Health and Lifestyles

Mildred Blaxter

• Publisher: Routledge
• Year: 2003
• ISBN:
  9781134989270
• Edition: 1
• Topic: Medicina
• Subtopic: Teoría, práctica y referencia médicas

What is a `healthy' lifestyle? Which is more significant: the social circumstances in which people live, or lifestyle habits such as exercise or smoking?
Health and Lifestyles is the first description of a large and representative survey of the British population asking just those questions. It examines the findings, and considers issues such as measured fitness, declared health, psychological status, life circumstances, health-related behaviour, attitudes and beliefs. Providing firm evidence of the importance of social circumstances and patterns of health-related behaviour, Health and Lifestyles is an important contribution to current debate, revealing the levels of inequality in health in Britain today.

Chapter One

INTRODUCTION

At the individual level, ill health may often seem to strike randomly. At the level of populations, however, it is well known that circumstances and ways of living are closely associated with health: poverty or prosperity, an urban or a rural environment, work and unemployment, stress and contentment—all these have an influence upon health. What fosters a ‘healthy’ lifestyle? How much responsibility does the individual have for his or her own health? These questions are currently at the forefront of public attention. Certain behaviour patterns are thought to be crucially related to the major diseases which are now prominent in advanced societies. More generally, interest has grown in the positive aspects of health and in health promotion. This movement is tied to rising public expectations of better health (WHO 1984). The ways in which the different factors which influence health interact are complex, however, and the relative importance of different aspects of life is not easy to gauge.

In 1984/5 a large national survey of the population of England, Wales and Scotland, the Health and Lifestyle Survey, was carried out. In it, people were asked in great detail about their health and their lifestyles, certain aspects of their fitness were measured, and they were invited to express their opinions and attitudes towards health and health-related behaviour. Because so many aspects of life are included about the same individuals, the opportunity arises to look in a very general way at the relationship between attitudes, circumstances, behaviour and health.

This volume attempts, first, to assess what ‘health’ means to people, and how it is distributed in the population. Then, the questions are asked: how do health-related behaviour and less ‘voluntary’ aspects of social circumstances interact, and which is the more important? To what extent is ‘inequality’ in health the failure of individuals to take responsibility for their health, and to what extent the result of environments which induce vulnerability? How much of ‘healthy’ behaviour is purposive, and based on accurate beliefs and positive attitudes to health promotion, and what are the factors which facilitate or prevent healthy lifestyles?

To suggest that definitive answers could be given to these questions is certainly over-ambitious. This analysis is no more than descriptive and model-building, and in modelling one is to some extent creating an artificial world, in which the infinite variety of human lives is glossed over. However, the study of the general determinants of health has been neglected in Britain, except for small-scale studies, or research on particular diseases (such as heart disease), or the study of particular health-related habits (such as smoking). We have nothing to compare, for instance, with the work of the Human Population Laboratory in the United States (Berkman and Breslow 1983) where the influence of lifestyle factors on health has been studied for over twenty years. The Health and Lifestyle Survey suffers from the great disadvantage, in comparison, of having no longitudinal element, so that any statements about cause and effect must be very tentative. The analysis presented here is, however, offered as a first attempt to consider the lives of individuals as a whole, with all the varied influences which bear upon their health.

Health

First, ‘health’ must be defined. There are no simple or obvious ways in which this can be done, as a great deal of literature over the past twenty or thirty years testifies (e.g. National Center for Health Statistics 1964; Belloc et al. 1971; Breslow 1972; Elinson 1974; Balinsky and Berger 1975; Chen and Bryant 1975; Kaplan et al. 1976; Sackett et al. 1977; Stacey 1977; WHO 1979; Ware et al. 1981; Headey et al. 1985; Kirshner and Guyatt 1985).

Disease or physiological status can be identified or measured (though less easily in a large population survey), but this is not the whole of health: health and illness are social as well as biological facts. Lay people themselves are very aware of this, as the data on concepts of health in Chapter 3 will show. The way in which the respondents to the survey defined the concept of health is dealt with in this early chapter because it seems important, in a survey in which people are asked to talk about health, to bear in mind what they appear to mean by it.

