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Socio-behavioural aspects of health and illness CHAPTER 3
There is also a distinction between individual risk
factors and environmental causes of disease. Differences in individual risk factors explain only a part of
the variation in the occurrence of disease. While reducing high risk factors might be beneficial for the
individual concerned, it makes a limited contribution
to reducing disease rates in the whole population.
Rose has suggested that the causes of individual differences in disease may be different from the causes
of differences between populations. A risk factor does
not necessarily cause the disease even if it is associated
with it.
Socio-economic determinants
These factors are also ‘environmental’, but it can be
debated as to whether they are genuine factors determining health or whether they only represent predisposing factors. Society establishes certain health
values, which are often reflected in the media. These
values can be both positive and negative. Being fit and
healthy is ‘good’ and exemplifies a positive value,
while celebrities smoking cigarettes or marijuana exemplify a negative value. The family is the closest and
most continuous social relationship for most people.
Therefore, many health-related habits, behaviours
and attitudes are learned and modelled from this
context. The degree of support or encouragement
received from family members and friends for
partaking in a health-related activity might be an important factor. This is dealt with in more detail later
(p. 38).
In developing countries factors such as poverty,
poor nutrition and poor resistance to pathogens are
all interrelated with a poor health status of the population. Similarly, historical statistics from industrialized countries show that over the last two or three
centuries there has been a strong positive correlation
between improved health, life expectancy and improved economy. In most countries the relationship
between socio-economic status and disease runs
across the social hierarchy. This shows that the relationship between socio-economic status and health is
a question of relative deprivation rather than absolute
deprivation. This linear association can only be partially explained by lifestyle factors. Usually people
with a higher socio-economic status have healthier
habits than those from lower socio-economic groups.
Similarly there are huge differences in life expectancy
between western and eastern European countries that
can be attributed to socio-economic factors.
Interaction of different factors
It is evident that no single factor can alone explain the
health of a nation, demographic group or individual. It
is difficult to capture all the relevant features and
their relationships. Having good genes can prevent
some people from getting a disease; on the otherhand,
somebody with poor genes can get ill regardless of a
healthy lifestyle and other positive factors. Considering the impact of all aspects of a person’s life as a total
entity in understanding health and illness is called
holism.
One comprehensive attempt to describe/model
the interactions between different factors 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:
*
Psychosocial environment (e.g. personal housing)
*
Microphysical environment (e.g. chemicals and
noise)
*
Work environment (e.g. work stress)
*
Behavioural environment (e.g. smoking, alcohol
use, exercise)
*
Race/class/gender environment.
These environments are thought to affect each other
and t o 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, the political/
economic climate (e.g. unemployment level), the
macro physical environment (e.g. air quality), social
justice/equity (e.g. social security system) and local
control/cohesiveness (e.g. local planning efforts).
These four components are interrelated and changes
in them are expected to lead to changes in the health
of individuals.
Process of illness
Becoming ill
Understanding illness behaviour can help pharmacists
appreciate and accept why patients respond differently to seemingly similar pain or discomfort. The general
criteria by which people view themselves as ‘well’
include a feeling of well-being, an absence of symptoms and an ability to perform normal functions. This
is the baseline situation against which any changes are
29
SECTION ONE Pharmacy practice and society
judged. When studying health-related behaviour it is
important to consider how behaviour changes with
the health status of the individual. Kasl & Cobb defined three types of behaviour that characterize three
stages in the progress of disease:
*
Health behaviour, which refers to any activity
undertaken by people believing themselves to be
healthy for the purpose of preventing disease or
detecting it at an asymptomatic stage
*
Illness behaviour, which involves any activity
undertaken by people who feel ill, to define the
state of their health and to discover a suitable
remedy
*
Sick-role behaviour, which refers to the activity
undertaken for the purpose of getting well by those
who consider themselves ill.
Ways of identifying and
reacting to symptoms
Symptoms can be classified into three broad groups:
those symptoms noted by the patient, symptoms noted by behavioural changes and patient complaints. A
behaviour which in some situations is regarded as
normal can in other situations be regarded as a sign
of illness. Not all symptoms can be regarded as medical, as they may have a natural explanation, like tiredness. Different symptoms may be perceived very
differently, depending on the person, setting and situation. Differences in illness behaviour occur as a
function of the immediate experience, past experiences and the patient’s information processing, organizing and recall. The significance of symptoms is
judged according to the degree of interference with
normal activities, the clarity of symptoms, the person’s tolerance threshold, familiarity of symptoms,
assumptions about cause and prognoses, interpersonal
influence from the lay-referral system and other life
crises making the symptoms appear more severe. The
subjective and psychosocial aspects of an incident can
be more important in determining decision and action
than the symptoms themselves.
