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).

Lifestyle and health

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)

5.

6.

7.

1.

2.

3.

4.

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 theories

genetic suggest that there may be a 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 1985).

et al.

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

the individual is a process in which 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

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.

Behaviourist learning theories

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

observes and occurs when an individual 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.

Social learning

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.

assume that In other words, they 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 meanings within a culture (for example, and

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.

1. 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.

five different types of exercise.

2. Isotonic exercise involves the contraction of muscles and the movement of joints, as in weight lifting. Muscle strength and endurance may be improved but the general improvement is in body appearance rather than improving fitness and health.

five different types of exercise.

3. Isokinetic exercise uses specialised equipment that requires exertion for lifting and additional effort to return to the starting position. This exercise is more effective than both isometric and isotonic exercise and promotes muscle strength and muscle endurance (Pipes and Wilmore, 1975).

five different types of exercise.

4.

Anaerobic exercise involves short, intensive bursts of energy without an increased amount of oxygen such as in short distance running. Such exercises improve speed and endurance but do not increase the fitness of the coronary and respiratory systems and indeed may be dangerous for people with coronary heart disease.

five different types of exercise.

5.

Aerobic exercise requires dramatically increased oxygen consumption over an extended period of time such as in jogging, walking, dancing, rope skipping, swimming and cycling. The heart rate must be in a certain range which is computed from a formula based on age and the maximum possible heart rate. The heart rate should stay at this elevated level for at least 12 minutes, and preferably 15 to 30 minutes. This exercise improves the respiratory system and the coronary system.

Organic & Dynamic Fitness

 Kuntzleman (1978) 

Organic fitness

-our capacity for action and movement determined by inherent factors such as genes, age and health status. 

Dynamic fitness

-determined by our experience.

London bus crews

 Maurice et al. (1953) studied London double decker bus drivers and their conductors. The more active conductors had significantly less incidence of C. H. D. than did the sedentary drivers. Can you think of any confounding factors in this study?

Exercise

 Exercise has been found to lower depressive moods in a variety of people, including young pregnant women from ethnically diverse backgrounds (Koniak-Griffin, 1994) and nursing home residents aged 66 to 97 (Ruuskanen and Parkatti, 1994). These findings could be due to the release of endogenous Opiates during exercise.

Exercise

 Exercise is a buffer against stress. This could be because of the positive effect on the immune system. Exercise produces a rise in natural killer cell activity and an increase in the percentage of T cells (lymphocytes) that bear natural killer cell markers (indicating the sites where killer cells are produced). This warns off invading cells before they have the chance to harm the body.

Exercise

 Both exercise and stress reduce adrenaline and other hormones yet exercise has a beneficial effect on heart functioning whereas stress may produce lesions in heart tissue. In exercise adrenaline metabolises differently and is released infrequently and gradually under conditions for which it was intended (e.g. jogging). In conditions of stress adrenaline is discharged in a chronic and enhanced manner.

Dietary habits

 The MRFIT study (Stamler et al. 1986), was a longitudinal study over six years of three hundred and fifty thousand adults. A linear relationship was found between blood cholesterol level and the incidence of coronary heart disease (CHD) or stroke. The risk for individuals within the top third of cholesterol levels was three and a half times greater than those in the lowest third.

Dietary habits

 A 24 year longitudinal study of American men working for western electricity found that men who consumed high levels of cholesterol were twice as likely to develop lung cancer compared with men who consumed low levels of cholesterol. Much of the cholesterol came from eggs (Shekelle et al, 1991).

Dietary habits

 High fibre diets protect men and women from cancer of the colon and the rectum. Fibre from fruits and vegetables offer more protection against colon cancer than that from cereals and other grains. Fruit consumption offers protection against lung cancer and we should be eating fruit 3 to 7 times per week (Fraser et al, 1991).

Obesity and eating disorders

 More than a quarter of children in English secondary schools are clinically obese, almost double the proportion a decade ago, and an official survey released in April 2006 also showed that girls were suffering more than boys from a crisp and chocolate-fuelled life of too much eating and too little exercise.

Obesity and eating disorders

 Researchers measured the height and weight of 11-15 year olds, and found 26.7% of girls and 24.2% of boys qualified as obese - nearly double the rate in 1995. Among children aged 2-10, 12.8% of girls and 15.9% of boys weighed above the obesity threshold also well up on 10 years before.

