Socio-behavioural aspects of health and illness

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Socio-behavioural aspects of health and illness




Study Points



image The importance of social and behavioural sciences to pharmacy


image The meaning of health and illness


image Changing health-related behaviour and the related models


image How people behave when they are ill


image Behavioural aspects of health care


image Factors affecting the treatment process



Introduction


To develop a full understanding of the use of medicines by individuals and society and the role that pharmacy contributes to health care, an understanding of the sociology and psychology of health is required. These two factors are closely interwoven, and help the pharmacist to understand the influences on an individual’s behaviour in relation to their health and any illness they encounter.


In pharmacy practice research, sociological and psychological influences on health have often been under researched, with research often focused on adherence in a mechanistic manner. However, if pharmacy as a profession wishes to understand and resolve medicine and medicine-related problems, we need to broaden our perspectives to incorporate relevant social and behavioural theory and research.


The purpose of this, and the following chapter is to provide the reader with a broad overview of the health-related issues from a health sociological and psychological perspective; emphasizing the need to understand the wider influences on individual behaviour in order to enhance our pharmacy practice. The social sciences have a shared focus on understanding patterns and meaning of human behaviour, which distinguishes them from the physical and biological sciences.


Illness can be perceived as either a solely biophysical state, or a more comprehensive view may be taken, viewing illness as a human societal state where behaviour varies with culture and other social factors. It is argued that viewing illness as purely a malfunction of a physical process or structure underemphasizes the influence of the individual and psychosocial issues on their beliefs, thoughts and behaviour.


Pharmacists have to deal with many social and behavioural issues in their daily work, either directly or indirectly through health-related behaviour. The contribution of social sciences to pharmacy and pharmacy practice can be summarized in the following three areas:



It is impossible in two chapters to provide a comprehensive review of all the aspects of health sociology and psychology that may be relevant to pharmacy. Instead, the aim is to highlight the relevant key areas that may lead the reader to explore the sociological and psychological literature in more detail; a good starting point is the books and articles on the topic that are included in the further reading (Appendix 4).


This chapter will focus on defining health and illness and exploring the determinants of health and illness for an individual. It is important for a pharmacist to understand the influences and processes involved in illness behaviour and treatment to enable effective, patient-centred practice. In each area, the major concepts and theories that provide a deeper understanding of health and illness are briefly discussed.


An overall framework is presented in Figure 2.1.




Defining health and illness


Health and illness mean different things to different people, it is very subjective, and it is easy to take good health for granted. Commonly, health is seen as the absence of signs that the body is not functioning properly or absence of symptoms of disease or injury. Health is often perceived as a dichotomy; you are either healthy or you are not, but in reality, health is a continuum of different states, and both societal and individual perceptions influence our understanding of health.


However, disease, in contrast to illness, is something professionally defined. The organization of current health care around the world uses this concept of illness to frame its structures, yet research has shown that physicians and experts vary in their views on both physical and mental disease, such that it is difficult to argue that disease can be easily defined.


In reality, illness is more often a state defined by the individual patient based on their own subjective reaction to a perceived biological alteration of body or mind. It has both physical and social connotations. Our perception of illness is influenced by individual, cultural, social and other factors. Illness is also a socially defined condition, resulting in the individual being assigned a particular social status by other members of their society. Parson’s concept of a societal ‘sick role’ and its effect on illness and health care will be explored in more detail.


It is important to understand that an individual may have a disease and not be ill, might be ill but not have a disease or might have both an illness and a disease.


The most widely used definition of health or wellness is that of the WHO, which states that: ‘health is a state of complete physical, mental and social well-being and not merely the absence of diseases and infirmity’. This definition incorporates all aspects of health and although holistic and widely quoted, it is used less by policy makers in the healthcare arena, as it does not provide guidance on which to base funding decisions.


The WHO definition offers a goal for health that is actively sought through positive actions and not merely through a passive process of avoiding disease-causing agents.



Dimensions of health


The WHO definition of health distinguishes between three aspects; physical, mental and social health, but very often healthcare systems use a narrower definition of health incorporating only physical and mental health to focus their resource allocation.


In utilizing the wider definition of health, there is a danger that we begin to ‘medicalize’ our society – issues such as loneliness, domestic violence and attention deficit disorder become the responsibility of medicine and public health, when they may not need medical treatment in the way that other diseases require. In opposing the argument, the broad definitions allow us to examine health issues in a holistic manner.







Determinants and models of health


Throughout history, the concepts of disease have changed. Early explanations involved evil spirits causing disease. Hippocrates (460–370 bc) suggested that the imbalance of the four body fluids caused disease, while during the Middle Ages, illness was seen as God’s punishment.


