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Control over health and patterns of health-related behaviour
SOC.Sci. Med. Vol. 29. No. 2, pp. 131-136, 1989 Prtnted tn Great Bntain. All rights reserved
Copyright
CONTROL OVER HEALTH AND PATTERNS HEALTH-RELATED BEHAVIOUR
0277-9536189 %3.00+ 0.00 C 1989 Pcrgamon Press plc
OF
MICHAEL CALNAN Health Services Research Unit, Cornwallis Building, University of Kent at Canterbury, Canterbury, Kent CT2 7NF, England Abstract-This paper empirically examines the relationship between position in the social structure, beliefs about control over health and three different types of health-related behaviour. The data are drawn from two large scale community surveys (N = 4224) carried out in southern England. The results show that the relationship between the Multi-dimensional Health Locus of Control (MHLC) and exercise, cigarette smoking and use of alcohol was never more than modest even within different social and economic contexts. Doubts are cast upon the value of the MHLC for explaining variations in health-related behaviour and more fruitful areas for research are suggested. Key
words-health
behaviour, health beliefs, locus of control, inequalities
INTRODUCITON Evidence from empirical research has shown that the strength of statistical relationships between types of health-related behaviours are at best modest [ 1.21, which has suggested that health-related behaviour cannot be conceptualised as a uni-dimensional phenomenon. Evidence has also shown [3,4] that certain socio-demographic factors such as social class, age, gender and educational background are strongly associated with patterns of health-related behaviours. One interpretation of these two pieces of evidence is that while individual beliefs about health-related behaviour or its consequences [5] may influence the decision to adopt the behaviour in question, socioeconomic circumstances may provide a setting which can act to enable or constrain the practice of healthrelated behaviour. Social and economic factors may act in a variety of ways. For example, studies have shown how people’s general beliefs about health and the extent to which they feel they have control over their daily activities are shaped by their position in the social structure [6]. Blaxter and Paterson [7] have shown how ‘low’ norms about health are adopted by those living in circumstances of social or economic disadvantage due to the relatively greater experience of ill-health suffered by this group. Such definitions of health are claimed to be antithetical to the adoption of health-related behaviour. Cornwell [8] in her ethnographic study amongst working class people in London showed how living and working conditions shaped not only beliefs about health but also beliefs about other aspects of social life. She found that the set of moral philosophical assumptions which underlay beliefs about work almost replicated those which underlay beliefs about health and illness. Differences or inequalities in occupation were believed to reflect the natural order of things and most people do the work that naturally suits them which is itself influenced by gender and natural abilities such as level of intelligence. Thus it was felt that people had little control over the job that they did, although they did have
some control or responsibility for how they went about their work. Similar dual theories were prevalent in her subjects’ accounts about health and illness. While ‘being healthy’ depended on whether or not one was naturally endowed with a good ‘constitution’, good health also had to be earned through leading a life of moderation, virtue and hard work. In this respect, people had little control over their health because it depended on differences in constitution, but they could control or have ‘responsibility for’ their health by having the right attitude. Alternatively, there is an approach that places greater emphasis on the direct impact of the circumstances in which people live and work. This approach is well illustrated in the work of Graham [8] who examined the patterns of health-related behaviour within families living in conditions of social and economic adversity. She showed that, although mothers were well aware of the health links associated with activities such as smoking, these activities provided a means of coping with pressures created by the conflicts between responsibilities for family care and the shortage of resources. In these situations, the social benefits of activities such as smoking may outweigh the known costs, and even if some of these women would like to give up smoking, changing their behaviour is difficult. Such evidence described above suggests that each form of health-related behaviour is a product of an inter-relationship between specific beliefs associated with a behaviour and more general conditions and ideologies associated with a particular location in the social structure. This paper explores further this inter-relationship between socio-demographic factors, health beliefs and health-related behaviour. Previous research has tended to concentrate on the way concepts of health are shaped by social structural position [7] which can also influence patterns of health-related behaviour. The analysis presented here aims to extend this approach by examining the possible relationship between social structural position, beliefs about control over health and healthrelated behaviours exploring the proposition that 131
132
MICHAEL CALNAN
those in relative weak positions of social or economic power are more likely to feel that they are not in control of their own lives. One manifestation of this self-perceived lack of control could be in their health. If furthermore it is assumed that health beliefs are precursors of health-related behaviour, then these feelings of low control over health might be antithetical to the observance of certain health-related behaviours. Evidence from ethnographic research has begun to show that lay conceptions of health include many dimensions such as health as being strong, health as being fit and active and health as the absence of illness [lo, 1I]. These conceptions of health will influence beliefs about control over health but quantitative measures based on this ethnographic research have yet to be developed. Thus, in this study we are confined to measuring beliefs about control over health through the Health Locus of Control which focuses solely on health as the absence of illness and the extent to which there is dependence on medical professionals to manage health problems. The general principle behind the Health Locus of Control is that those who feel they have control over their own health are also more likely to carry out health-related behaviour, whereas those who feel powerless to control their own health will be less likely to comply with officially recommended health actions. Since its original formulation, the general model of the Health Locus of Control has been modified and the