Obesity and eating disorders

 The increase in obesity accelerated sharply in 2004, especially among girls, the survey said. Figures for the 11-15 age group showed the proportion of obese girls grew from 15.4% in 1995 to 22.1% in 2003. But in 2004 it shot up to 26.7%.

Obesity and eating disorders

 The survey also found that the obesity rate among adults had risen to 24%, in spite of people exercising more and eating more fruit and vegetables.  However, more men gave up smoking than women, and in 2004 there were for the first time more women smokers (23%) than there were men (22%).

Obesity and eating disorders

 Obesity is defined in terms of the percentage and distribution of an individual's body fat. Techniques used to assess the body fat range from using computer tomography (e.g. ultrasound waves) to magnetic resonance imaging (MRI). Obesity may also be defined in terms of body mass index (B. M. I.) which is calculated by dividing a person's weight by their height squared using metric units (i.e. kilogrammes and metres squared).

Obesity and eating disorders

 Stunkarda (1984) suggested that obesity should be categorised as either mild (20 to 40% overweight), moderate (41 to 100% overweight) or severe (more than 100% overweight). This would suggest that 24% of American men and 27% of American women are at least mildly obese (Kuczmarski, 1992).

Obesity

 There are three different types of theories that attempt to explain obesity; they are:

1.

Physiological

elements. theories suggesting that there are genetic

2.

3.

Metabolic rate

theories proposing that obese people have a lower resting metabolic rate, burn up less calories when resting and therefore require less food. They also tend to have more fat cells which are genetically determined.

Behavioural

theories suggest that obese people tend to be less physically active and eat more food than required.

Eating disorders

 The two main eating disorders are

anorexia nervosa

and

bulimia

.

Anorexia

 Individuals are diagnosed as anorexic only if they weigh at least 15% less than their minimal normal weight and have stopped menstruating. In extreme cases, anorexics may weight less than 50% of their normal weight. Weight loss leads to a number of potentially dangerous side-effects, including emaciation (wasting of the body), susceptibility to infection and other symptoms of under nourishment. Females are 20 times more likely to develop anorexia than males. But horseracing Jockeys, who are usually male, are susceptible to anorexia. Anorexia particularly affects white, Western, middle to upper class, teenage women.

Anorexia

 Another characteristic of anorexia nervosa is that of distortion of body image. Anorexics think that they are too fat. This was investigated by Garfinkel and Garner (1982). Participants used a device that could adjust pictures of themselves and others up to 20 per cent above or below their actual body size. An anorexic was more likely to adjust the picture of herself so that it was larger than the actual size. They did not do the same for photographs of other people.

Anorexia

 American undergraduates were shown figures of their own sex and asked to indicate the figure that looked most like their own shape, their ideal figure and the figure they found would be most attractive to the opposite sex. Men selected very similar figures for all three body shapes! Women chose ideal and attractive body shapes that were much thinner than the shape that was indicated as representing their current shape. Women tended to choose thinner body shapes for all three choices (ideal, attractive and current) compared to the men (Fallon and Rozin, 1985).

Anorexia

 The perfect figure has changed over the years. In the 1950s female sex symbols had much larger bodies compared with present day female sex symbols.

Anorexia

 The hypothalamus is implicated in anorexia. The hypothalamus controls both eating and hormonal functions (which may also explain irregularities in menstruation).

Anorexia

 Personality factors and family dynamics could also play a part in anorexia. The anorexic lacks self confidence, needs approval, is conscientious, is a perfectionist and feels the pressure to succeed (Taylor, 1995).

 Parental psychopathology or alcoholism also plays a part as does being in an extremely close or interdependent family with poor skills for communicating emotion or dealing with conflict (Rakoff, 1983).

Anorexia

 The mother daughter relationship has been implicated. Mothers of anorexic daughters tend to be dissatisfied with their daughter's appearance and tend to be vulnerable to eating disorders themselves (Pike and Rodin, 1991).  Genetics could explain this result as De Castro (2001) has found that identical twins have similar eating patterns compared with fraternal twins

Bulimia

 Bulimia is characterised by recurrent episodes of binge eating followed by attempts to purge the excess eating by vomiting or using laxatives. The binges occur at least once a day usually in the evening and when alone. Vomiting and the use of laxatives disrupts the balance of the electrolyte potassium resulting in dehydration, cardiac arrhythmias and urinary infections.

Bulimia

 This disorder mainly affects young women and is more common than anorexia affecting five to ten% of American women. Bulimia is not confined to middle or upper-class females and transcends racial, ethnic and socioeconomic boundaries. Like anorexia explanations encompass biological, personality and social factors. Bulimics often suffer from other disorders such as alcohol or drug abuse, impulsivity and kleptomania.

