‘alternative’ therapist (such as a chiropractor or an osteopath).
Health behaviour is influenced by many factors. Helman (2001) discusses the variety of people in different societies who each offer users their own way of advising on, explaining, diagnosing and treating ill health. As a result, people may decide to rest or take a home remedy; ask advice from a friend, relative or neighbour; consult a local priest, folk healer or wise person; or consult a doctor if one is available. People seek different forms of help and advice depending on the stage and progression of their condition. They may be more likely to seek professional help after other channels of advice and treatment, including self-management, have proved ineffective.
People choose one form of healing rather than another for a variety of reasons, including beliefs, expectations, geographical access, affordability, or congruence with wider cultural beliefs. Research shows that whom people talk to about their health influences what they do and the course of action they take to resolve health problems (Wellman, 2000). The influence of other people varies according to the strength of the tie (whether the advice is given by an intimate friend or merely an acquaintance) and the basis of the relationship (whether it is kinship, friendship or professional). These sources of advice and influence are often described as ‘health networks’. Granovetter (1973) argues that weak ties (those between socially dissimilar people, rather than members of the same social circle) transmit a greater range of information, including information about potential alternatives, although strong ties may be more persuasive (Wellman and Wellman, 1992). In making health decisions, people also access and draw on health information from a variety of sources, including self-help groups, health magazines and websites (for example, NHS Direct).
Various models of health and illness behaviour have been devised to answer the question: ‘How do individuals come to recognise, understand and cope with health problems?’ Four models of health and illness behaviour dominate the literature (Pescosolido, 2000): the Socio-Behavioural Model, the Health Belief Model, the Theory of Reasoned Action, and the Theory of Planned Behaviour. The key features of these models are described in Box 1.
Box 1: Models of health and illness behaviour
The Socio-Behavioural Model (SBM)
The SBM details three basic categories: need, predisposing characteristics and enabling factors. Need for care must be established, which depends on the nature of the illness and its severity (for example, the ‘hurt’, ‘worry’, ‘bother’ or ‘pain’ that it causes). The SBM considers how people perceive this need and how symptoms are experienced. Predisposing characteristics include gender, ethnicity, education and beliefs: that is, the social and cultural factors which shape an individual's tendency to seek care. Enabling characteristics recognise that individuals need to act on a desire to receive care, and include the means and knowledge to get treatment (having a source of care, travel time and financial ability, as well as the geographical availability of doctors, clinics, etc.).
The Health Belief Model (HBM)
Whereas the SBM focuses on the influence of the system and issues of access, the HBM examines the meaning of ‘predisposing’ characteristics and analyses how an individual's specific health beliefs (for example, about the severity of symptoms) and their preferences (for example, the perceived benefits of treatment), as well as their experiences (with health care problems and with providers and their knowledge), affect decisions to seek care and adopt health behaviours.
The Theory of Reasoned Action (TRA)
The TRA concerns expectancy: individuals rate how current and alternative actions can reduce their health problems. Like the HBM, this theory focuses on motivations, the individual's assessment of risk, and the desire to avoid negative outcomes. Individuals evaluate whether or not to engage in healthy (for example, taking exercise) or risky (for example, smoking) behaviours and whether to seek preventive as well as curative medical services.
The Theory of Planned Behaviour (TPB)
The TPB evolved from the TRA, but differs by recognising that individuals do not necessarily have control over their behaviour. The amount of behavioural control – or self-efficacy – that individuals perceive they have is an important element in this model. Also, ‘cues’ or ‘habits’ become an important part of the decisions individuals make to engage in health and illness behaviours.
Although the four models are practical, Pescosolido (2000) notes some weaknesses: for example, what she calls the ‘tyranny of use/no use’ created by the strict either/or conceptualisation of choices inherent in these empirical models. She argues that the traditional models do not capture the richness of ethnographic research, which provides deeper understandings of procedures and users. She also notes that focusing on ‘illness’ overlooks the fact that people may define physical and mental health in terms of moral failure, supernatural punishment, the ‘ups and downs’ of life, etc., for which seeking medical care is only one of several possible responses. Pescosolido argues that this unnatural separation of illness behaviour from social life is reflected in the reliance of traditional models on rational choice as the underlying mechanism at work. By calling these models ‘decision-making’ or ‘help-seeking’ models, the values of rationality and individuality are overemphasised, which are precisely the same values that led to the professional dominance of allopathic medicine.
Having looked at some of the influences on health and illness behaviour, it is clear that users' knowledge of and beliefs about different forms of health care shape their choices about which practitioners to consult in different circumstances. The next section focuses on some models of health care delivery.