The experience of illness involves affective and
cognitive reactions to illness, in which the patient
undergoes emotional changes and attempts to understand the illness. Bernstein & Bernstein have described these emotional reactions to illness and
treatment in the following ways:
*
Emotional reactions directly related to illness or
treatment, including fear, anxiety and a feeling of
damage and frustration caused by loss of habitual
gratification and pleasure
*
Reactions determined primarily by life experience
before or during illness, such as anger, dependency
and guilt
*
Complications such as depression and loss of
self-esteem.
Women are more likely than men to interpret discomfort as a medical symptom; they also recall and report
more symptoms. These differences may partly be
explained by a higher interest in and concern with
health issues among women than men. The family
often plays an active rolein the symptom identification
process. Other family members may recognize some
symptoms before the person does. The family also
takes part in the interpretation process of symptoms.
The culture is also an important factor influencing the
process of symptom identification and evaluation.
Some cultures describe more readily common symptoms as medical, while others tend to suppress signs of
medical symptoms. There might also be differences
between generations in this respect. What was earlier
considered as normal may today be seen as something
requiring medical attention. The individual’s feeling of
anxiety may also explain the symptom levels, since
high anxiety hasbeen associated with the identification
of many symptoms.
Sick-role behaviour
When people perceive themselves to be sick they
adopt the so-called ‘sick-role behaviour’. According
to Parsons this includes the following components:
*
The patient is not blamed for being sick
*
The patient is exempt from work and other
responsibilities
*
The illness is seen as legitimate as long as the
patient accepts the undesirability of it
*
The patient is expected to seek competent help to
get well again.
It has been found that not all people follow these
patterns of the sick role and it should be seen more
as a general framework for understanding illness behaviour. However, this framework is not able to explain variations within illness behaviour; it is not
applicable to chronic disease and often not to mental
illness. There are also certain diseases where there
might be some unwillingness to grant the exemptions
from blame. These include certain conditions related
to smoking, overuse of alcohol and AIDS. But even
epilepsy has been stigmatized in many cultures.
30
Socio-behavioural aspects of health and illness CHAPTER 3
The role of personality in illness
Personality has been shown to be associated with illness. People who have high levels of anxiety, depression and anger/hostility traits seem to be more disease
prone than others. These emotions are part of reactions to different types of stress. People handle stressful situations in different ways. People who approach
stressful situations more positively and hopefully are
less disease prone and also tend to recover more
quickly if they get ill. People who are ill need to
overcome their negative thoughts and feelings in order to recover more quickly.
The cardiologists Friedman and Rosenman were
the first ones to describe differences in behavioural
and emotional style, when studying the behaviour of
heart patients. These patterns have been named Type
A and Type B behaviour. The Type A behaviour pattern is characterized by:
*
A competitive achievement orientation, including a
high level of self-criticism and striving towards
goals without feeling a sense of joy in achievements
*
Time urgency, e.g. tight scheduling of
commitments, impatience with time delays and
unproductive time
*
Anger/hostility which is easily aroused. This
component, especially, seems to be detrimental to
good health. Type A individuals respond more
quickly and strongly to stress, often seeing stressors
as threats to their personal control.
The Type A pattern may also increase the person’s
probability of getting into stressful situations. The
relationships between Type A behaviour and psychosocial factors are very complex, involving multiple
levels of human experience.
Type B behaviour is opposite to Type A, with individuals taking life more easily with little competitiveness, time urgency and hostility. Interestingly the
overall evidence for an association between Type A
and B behaviour and general illnesses is weak and
inconsistent. However,many studies, but not all, have
shown a clear association between Type A behaviour
and coronary heart disease.
Health knowledge, beliefs and attitudes
There are different definitions of what this knowledge
is. Sometimes it may include a variety of things such
as beliefs, expectations, norms and cognitive percep-
tions. If this is the case, knowledge has to be considered in a wider framework than merely having some
factual knowledge about diseases and treatment.
One of the goals in current health care is to improve
the patient’s problem solving capacity. The starting
point is providing the necessary information and
improving the factual knowledge of the patient. It
has been shown several times that knowledge alone
is not sufficient to ensure change in behaviour, which
is often the goal. Preventive behaviours, the treatment
process and taking medications all require a certain
amount of knowledge. The current trend emphasizing
guided self-care in chronic diseases such as asthma,
diabetes and hypertension requires a well-informed
patient. The aim is to produce patients who actively
participate in their own treatment. In research settings, the narrow approach towards knowledge usually
involves using a knowledge index (set of questions)
that the patient has to answer before and after an
educational intervention.