Later in time, in the post-Renaissance period, René Descartes suggested that the body could be viewed as a machine and he theorized how action and sensation occur. In addition, he proposed that the body and mind were separate but could communicate, and that the soul leaves the human body at death.


Since Descartes’ time, advances in science have led scientists to develop a more advanced understanding of the working of the body and the processes of illness and disease. The role of microbes and other agents in causing disease is understood, along with the effect of nutrition, hygiene and other lifestyle factors.


The biomedical model of disease proposes that all diseases and illness can be explained by disturbed physiological processes. The disturbances may be caused by injury, biochemical changes and bacterial, viral or fungal infection. This model separates the physical from the psychological and sociological influences on health. The biomedical model has dominated healthcare processes for a significant period of time, but in more recent years, there has been a recognition that it is not possible, or helpful, to separate out the components of an individual’s life; the biopsychosocial model incorporates the interplay of biological, psychological and social aspects of a person’s life on their health.


Individuals in both industrialized and less developed cultures continue to be influenced in their health behaviours by both cultural and religious beliefs. These may relate to ‘bad’ behaviour, weather, accidents, black magic, witchcraft, spirits and one or more Gods, to name but a few.



Genetic and biological determinants


In line with scientific developments, current medicine is interested in the genetic basis of disease and it does seem that it may be possible to determine an origin of many health problems in the human genes. Newspapers proclaim each discovery loudly, such as the possibility of genes that predispose to alcoholism and obesity, along with many others. This may lead to the belief that all health problems develop from a genetic ‘fault’ and these lie beyond the control of each individual, which may legitimize poor health behaviour. In reality, the picture is more complex, with health, and conversely disease, arising from an interaction of individual genetic, psychosocial and physical factors.


The scientific interest in this field lies in interactions between genetic predisposition and psychosocial factors encountered in early childhood. For example, research has shown that genetically predisposed, spontaneously hypertensive rat pups who were fostered to normotensive mothers did not develop hypertension as they matured, suggesting that genetic predisposition can be overcome by a favourable environment in the early years.



Behavioural determinants


The major leading causes of death in Western society today – heart disease, cancer, stroke and accidents – are all associated with behavioural risk factors. The origin of many chronic diseases such as diabetes and hypertension can be found in lifestyle factors. A sedentary lifestyle predisposes an individual to develop these diseases, regardless of genetic factors. Simple changes to behaviour, such as effective weight control, stopping smoking and regular exercise, will often prevent the onset of diseases such as heart disease and diabetes. It is possible, however, that for some individuals, the inheritance of a protective genetic profile protects them from poor health caused by poor health-related habits.


Health psychology is a branch of psychology focusing on the behavioural and mental processes that contribute to health and illness. It focuses on cognition, emotion and motivation. Cognition involves perceiving, knowing, learning, remembering, thinking, interpreting, believing and problem solving. Emotion is a subjective feeling that affects and is affected by our thoughts, beliefs and behaviour. Emotions can be positive/pleasant or negative/unpleasant. Those individuals whose emotions are more positive have reduced incidence of disease and have much faster recovery times than those whose emotions are more negative. Motivation is the driver for individuals to behave the way that they do, influences individuals adopting new health-related behaviour, and the way they choose to take their medication or otherwise. Health psychology studies the effects of interpersonal relationships on individuals; our interactions with others, their thoughts, feelings and actions which in turn influences our own thinking and behaviour.


In studying a particular situation, there can be components of cognitive, affective (emotional), behavioural and interpersonal influences and separating these may be difficult. For example, an individual experiencing anxiety in a given situation may think that they lack control (cognitive), feel fear (affective), experience physical symptoms such as sweating palms and raised heart rate (behavioural) and seek out support and reassurance from others (interpersonal).


One of the major psychological issues that affects health is stress. Stress is an increasing factor in modern lives and arises when an individual experiences a situation in which they perceive that they are not able to cope with what is being asked of them, either physically emotionally or socially. Due to the interconnection of body and mind, the mental stress causes physical responses, including the release of catecholamines and corticosteroids, which may contribute to illness with continued exposure. The cardiovascular system can be affected and the emotional response to stress can result in anxiety and depression, which in turn have been shown to reduce the effectiveness of the immune system, putting the individual at risk of other diseases.


Stress can also affect an individual’s health through altered health-related behaviour. People experiencing high levels of stress often consume more alcohol, drugs and smoke more than those with less stress, and they also experience more accidents.


Stress is therefore of concern when helping individuals to improve their health, and needs to be considered when advising patients in a pharmacy, as it will be affecting their behaviour and thinking.