approach which is now favoured is the Multi-dimensional Health Locus of Control (MHLC) [12]. The MHLC consists of three distinct dimensions which are called internal, powerful other and chance. Those who score high on the internal scale are more likely to believe that health is the result of their own behaviour, whereas high scores on the other two suggest either that health is dependent on the power of doctors or that health is a matter of chance, fate or luck. It is unclear, as yet, which, if any, of these dimensions is the most powerful predictor of healthrelated behaviour, although the limited evidence that is available suggests that the internal/external characteristic may have the most powerful explanatory value [13] (Fig. 1). The specific aims of this analysis are first to examine the inter-relationships between the three dimensions of the MHLC and different types of health-related behaviour. Cigarette smoking, alcohol use and level of physical exercise were the three behaviours included in the analysis. Evidence [2] has suggested that while health-related behaviour may not be uni-dimensional, it might be conceptualised along the lines of direct risk behaviour such as smoking and alcohol and indirect risk or avoidance behaviour such as exercise. This is a proposition that can be further examined in this study. The second aim is to examine the relationship between structural positions, MHLC and the three types of health-related behaviour. Social class, educational background, age, gender, marital status and employment status were included in the study as indices of social structural position. The aim was to develop a specific scale or index to measure the social and economic power of the individual. One of the problems with the traditional
Mean rmre
9
+
Internal
rangs
24.87
0
Chance
range
19.00
0
POwerfUL
range
q9.23
otnsr
Distibution
Fig. 1. Distributions
of scores
of scores
on the three MHLC
scales.
measures such as social class is it tends to misrepresent or neglect the current position of the retired, those not in paid work and many married women. Thus, an attempt was made to build up an index which represented both current social and economic status. This was done through a combined index of employment status and educational background. METHOD
The information on which these analyses are based are taken from a study examining the Health Locus of Control and Health-Related Behaviour of Adults (aged 18 and over) who in the spring of 1985 were residing within two health districts in southern England. A 1 in 75 sample was selected from the electoral registers which covered the population of adults living in District A. Three thousand and twenty-seven names were selected from the register and a mail questionnaire was sent to each. Two thousand and ten completed questionnaires were returned after two further follow-up contacts, giving a response rate of 70%. A 1 in 50 sample was selected from the electoral registers which covered the population of adults living in District B, 2905 names were selected and a mail questionnaire was sent to each. Two thousand, one hundred and fourteen completed questionnaires were returned after two follow-up contacts giving a response rate of 73%. The two surveys were carried over the same period of time. The background characteristics of the responders in the two studies were compared with their respective background populations and showed that overall the respondents were repreientative of the adult populations of both districts. Because the distributions of the background characteristics of the populations in the two districts were similar, as were the distributions of the measures of smoking, alcohol and
Health-related Table
I,
133
bchaviour
Distribution for the three types of health-related bchaviour %
Cigarefle smoking Never smoked
37 31 13 12 6 I N = 4224 Mean score 2.2
Ex-smoker Smoker, 10 or less cigarettes a day Smoker, I I-20 cigarettes a day Smoker, 21+ cigarettes a day No answer
Alcohol
use (frequency
and number
ofdrinks)
19 48 18 6 6 3 N = 4224 Mean score 2.3
Don’t drink Less than 3 days per week and less than 5 drinks 3 days, >everyday and less than 5 drinks Less than 3 days per week and 5+ drinks 3 days, >everyday and 5+ drinks No answer
Exercise
Low
Pts 0
I Level of physical exercise
High No answer
exercise and scores on the MHLC, it was decided to combine the two data sets giving an overall achieved sample size of 4224. Data were gathered on cigarette smoking, alcohol use and exercise, the patterns of health-related behaviour being derived from respondents self-reports. The questions which elicited this information had been extensively piloted and used in previous surveys. An index for each of the different types of healthrelated behaviour was constructed through combining responses to a number of different questions. The index of smoking behaviour was made up from two questions about current smoking status and number of cigarettes smoked. This was a five category item and it is shown in Table 1 along with the distribution of responses for both surveys. An index of alcohol use was also made up from two different questions about the frequency and level of drinking. This was also a five category item which is shown in Table 1. The third and final index of health-related behaviour was on levels of exercise. The index ranged from 0 to 7 points, and was constructed from responses to two different questions. The first one asked about the level of activity in the respondents daily work or other daytime activity. Those whose work or daytime activity involved a lot of exercise (lifting or
Table 2. Rclationshios
Internal Chance Powerful Smoking Alcohol ‘P
< 0.05;
l**p
carrying loads, heavy work etc.) were allocated 1 point and those who had more sedentary daily activities were given 0 points. In addition to this, respondents were given one point each for the number of times in the last few weeks that they had undertaken vigorous sport or recreational activities which had made them breathless or made them sweat. The distributions are presented in Table 1. The three dimensions of the MHLC were each measured by six items and the scores were constructed following the method previously prescribed [12]. The scores ranged from 6 to 36 and the distributions of each are shown in Table 1, along with mean scores. RESULTS
The relationships between the three dimensions of the Health Locus of Control and the health-related behaviours were examined using both bivariate and multivariate statistical techniques. Table 2 shows the overall statistical relationships and inter-relationships between alcohol use, cigarette smoking and the level of exercise and the three belief dimensions. It must be emphasised that the large sample increased the likelihood of even weak relationships being statistically significant. The table shows that none of the
between dimensions of MHLC and health-related behaviour (Swarman’s
Internal
Chance
Powerful other
-
-0.0090 -
0.1033*** 0.2391*** -
< 0.001.