Attitudes have been defined as states of readiness
or predisposition, feeling for or against something,
which predisposes to particular responses. They involve emotions (feelings) and knowledge (or beliefs)
about the object and emanate in behaviour. Attitudes
are not inherited but learned and, though relatively
stable, are modifiable by education.
The health belief model
The health belief model, which was originally developed by Rosenstock and his colleagues to predict the
use of preventive health services, has been extensively
used during the last two decades to try to explain
various health behaviours. The model was further
developed for predicting health behaviour in chronic
diseases and reformulated for predicting compliance
with healthcare regimens.
The elements of the model are subjective perceptions which can be modified, at least in theory. According to the model, the probability that a person will take
a preventive health action – that is, perform some
health, illness or sick-role behaviour – is a function of:
*
The perceived susceptibility to the health problem
or disease
*
The perceived severity of medical and social
consequences of the disease
*
The perceived benefits and barriers (costs) related
to the recommended behaviour.
According to the model, the more vulnerable the person feels and the more serious the disease the more
31
SECTION ONE Pharmacy practice and society
likely it is the person will act. Furthermore, various
factors that result from the perceptions are expected
to modify this motivating force. These factors include
demographic, socio-economic and therapy-related
factors as well as the illness itself and the prescribed
regimen. Prior contact with the disease or knowledge
about the disease may modify the behaviour. Some
incidents, so-called ‘cues to action’, are also expected
to trigger the behaviour. These include, for example, a
mass media campaign, magazine article, advice from
significant others or illness of a family member or
friend.
The concept of perception is important in the
health belief model. It is the patient’s and not the
pharmacist’s perceptions that drive the decisions
and behaviours of the patient. In studies of compliance with prescribed medications the concept of personal susceptibility has been modified because the
illness has already been diagnosed. One approach
includes examining the individual’s estimate of or
belief in the accuracy of the diagnosis. This concept
has also been extended to estimating resusceptibility
or measuring the individual’s subjective feelings of
vulnerability to various other diseases or to illness in
general. Studies show that in hypertension, for example, the threat posed by hypertension and the perceived effectiveness of treatment in reducing this
threat seem to be important predictors of compliance.
Likewise the perceived control over one’s own health
is important. There is some controversy about the
chronology of these beliefs and whether they precede
or develop simultaneously with health behaviour.
The health belief model and common sense might
tell us that the patient’s decision to seek health care,
accept a diagnosis and engage in health-related behaviours would be related to the seriousness of the disease. Research indicates this may not always be the
case. Patients’ health behaviours are a function of
many psychosocial variables. Reasons why humans
may behave illogically are dealt with in more detail
in the section ‘The conflict theory’, below, and also in
the section ‘Decision analysis and behavioural decision theory’ (p. 34).
The theory of reasoned action
According to the theory of reasoned action by Ajzen &
Fishbein, a person’s intention is the best predictor of
what he will do. The person’s intention is determined
by his attitude regarding the behaviour and whether
he thinks it is a good or bad thing to do. This assess-
ment is based on behavioural beliefs about possible
outcomes of the behaviour and evaluations of whether
these outcomes would be rewarding. The other attitude represents the impact of social pressure or influence. These are based on normative beliefs regarding
others’ opinions about the behaviour and the person’s
motivation to follow those opinions, i.e. what do other
people think I should do? The theory proposes that
the subjective norm and the attitude regarding the
behaviour combine to produce an intention, which
leads to the behaviour.
If behaviour is determined by beliefs, this raises the
question of what factors determine beliefs? These
factors would include things like age, sex, education,
social class, culture and personality traits. These variables influence behaviour indirectly rather than
directly. One of the problems with the theory is that
people do not always do what they plan, i.e. intentions
and behaviour are only moderately related. Another
problem is that people do not always act rationally.
Irrational decisions such as delaying medical treatment when symptoms exist cannot be explained by
the model. Neither does the model include prior
experiences with the behaviour, which might be an
important factor to consider, since past behaviour is a
strong predictor of future practice of that behaviour.