Environmental determinants


Environmental factors (biological, chemical, physical, mechanical) that affect human health are widely understood and have been studied in detail. External contaminants can enter the body through the air we breathe, the items we ingest, either through direct contamination on food, or indirectly through the food produced from the soil.


The role of air-borne pollen in hayfever, other allergens such as pet dander and dust mites in asthma and the risks to health from contaminated water are well understood, but there are other contaminants from the environment that need to be considered, such as drug residues in the meat and meat products we eat, that can have an effect on health from the time of conception onwards.


Environmental risk factors can affect a far greater number of people at a given time than more individual factors such as genetic susceptibility or psychological responses. While individual risk factors can account for some of the differences seen in disease occurrence, they cannot account for all. Work to reduce individuals’ risk factors for a given disease has only a limited impact on the disease occurrence, and Rose (1985) suggested that the causes of individual differences in disease may be different from the causes of differences between populations. Even where there is a strong link between a risk factor and the incidence of a disease, the disease may never develop in a particular individual.



Socioeconomic determinants


Socioeconomic determinants of health are socially situated factors that influence health, or may predispose an individual or population to poor health. Each society develops its own set of health-related values, both positive and negative, and these are reflected in the media used within the society. Western society sees being fit and healthy as ‘good’ and this exemplifies a positive value, while individuals in the public eye seen undertaking activities such smoking cigarettes or using illegal drugs exemplify a negative value. These societal values influence individuals and the way in which they behave, but the primary influence on an individual’s behaviour is often their families.


An individual’s family is the closest and most constant social relationship for the majority of people. Therefore, we learn and model many of our health-related habits, behaviours and attitudes on those of our close family. The degree of support or encouragement provided by family and friends when an individual undertakes a health-related activity can be an important factor in the potential for success.


The economic situation of an individual has been shown to have a great influence on their health. In developing countries, factors such as poverty, poor nutrition and poor resistance to pathogens are all interrelated in producing poor health status for the population, and in reducing the average life expectancy. Individuals living in the more industrialized, richer countries have improved health and greater life expectancy.


In addition to the international correlation between health and socioeconomics, the relationship between socioeconomic status and ill health can also be seen across the levels of the social hierarchy within a population. Those individuals who are wealthier within a society also have better health. Health is also linked to education, and those with better education levels tend to be healthier – their increased education level may also lead to a better financial situation, and this also correlates to improved health and longevity.


The relationship between socioeconomic status and health may therefore be related more to relative deprivation rather than absolute deprivation. Having less within your own society, even where this does not mean that the individual is deprived of the basic needs for life, or health care, still has a negative impact on your health. Better lifestyle habits may partially explain these social hierarchy differences, with those of a higher socioeconomic status potentially having healthier habits than those from lower socioeconomic groups, but does not provide a full explanation for the observed differences in health.


These differences in social situations that produce an effect on health are referred to as ‘health inequalities’. Health inequalities within a society are often targeted with resources and interventions in order to try and produce population-wide improvements and equality in health (see Ch. 13).



Interaction of different factors


It is evident that no single influencing factor provides an explanation for the health of a nation, demographic group or individual. The factors discussed above interlink and provide a complex picture in which to determine the defining influences on the health. In considering an individual’s health and illness, it is necessary to assess the impact of all aspects of a person’s life as a total entity – this approach is called ‘holism’.


There are models that try to describe the interactions between factors influencing health, and one such comprehensive model is the ‘nested model of health’. This model consists of two levels of activity: the individual and the community level. The individual level is composed of five different categories:



These categories are thought to affect each other and to affect and be affected by the individual. The individual level is nested/located in the centre of the community level.


This community level, which is the main focus of health policy decision-makers, is composed of four components:



These four components are interrelated and changes in them are expected to lead to changes in the health of individuals.


This model shows the potential influences on the health of an individual and provides the healthcare professional with an idea of the complexity of the influences on an individual’s health status.



Process of illness



Becoming ill


As pharmacists, we need to understand how and why people respond to illness in such differing ways. Health-related behaviour varies between individuals for all the reasons discussed above, and this may help to explain the subjective way in which patients respond to seemingly similar symptoms, such as pain or discomfort. Generally, individuals perceive themselves as ‘well’ if they have a feeling of well-being, experience no symptoms and are able to perform normal functions. This is the baseline situation against which any changes in health are measured. As an individual’s health status changes, there will be a corresponding change in their health-related behaviour.


Kasl and Cobb in 1966 defined three types of behaviour that characterize three stages in the progress of disease:


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Jun 24, 2016 | Posted by in PHARMACY | Comments Off on Socio-behavioural aspects of health and illness

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