Bulimia

 It may be triggered by life events such as feeling guilty or feeling depressed. There is a stronger link between depression and bulimia compared with depression and anorexia. The depression seems to be linked to a deficit in the neurotransmitter substance serotonin. Bulimics may report lacking self-confidence and use food to fulfil their feelings of longing and emptiness. The binge eating and vomiting is justified in terms of needing to have a high calorie intake of food and a desire to stay slim.

Bulimia

 Treatment involves medication and cognitive behavioural therapy. Antidepressants drugs are used in combination with psychotherapy. Treatment for bulimia tends to be more successful because bulimics recognise that they have a problem whereas anorexics don't.

Health and Poverty

 It is important to point out that the most damaging lifestyles for our health are those associated with low incomes. Throughout the Western world, the most consistent predictor of illness and early death is income. People who are unemployed, homeless, or on low incomes have higher rates of all the major causes of premature death (Fitzpatrick and Dollamore, 1999).

Health and Poverty

 The reasons for this are not clear although there are two main lines of argument. First, it is possible that people with low incomes engage in risky behaviours more frequently, so they might smoke more cigarettes and drink more alcohol. This argument probably owes more to negative stereotypes of working-class people than it does to any systematic research.

Health and Poverty

 The second line of argument is that poor people are exposed to greater health risks in the environment in the form of hazardous jobs and poor living accommodation. Also, people on low incomes will probably buy cheaper foods which have a higher content of fat (regarded as a risk factor for coronary heart disease).

Health and Poverty

 All this means that psychological interventions on behaviour can only have a limited effect, since it is economic circumstances that most affect the health of the nation.

Health and Poverty

 The effects of poverty are long lasting and far-reaching. A remarkable study by Dorling et al. (2000) compared late 20th century death rates in London with modern patterns of poverty, and also with patterns of poverty from the late 19th century.

Health and Poverty

 The researchers used information from Charles Booth’s survey of inner London carried out in 1896, and matched it to modern local government records.

Health and Poverty

 When they looked at the recent mortality (death) rates from diseases that are commonly associated with poverty (such as stomach cancer, stroke and lung cancer), they found that the measures of deprivation from 1896 were even more strongly related to them than the deprivation measures from the 1990s. They concluded that patterns of disease must have their roots in the past.

Health and Poverty

 It is remarkable, but true, that geographical patterns of social deprivation and disease are so strong that a century of change in inner London has not disrupted them.

Health and Poverty

 Another study by Dorling et al. (2001) plotted the mortality ratio (rate of deaths compared to the national average) against voting patterns in the 1997 general election. They divided the constituencies into ten categories, ranging from those who had the highest Labour vote to those who had the lowest.

Health and Poverty

 The analysis found that the constituencies with the highest Labour vote (72 per cent on average) had the highest mortality ratio (127), and that this ratio decreased in line with the proportion of people voting Labour, down to the lower Labour vote (22 per cent on average) where there was a much lower mortality ratio (84).

Health and Poverty

 This means that early death, and presumably poor health, was more common in areas that chose to vote Labour. If we take Labour voting as still being influenced by class and social status then this study gives us another measure of the effects of wealth on health.

Health and Poverty

 The influence of poverty shows up in a number of ways. Glaucoma is a damaging eye disease that can cause blindness if untreated. A study by Fraser et al. (2001) looked at the differences between people who sought medical help early (early presenters) and those who sought help for the first time when the disease was already quite advanced (late presenters).

Health and Poverty

 The late presenters were more likely to be in lower occupational classes, more likely to have left full-time education at age 14 or younger, more likely to be tenants than owner occupiers, and less likely to have access to a car.

Health and Poverty

 It showed that a persons personal circumstances and the area they lived in had an effect on their decision to seek help with their vision. It also appeared that the disease developed more quickly in people with low incomes.

Health and Poverty

 One uncomfortable explanation of the differences in mortality rates for rich and poor might be that the poor receive worse treatment from the NHS. Affluent women have a higher incidence of breast cancer than women who are socially deprived, but they have a better chance of survival.

Health and Poverty

 A study to investigate the care of the breast cancer patients from the most and least well off areas in Glasgow was carried out by Macleod et al. (2000). They looked at records from hospital and general practice to evaluate the treatment that was given, the delay between consultation and treatment, and the type and frequency of follow-up care.