The conflict theory
The conflict theory has been used to explain rational
and irrational decision making. According to the model the process a person is using in arriving at a healthrelated decision involves five stages. It starts when
something challenges the person’s current course of
action. It can be a threat (e.g. symptom) or a mass
media alert about, for example, the danger of narcotics or an opportunity (e.g. free membership to a
health club). The different stages of the conflict
theory model are:
*
Assessing the challenge, i.e. whether the risk is
serious enough. The assessment may involve
thoughts such as the risk is not real, it is irrelevant
or inapplicable. If the risk is not considered
serious enough, the behaviour continues as before
and the decision-making process stops.
*
Assessing alternatives, i.e. the search for
alternatives for dealing with the risk starts when the
risk is acknowledged. This stage ends when the
32
Socio-behavioural aspects of health and illness CHAPTER 3
suitability of available alternatives has been
surveyed.
*
Weighing alternatives, i.e. the pros and cons of each
alternative are weighed to find the best option.
*
Making a final choice and committing to it.
*
Adhering despite negative feedback, i.e. after
starting a new behaviour people may have second
thoughts about it if the environment is not
supportive or it gives negative feedback.
The decision process can be aborted at any point.
Errors in decision making are often caused by stress,
information overload, group pressure and other factors. The way people cope with stress has an important role in health, illness and sick-role behaviour.
According to the conflict theory, a person’s coping
with a conflict is dependent on the presence and
absence of risks, hope and adequate time. Different
combinations of these may result in different types of
behavioural response. For example, when there are
perceptions of high risk in changing the behaviour
and no hope in finding a better alternative, a high level
of stress is experienced. Denial and shifting responsibility to someone else are typical responses, with
delays in seeking care when needed. The perception
of serious risk, and belief in a better alternative, but
also a perception of running out of time, also create
high levels of stress. People search desperately for
solutions and may choose an alternative hastily if
promised immediate relief.Different untested cancer
quacks are good examples where unscrupulous people
try to make use of this kind of situation. The perception of serious risk, with a belief that a better alternative will become available and there is time to search
for it, results in low levels of stress and rational
choices.
Locus of control
It has been claimed that how individuals perceive
their ability to influence disease and the treatment
is an important determinant of health behaviour. People have been categorized into two groups: those with
an internal locus of control and those with an external
locus of control. The former tend to perceive that
they are in control of their own health by their actions
and behaviour, while the latter consider that health is
externally determined and their actions have little or
no effect. Therefore those with a strongly internal
locus of control should tend to practise behaviours
that prevent illness and promote health. Research
has shown that this is the case, but the relationship
is not very strong. This shows that the locus of control
is just one factor among many others that determine
health behaviour. Belief in internal control is likely to
have a greater impact among people who place a
higher value on their health than among those who
do not.
Self-efficacy and social learning
Sometimes performing a health action is hard to do
because it is technically difficult or it may involve
several steps. Therefore the belief in the success in
doing something – called self-efficacy – may be an
important determinant in choosing or not choosing
to change behaviour. People develop a sense of efficacy through their successes and failures, observations
of others’ experiences and assessments of their abilities by others. People assess their efficacy based on
the effort that is required, complexity of the task and
situational factors, e.g. the possibility of receiving help
if needed. People who think they are not able to quit
smoking will not even try, while people who believe
they can succeed will try and eventually some may
even succeed.
Those with a strong sense of self-efficacy show less
psychological strain in response to stressors than those
with a weak sense of efficacy. People differ in the
degree to which they believe they have control over
the things that happen in their lives. Those who experience prolonged, high levels of stress and lack a
sense of personal control tend to feel helpless. Having
a strong sense of control seems to benefit health and
adjustment to sickness.
As environmental factors and expectations directed towards the individuals change, they must either
intensify their activities or change their environment.
Individuals have different capabilities of coping and
different coping strategies. According to the social
learning theory, people change their environment
with the help of symbols they choose in accordance
with their values, norms and goals. On the other hand,
the environment changes the individual’s behaviour
by rewarding beneficial activities and punishing or
not rewarding activities that harm the environment.
Through the socialization process the individual
adopts the values and norms of the community, is
socialized as its member and gains identity. Through
this process the individual has learned to act efficiently in social systems.
Antonowsky has used the ‘sense of coherence’
concept, which is an extensive and constant feeling
33
SECTION ONE Pharmacy practice and society
of an individual’s internal and external environment
being in harmony with each other. Every individual
has characteristic psychosocial potentials that include
material resources, intelligence, knowledge, coping
strategies, social support, arts, religion, philosophy
and health behaviour. Antonowsky calls a sense of
coherence ‘salutogenic’ or health generating. Disease–health is a continuum, at one end of which is a
high degree of coherence and health (ease) and at the
other end a low degree of coherence and illness (disease). External factors that the individual considers
threatening mobilize the defence mechanisms and
cause stress conditions in the individual. Prolonged
stress is disease generating and causes the condition
dis-ease.