In the biomedical model on which much of modern medicine is based, disease is defined as deviations of measurable biological variables from the norm, or the presence of defined and categorized forms of pathology. This is certainly one component of lay models of health and illness, too. However, as many historians and philosophers of medicine have pointed out, even this apparently clear-cut view of ill health is not without its problems: the definition and classification of disease is inevitably to some extent socially constructed, and ‘normality’ itself is a relative and judgemental concept (Dubos 1961; Engel 1977; Ryle 1961; Mishler 1981).

The respondents to this survey demonstrated clearly that ‘health’, more widely defined, was for them essentially a relative state, influenced notably by the normal ageing process. Health could be identified simply as the absence of disease, but for most people it was more than that. They tended to agree, it would seem, with the World Health Organization’s definition of health as a ‘state of complete physical, social and mental well being and not merely the absence of disease or infirmity’.

Such broad definitions of health are not new, of course: they echo the classical Platonic model of health as harmony among the body’s processes, or the Galenian concept of disease as disturbance of equilibrium. Nor are they at odds with modern scientific theories of vulnerability and immunity. Trying to operationalize such a wide concept of health has the danger of subsuming all human life and happiness under this label: nevertheless, it does draw attention to the fact that positive aspects of healthiness ought to be considered, and not only the negative aspects of pathology. It may be that it is as important to distinguish the factors which differentiate health which is above average and that which is merely average, as it is to look at those which cause the average to become ‘bad’. We know much less about the things which favour positive health than about those which cause disease (Brown 1981).

The definition of health used in this study, therefore, is essentially multi-dimensional and relative. It includes both objective and subjective components, and attempts to consider the positive as well as the negative range.

The search for causes

During the nineteenth century the work of Pasteur and Koch, demonstrating that specific diseases could be caused by the invasion of specific micro-organisms, gave rise to what Dubos (1961) has named the ‘doctrine of specific etiology’. Illness is postulated as consisting of distinct and discrete clinical states, each with specific pathological manifestations and each caused by a different agent (Koch 1890). The subsequent era of classical epidemiology focused, with great success, upon diseases—whether caused by micro-organisms, viruses, nutrient deficiencies, toxins or other causative agents—where the model of a specific agent, giving rise to a distinct pathology, seemed appropriate.

The traditional approaches of epidemiology become more complex, however, in the modern Western world, where many of the health problems are degenerative and chronic. There is now recognition that most diseases have multiple and interactive causes. Indeed, perhaps all ill health must be viewed in this way, given modern knowledge about susceptibility, about genetic dispositions, and about the influence of psycho-social factors. More complex—if at the same time less precise and demonstrable levels of explanation may be required.

It must be made clear that the present study does not address the classical epidemiological issues—what are the causes of specific diseases? A household survey is certainly not the most appropriate method for such questions: no study in the community can provide accurate prevalences of more serious disease, since those who are suffering from such diseases are likely to be in hospital, or at the least less likely to be available for interview. Instead of narrowing down to particular causes and particular pathologies, the intention is to build up, at the most general level possible, models of the relationship between lifestyle and health.

Lifestyle

‘Lifestyle’ is a vague term. Although it is a popular concept, what we mean by it has been questioned (McQueen 1988; Wiley and Comacho 1980; Taylor and Ford 1981). Often it is used to mean only voluntary lifestyles, the choices that people make about their behaviour and especially about their consumption patterns. In the context of health, choices about food, about smoking and drinking, and about the way in which leisure time is spent, are often thought to be the most relevant. Styles of living also have economic and cultural dimensions, however: the way of life of the city may inevitably be different from that of the country, the single from the married, the North from the South. There is overwhelming evidence for persistent socio-economic influences upon health: income, work, housing, and the physical and social environments are also part of ways of living. These have to be considered both as having a direct effect on health and as factors influencing behaviour.

This wide definition of lifestyle is the one which is used here, rather than one based on personal behaviours which are known to be risk factors. The issue of responsibility for these personal behaviours, and more generally for the maintenance of health, is of course a controversial one which has become of increasing importance. Debate has focused on whether policies aimed at health promotion should be individualistic, placing responsibility firmly on the individual and the family, or whether they should be collectivist. On the one hand, it is argued that many of the currently most important diseases are ‘self-inflicted’, and remedies lie in the hands of the public. On the other, it is suggested that this approach minimizes the social and economic factors which are outside the individual’s control. The issue of personal liberty may be invoked in the first case: the right of individuals to do what they wish with their own lives, guided only by education about the ‘right’ decisions. In the second, the inability of many people to exert control over their environment and ways of living is emphasized.