Health and Poverty

 The data showed that women from the affluent areas did not receive better care from the NHS. The women from the deprived areas received similar treatment, were admitted to hospital more often for other conditions than the cancer, and had more consultations after the treatment than the women from the affluent areas.

Health and Poverty

 Perhaps the reasons for the worse survival rate of women from deprived areas are not related to the quality of care, but to the number and severity of other diseases that they have alongside the cancer.

THE TYPE A BEHAVIOUR PATTERN

 Do some lifestyles make people more vulnerable to disease? Are we justified, for example, in associating high stress behaviour with certain health problems such as heart disease? Friedman and Rosenman (1959) investigated this and created a description of behaviour patterns that has generated a large amount of research and also become part of the general discussions on health in popular magazines.

THE TYPE A BEHAVIOUR PATTERN

 Before we look at the work of Friedman and Rosenman, it is worth making a psychological distinction between behaviour patterns and personality. Textbooks and articles often refer to the Type A personality, though, at least in the original paper, the authors describe it as a behaviour pattern rather than a personality type.

THE TYPE A BEHAVIOUR PATTERN

 The difference between these two is that a personality type is what you are, whereas a behaviour pattern is what you do. The importance of this distinction comes in our analysis of why we behave in a particular way (‘I was made this way’ or ‘I learnt to be this way’), and what can be done about it. It is easier to change a person’s pattern of learnt behaviour than it is to change their nature.

THE TYPE A BEHAVIOUR PATTERN

 Friedman and Rosenman devised a description of Pattern A behaviour that they expected to be associated with high levels of blood cholesterol and hence coronary heart disease. This description was based on their previous research and their clinical experience with patients.

THE TYPE A BEHAVIOUR PATTERN

 A summary of Pattern A behaviour is given below:  (1) an intense, sustained drive to achieve personal (and often poorly defined) goals  (2) a profound tendency and eagerness to compete in all situations  (3) a persistent desire for recognition and advancement

THE TYPE A BEHAVIOUR PATTERN

 (4) continuous involvement in several activities at the same time that are constantly subject to deadlines  (5) an habitual tendency to rush to finish activities  (6) extraordinary mental and physical alertness.

THE TYPE A BEHAVIOUR PATTERN

 Pattern B behaviour, on the other hand, is the opposite of Pattern A, characterised by the relative absence of drive, ambition, urgency, desire to compete, or involvement in deadlines.

Research into type A behaviour

 The classic study of Type A and Type B behaviour patterns was a twelve-year longitudinal study of over 3,500 healthy middle-aged men reported by Friedman and Rosenman in 1974. They found that, compared to people with the Type B behaviour pattern, people with the Type A behaviour pattern were twice as likely to develop coronary heart disease.

Research into type A behaviour

 Other researchers found that differences in the kinds of Type A behaviour correlated with different kinds of heart disease: angina sufferers tended to be impatient and intolerant with others, while those with heart failure tended to be hurried and rushed, inflicting the pressures on themselves.

Research into type A behaviour

 Recent reviews of Type A behaviour suggest that it is not a useful measure for predicting whether someone will have a heart attack or not. Myrtek (2001), for example, looked at a wide range of studies on this issue and concluded that measures of Type A and of hostility were so weakly associated with coronary heart disease as to make them no use for prevention or prediction.

Research into type A behaviour

 The lasting appeal of the Type A behaviour pattern is its simplicity and plausibility. Unfortunately, health is rarely that simple and the interaction of stress with physiological, psychological, social and cultural factors cannot be reduced to two simple behaviour patterns.

RELIGIOSITY AND HEALTH

 In 1921 Lewis Terman started the Terman Life-Cycle Study looking at the lives of over 1500 people. The sample was recruited from schools in California after the teachers identified children who were gifted and had an IQ of 135 and above. The average year of birth was 1910 so their age at the start of the study was 11 years.

RELIGIOSITY AND HEALTH

 It was not a very diverse sample, as they were mostly selected from white middle class families, but this apparent weakness is a strength if we want to look at the effect of selected variables that do not include ethnicity and class.

RELIGIOSITY AND HEALTH

 Data was collected over the years and in 1950 (when the participants were aged about 40) they were asked about their religiosity on a four-point scale (not at all: little: moderate: strong). Forty years later the researchers were able to compare this data against the mortality of the sample.

RELIGIOSITY AND HEALTH

 To cut to the chase, once the researchers had accounted for all the other variables they were able to say that people who were more religious lived longer (Clark et al. 1999).

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