Coping
Because of the emotional and physical strain that
accompanies it, stress is uncomfortable and people
are motivated to do things that reduce their stress.
The concept of coping is used to describe how people
adjust to stressful situations in their life. Coping is the
process by which people try to manage the perceived
discrepancy between the demands and resources they
appraise in stressful situations. Coping means the ability to meet the demands of new situations and solve
the problems with which one is confronted. Coping is
determined by situational and personal determinants.
At the individual level, external factors turn into
stress factors if previous experiences together with
personality traits, consciously or unconsciously, are
considered as threatening or diminish self-esteem.
Coping efforts can be quite varied and do not necessarily lead to a solution of the problem. It can help the
person to alter his perception of a discrepancy, tolerate or accept the harm or threat and escape or avoid
the situation. The coping process is not a single event.
Coping mechanisms
Coping can alter the problem or it can regulate the
emotional response causing the stress reaction to the
problem. Behavioural approaches include using alcohol or drugs, seeking social support from friends
or simply watching TV. Cognitive approaches involve how people think about the stressful situation,
e.g. changing the meaning of the situation. Emotionfocused approaches are used when people think they
cannot do anything to change the stressful situation.
Problem-focused coping is used to reduce the
demands of the stressful situation or to expand the
capacity and resources to deal with it. The two types
of coping can also be used together. Sarafino (2005)
has summarized commonly used methods of coping as
follows:
*
The direct method, i.e. doing something
specifically and directly to cope with a stressor, for
example negotiating, consulting, arguing, running
away
*
Seeking information and acquiring knowledge
about the stressful situation
*
Turning to others, i.e. seeking help, reassurance and
comfort from family and friends
*
Resigned acceptance, i.e. the person comes to
terms with the situation and accepts it as it is
*
Emotional discharge, i.e. expressing feelings or
reducing tension by taking, for example, alcohol or
drugs, smoking cigarettes
*
Intrapsychic processes, i.e. cognitive redefinition,
for example the ‘things could be worse’ attitude.
Decision analysis and behavioural decision theory
Decision analysis is a systematic way of studying the
process of decision making among patients, pharmacists and physicians. This is a widely used tool in pharmacoeconomics today (see Ch. 19). It usually involves
assigning numbers to perceived values of the therapeutic outcomes and the probability that the outcome will
occur. This gives a utility of each outcome and the one
with the highest utility would be chosen. One problem
is that humans do not always make decisions logically
or treat information as value free.
Why don’t humans behave logically? One explanation that has been offered is that humans are biased
when making decisions under uncertainty because we
fail to appreciate randomness. We believe that there
are known causes and effects for all phenomena and we
have a need to be able to explain outcomes. It is easier
to explain, even incorrectly, than to have to deal with
uncertain situations.People also tend to be inconsistent
in judgment, often because of difficulties in remembering how a judgment was made. Another reason is
that we seldom receive feedback from negative decisions,for example ifwe decide not to take the medicine
we do not know how effective it would have been.
Behaviour decision theory has been used to understand how patients make decisions about their medicine and health-related behaviour. These include
acquisition of information, information processing,
34
Socio-behavioural aspects of health and illness CHAPTER 3
making decisions under uncertainty and interpreting
outcomes of that decision. It has been found that
patients are more likely to take a health risk to avoid
an aversive situation than to gain a positive health
outcome. Patients are also more likely to choose a
certain outcome than an outcome with a high probability of occurrence, even if the certain outcome is less
valued than that one with a high probability of occurrence. When a person has already invested time and
money on a product or activity they are likely to
continue it, even if it does not appear to be effective.
Hogarth has described different biases that people
tend to have in decision making which may be helpful
in understanding patient choices about health behaviour. We tend to believe more in well-publicized
events than in those that are less publicized. This
has direct links with the consumer’s choice of welladvertised over the counter (OTC) medicines. There
is a tendency to believe what matches our existing
beliefs. This selective perception has direct implications for health education in pharmacies. We also tend
to believe real incidents more than abstract statistics.