This debate is a major focus of this analysis. There is no doubt that social and economic circumstances, and the more voluntary aspects of lifestyle, are both associated with health. Can evidence be offered as to which is the more important?

Inequalities in health

The issue of social inequalities in health is thus a major topic. In this context, ‘inequalities’ does not mean simply that individuals differ—variation in health and strength is, after all, part of the human condition—but that the differences are socially patterned, and are felt by society to be inequitable or perhaps avoidable. Concern about this sort of inequality is not, of course, new: the pioneers of public health drew attention to the social and physical environment as a primary cause of the unequal distribution of disease and death over a century ago. Chadwick, for instance, carefully recorded in 1842 that while the expectation of life of ‘Gentlemen, and persons engaged in professions, and their families’ in the district of Bethnal Green was only 45 years, ‘Mechanics, servants, and labourers, and their families’ had an average age of death of 16.

Despite the remarkable achievements in public health and disease prevention in the hundred years which followed, concern about health inequality persisted in the mid-twentieth century and was offered as a major justification for the setting up of the National Health Service in 1948. The substantive area of concern in the 1950s and 1960s was, particularly, the health and growth of children. However, remarkable decreases in infant and child mortality were achieved in the decade or two after 1940, as infections were conquered and widespread gross deprivation disappeared, and differences between social classes in child health lessened. Inequality in health as a more general issue became again a matter of public discussion only in the 1970s, leading to the publication of the Black Report in 1980. This ‘rediscovery’ of inequality was perhaps based on two concerns: one was the growing realization of a failure in Britain to match the absolute improvements achieved in other developed countries, and the other the suggestion that relative differences between groups of the population might not, as anticipated, be decreasing. Much discussion and research during the 1980s has reached a generally-agreed conclusion that ‘It is now possible to say, without risk of serious challenge, that the differences in life expectancy associated with socio-economic position…have been increasing since 1951’ (Wilkinson 1986a:19).

This debate has related to, and largely been based on, mortality rates. However, the general increase in life expectancy (principally due to the control of fatal communicable diseases and the reduction of infant deaths) has meant mortality rates which are generally low, before old age, and thus not always clearly discriminatory. Inequalities in health may not be the same as inequalities in death. A general lack of morbidity data, together with the problems of measuring ‘health’, means that the relationship of death rates to general health status during a lifetime is difficult to study. There has been some suggestion that morbidity differences between social classes or income groups are less marked than mortality differences, i.e. that the disadvantaged may die earlier, because of a greater prevalence of life-threatening disease, but do not necessarily suffer more ‘everyday’ illness. On the other hand, there is evidence (for instance, from the General Household Survey) that social class trends in the experience of chronic illness, or in the proportion of people who assess their own health as ‘poor’, are steeper than class differences in mortality. This is one of the major issues which the Health and Lifestyle data can address: class differences not so much in severe or life-threatening disease, as in the everyday experience of illness, in physiological fitness, and in psycho-social health.

The Black Report, and the subsequent research and discussion, have identified several alternative reasons why social class is linked to health and illness experience. There may be a direct link: the less favourable working and living conditions of those in the lowest occupational classes expose them to greater health hazards; poverty—more likely among those in lower social classes—may mean inadequate diets or poor, damp housing. There is also an increasing emphasis on the possibility of indirect links through the role of stress. The second type of explanation gives more importance to health attitudes and health-related behaviour. Riskier behaviour (smoking, unwise diets) is associated with less education and poorer circumstances. Cultural explanations such as a lack of ‘future orientation’, a lower valuation placed on health, or a lack of a feeling of control over health have all been suggested. The structural and the cultural or behavioural types of explanation meet when it is suggested that it is powerlessness or constraints upon resources (time, money, social skills, energy) that limit the extent to which behaviour can be a matter of choice (Graham 1984).

The Health and Lifestyle Survey can offer only a limited contribution to this debate. In particular, the ‘selection’ question-crudely, the extent to which people fall into, or remain in, disadvantaged circumstances because their health is poor, or the extent to which their health is a consequence of their circumstances—cannot be answered in a single cross-sectional survey. To explore these social mechanisms properly, lifelong and perhaps intergenerational studies are required (see e.g. Wadsworth 1986).

However, some investigation can be made of the apparent relative weights of economic, cultural and behavioural factors. The question is important, becaus...