Positive experiences from a family member quitting
smoking is more likely to be effective than showing
statistics about future (uncertain) consequences of
smoking. Two incidents occurring close in time and
place tend to be regarded as causal. Becoming ill after
having taken a medicine (regardless of cause and effect) would usually trigger a response of aversion next
time seeing the same medicine. We are reluctant to
change our beliefs, even when given new data, and
tend to discount the new information rather than
discount our belief. Very few instances of an occurrence are needed for us to form a new belief if it has a
strong effect upon us. This has direct implications to
the experience of side-effects of drugs. We also believe something is more likely to happen if we want it
to happen. A decision that was successful is more
likely to be considered to be due to the knowledge
and wisdom of the decision maker. On the other hand,
a decision resulting in bad outcomes is likely to be
blamed on others.
Theory into practice – the
process of behaviour change
A lot of pharmacists’ activities will focus on changing
the behaviour of patients. Without going into the
ethical aspects of behaviour change, we will concentrate on the process of change. It has been proved
several times that merely using common sense is not
enough to reach permanent behaviour change. Using a
common-sense approach would assume that, given
the facts, people will be able to change their behaviour
in a direction anticipated by the healthcare professional. A simple example illustrates the limits of this
approach – why do so many people still smoke cigarettes despite knowing all the negative consequences
of smoking?
Even if many of the behavioural theories are far
from complete or comprehensive, they may guide
us in improving the outcome of behavioural interventions. Behaviour change includes a long list of steps
that need to be taken before it is finalized:
*
The process starts with attention. The person needs
to be exposed to the message; this might be a
counselling session by the pharmacist or a health
campaign in the mass media. If the same message is
repeated from different sources and these sources
are regarded as credible, the likelihood of change
grows. Therefore it is important that the
information received from physicians and
pharmacists is congruent. If patients receive mixed
messages they are more likely to ignore them.
*
Attention is followed by motivation. The person
must feel motivated to change their behaviour. It is
well known that immediate rewards are more
motivating than anticipated rewards after several
years.
*
Next the person has to comprehend the message to
be able to act upon it, but they also need to learn
some facts, i.e. improve their knowledge base.
These facts need to be simple and match the local
culture.
*
The following step is persuasion, i.e. the person
needs to ‘change their attitude’.
*
Furthermore they might need to learn some new
techniques and skills in how to take or handle the
medication. Demonstration and guided practice
are the best ways of handling this step.
*
The person must also be able to perform the skills
and maintain the learned skills, which include selfefficacy training and feedback of success. Many
experiments with a long enough follow-up show
that positive results can be achieved with
pharmacists’ interventions, but when the
experiment is over, the results soon deteriorate to
pre-experiment levels.
*
Continuous reinforcement is necessary to maintain
good results in any intervention, be it changing
medicine-taking behaviour or modification of
preventive health behaviour.
35
SECTION ONE Pharmacy practice and society
The treatment process
Self- and lay care
During the 1970s and 1980s a new trend emphasizing
the role of the individual and patient emerged as a part
of a more general trend called consumerism. People
have become more committed to getting and taking
control of their own lives and assessing the impact of
their behaviour on their health. Different self-care
and self-help movements were a direct result of this
trend. The same trend has been obvious in most countries although the starting time and speed of it has
varied. At the same time the dominant role of healthcare personnel has diminished. With new information
sources, and especially the Internet, the trend continues to grow and spread to countries where physicians and other healthcare personnel still dominate.
This new trend has included a much more critical
attitude towards what is being done in health care
and the quality of care given. Patients are asking more
questions, seeking more information and taking a
more active role in their health care. They have a
better basic education and greater knowledge, especially about their own disease and treatment of that
disease.
The new trend has also put increasing demands on
pharmacists regarding their knowledge base, especially in therapeutics but also in communication. The
priorities in treatment goals may differ between the
patient and the treating physician and this calls for
negotiation. One aspect is that patients’ views have to
be taken seriously.
According to the self-care philosophy, people
should be given more responsibility for their own
health. One way this can be achieved is to emphasize the role of self-care in treating minor ailments
using home remedies and an in crea sed number of
self-medication products. Especially in the 1980s
and early 1990s this trend was obvious in many
countries. The most common ‘action’ in response
to a perceived health problem has been to ignore
the problem or wait for a few days. It is estimated
that some 30–40% of health problems are dealt
with in this way. Of those who take some action,
75–80% self-diagnose and use self-treatment, while
only 20–25% seek professional care. Therefore a
seemingly small change in this ratio (towards using
more professional care) has a substantial impact
and burden on the official healthcare system. Of
those who use self-treatment, some 70–90% are
self-medicating, and of those self-medicating, some
80% are using OTC drugs. Home remedies such as
onion, garlic and warm drinks, as well as different
herbal products, vitamins and minerals, are widely
used all over the world. Some of the newly emerging preparations are marketed with high promi ses
of eternal youth and health, the evidence base for
which is n onexistent or weak.
Before people decide to seek medical care for their
symptoms they get and seek advice from friends,
relatives and co-workers. These advisors form a lay
referral network that provides its own information
and interpretation regarding the symptoms, recommending home remedies, self-medication, professional help or consulting another ‘lay expert’ who
may have had a similar problem.
The pharmacy is often the first place where people come to seek help within the healthcare system.
Increased self-care includes also potential risks in
thatlaypeoplemaynotbeabletodistinguishbetween serious and non-serious symptoms. Certain
situations may demand professional care without
further delay cau sed by inappropriate self-medication practices. The lay referral network can in some
cases be guilty of causing delay in seeking care. This
treatment delay has been divided into three stages:
appraisal delay, illness delay and utilization delay.
Appraisal d elay is the time it takes to interpret a
symptom as a part of an illness. Illness delay is the
time between recognizing the illness and the decision to seek care. Finally, utilization delay is the
time between the decision to seek care and actually
using a health serv ice.
There has also been concern about misuse of OTC
drugs such as laxatives, codeine-containing cough
medicines, etc. The other side of the coin is saved
resources in health care when there is less reliance
on professionals. This seems to be an important aspect
as healthcare budgets tend to increase more rapidly
than the general inflation rate.
Primary care
Simultaneously with emerging self-care, the concept of primary heal th care was intr oduced. In
1977 the World Health Assembly of the World
Health Organization adopted the concept of Health
for All by the Year 2000. The following year this
concept was translated into the so-called Alma Ata
Declaration at the Alma Ata conference on primary
health care. The focus was on making health care
36
Socio-behavioural aspects of health and illness CHAPTER 3
more accessible and lowering the healthcare costs
and thus improving the quality of life for the whole
population. According to the declaration, primary
health care should include:
*
Education about prevailing health problems
*
Methods of identifying, preventing and controlling
them
*
Promotion of food supply and proper nutrition
*
Adequate water supply and basic sanitation
*
Maternal and child health care including family
planning
*
Immunization against the major infectious diseases
*
Prevention and control of locally endemic diseases
*
Appropriate treatment of common diseases and
injuries
*
Promotion of mental health
*
Provision of essential drugs.
Primary health care focuses on principal health problems and must be part of national health policy
and planning. The conference recommended a reevaluation of health priorities, putting less emphasis
on curative facilities, especially in third world countries. The conference also called for cooperation
and commitment in striving for an acceptable level
of health for all people by the year 2000.
The scope of public health is population based
rather than individually based. Public health problems
are not a series of individuals presenting diseases to a
healthcare provider for cure, alleviation or prevention, but are considered in the context of the community. It is a public health problem to determine the
prevalence of a disease in the community, compare
that with figures from previous years and plan health
services to reduce the prevalence. Public health
includes enumeration, analysing and planning, but
also specific actions to be taken. Public health exists
on two levels: the micro level, for example performing
some public health function such as immunization or
preventing inappropriate use of illicit drugs, and the
macro level, with activities like planning or policy
formulation.
Factors influencing the use of
health services
The structures of the healthcare systems in different countries have a lot of similarities but also a lot
of differences. The system is the sum of historical
development, culture and economic factors. In
some countries there are actually several different
systems in place within the healthcare system. It is
not within the scope of this chapter to describe
these different systems, rather to highlight some
of the current issues in organizing the health
care of the citizens and to highlight some sociobehavioural factors influencing the provision of
care. It may seem obvious that when having bad
angina you will need hospital care and you will be
provided with all the technical know-how and help
in dealing with the problem. However, the country
you happen to live in, the insuranc e policy you
have, the services available, quality of care, etc. will
all influence the outcome of the disease. The organization and financing of health care, the environment of medical care, social and cultural factors all
influence t he care that you will receive.
Demographic factors
Several important differences have been reported
between different age groups and between genders.
However, few reports have been able to validate
the reasons for these differences. As mentioned
before,itiswellknownthatwomenreportmore
symptoms and that they have a lower threshold of
pain and discomfort and are more likely to seek
care. Men are more hesitant than women to admit
to having symptoms and to seek medical care for
these symptoms. This can be a result of perceived
sex-role stereotypes – men should be tough and
independent and ignore or endure pain. Women
use physician services more than men in all age
groups except for the first few years of life. Regardless of this, men have a higher mortality and shorter
life expectancy at all ages.
In general, young children and the elderly use
physician services more often than adolescents and
young adults. Age differences in health behaviour
cannot be explained by biological ageing alone. Elderly people have different views on health and
illness, symptoms, healthcare use and drugs. There
is a danger in labelling all elderly people as having
similar attitudes concerning health issues, but, as
with younger persons, among the elderly there are
also a wide variety of views on health and treatment. Certain ideas are more prevalent am ong t he
elderly than the young. The differences can partly
be explained by so-called cohort effects, meaning
people of the same age have been exposed to the
same kind of experiences and attitudes in society
and therefore are also likely to share certain behavioural characteristics.
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SECTION ONE Pharmacy practice and society
Cultural and socio-economic factors
Ethnic and cultural background may explain some
differences in symptom experience, how people seek
medical care and how they take their medicines. In
the 1950s a classic study about how people deal with
pain found big differences between Italian, Jewish,
Irish and Yankee (Old American) hospitalized
patients. Italian and Jewish patients were more likely
to respond emotionally and expressively to pain than
Irish or Yankee patients, who tended to deny pain.
Italian and Jewish patients showed their pain by crying, complaining and demanding, while the Irish and
Yankee patients preferred to hide their pain and withdraw from others. More recent studies among immigrants in the USA found that the differences in
willingness to tolerate pain diminish in succeeding
generations. Other similar studies have shown cultural differences among European countries and the
USA, e.g. in perception of fever and the need to
medicate children’s fever.
There are also differences in seeking care according
to social class, education and income. These factors all
point in the same direction – those who are better off
also use more health services. Different models of
why people seek or do not seek health services have
been proposed. The health belief model has also been
used in this context.
Social support
Social environments and networks are important in
the growth, development and health of people. Social support is an important factor in all phases of
the process of illness and the treatment process.
Social support relates directly to the general a nd
universal needs of people. The best known theory is
that by Maslow. According to his theory, human
needs are hierarchical, starting with basic physiological needs, followed by safety needs, belongingness and love needs, esteem needs, and finishing
with the highest – self-actualization needs . A slight-
ly modified and simplified model is that by Allardt;
according to Allardt, people’s needs include standard of living (having), social relations (loving) and
forms of self-actualization (being). Social relations
include social networks and belonging to them is
the basis of one’s identity and social existence.
Social support is the term used for different forms
of emotional and material supp ort. The nature of
social support is reciprocal. It can be support provided directly by one person to another or indirectly through the system or community.
Forms andlevels of social support
*
Material or instrumental support includes money,
goods, auxiliary appliances and medicine
*
Operational support includes service,
transportation and rehabilitation
*
Informational support includes advice, directions,
feedback, education and training
*
Emotional support involves the expression of caring,
empathy, love and encouragement
*
Mental support involves a common ideology, belief
and philosophy.
Social support has two dimensions, a qualitative and a
quantitative dimension. It can also be subjective and
objective in nature. The quality of social support can
be measured only by subjective assessments. When
providing material support the quantitative aspect is
more prominent (medicines an exception); in the
other support forms the qualitative aspect (including
timing) is more important than the quantitative aspect. Thus a small functioning support network is
better than a broad but passive one.
Social support has been divided into primary, secondary and tertiary levels bas ed on the in timacy of
the social relationships. The primary level includes
family and close friends, the secondary level
includes friends, colleagues and neighbours and the
tertiary level acquaintances, authorities, public and
private services. Social support can be provided by
a lay person (usually on the primary and secondary
level) or a professional (usually on the tertiary
level). Recently different organizations have started
training courses for lay providers of support aiming
at strengthening the second level of s upport. Social
support has both direct effects on health and wellbeing and indirect stress-buffering effects o n coping
in stressful situations.
The research on the effects of social support on
health goes back to the late 1940s and early 1950s.
The first studies in this area showed that lack of social
support exposes people to recurrent accidents, suicide
and risk of catching tuberculosis. In the 1970s the
emphasis was on relationships between social support
structures and health in communities. It was shown
that the lack of social support increases the incidence
of coronary heart disease, mortality due to myocardial
infarction and total mortality in the population. It has
also been shown that social support is important in
perceived health and in reducing hypertension. Social
support also has a positive effect on physical, social
and emotional recovery. It reduces the need for medication and speeds up symptom amelioration. The
38