2 3 4 5 6 7+
43 12 7 5 s 3 12 4 8 N = 4224 Mean score 3.0
correlations1
Smoking
Alcohol
Exercise
0.0372’ o.o5g2*** 0.0198 -
-0.0034 -0.0701*** -0.1424*** 0.1923*** -
o&535*** -0.1152*** -0.1522*** -0.0790*** 0.1492***
MICHAEL
134 Table 3. Employment
Self-employed Employed and left school at l6+ Employed and left school at I5 or less Housewife Retired Student Unemployed Whole sample
status and inter-relationships
between health beliefs and health behaviour significant correlations)
Internal
Internal
Internal
by smoking
by alcohol
by exercise
Chance by smoking
0.1672..
-
0.0996.
-
-
0.0748’
-0.0894 0.0372’
‘P < 0.05; l*P < 0.01: ***p
<
-
0.043 I -
CALNAN
0.0585. 0.0938. 0.1441’ 0.1117 0.0635***
0.1013** 0.1579 0.0582***
Chance
Chance
by alcohol
by exerc*se
(Spearman’s Powerful other by smoking
-0.0712’ -0.0713 -0.0701***
-0.0740*
-0.0747.
- 0.0998 -0.0945.. -0.1381’** -
-0.1041** -
-0.2545** -0.1152***
-0.0658 -
only starlstxally
Powerful other by alcohol -
-
correlatrons:
-0.1118 -0.1424***
Powerful other by exercw -0.12w -0.0732. -0.1200* -0.0928.’ -0.139F3*** - 0.07Gu -0.1522***
0.001
statistical associations between any of the three belief dimensions and the behaviours were strong. The statistical relationship between the internal dimension and the three behaviours was weak as was the relationship between the chance dimension and the behaviours. The statistical relationships between the powerful other dimension and the behaviours were at best of modest strength with those who tended to believe that their health depended on the actions of medical professionals being less likely to be heavy drinkers and to carry out regular exercise. The table also shows that the overall strength of the relationships between the behaviours was no more than modest with drinkers being also likely to be smokers and exercisers more likely to be drinkers. The relationship between smoking and exercise was a negative one and was much weaker than the other associations between the behaviours. The interrelationships between the belief dimensions are also shown in Table 2. While the internal and chance dimensions were not associated, there was a positive association between both these dimensions and the powerful other dimension. The second stage of the analysis examines the inter-relationship between beliefs and behaviour taking into account social structural position. It is possible that within certain social groups the relationship between beliefs and behaviour might be stronger or weaker than the relationships between beliefs and behaviour in the sample as a whole. For example, the statistical relationship between the powerful other dimension and alcohol and exercise, although at best modest in strength might be a spurious one. The powerful other dimension varies with a range of socio-demographic characteristics particularly age, as does alcohol use and the taking of exercise. Thus, the powerful other dimension and the two other dimensions of the MHLC may be acting as confounding variables between aspects of social structure and the health-related behaviours. The index of social structural position was based on employment status in an attempt to take into account the position of those not in paid work such as housewives, retired, students and the unemployed. However, the employed group were too heterogeneous and thus they were divided into those who left school before 16 and those who left at or after they were 16. The aim was to divide the employed group into those with relatively high and low social status. The index of economic and social power is
shown in Table 3 and the groups are ordered in terms of imputed economic power with self-employed at the top and unemployed at the bottom. The table shows the strength of the inter-relationships between beliefs and behaviour within each economic group. The results confirm the overall trends shown before that the statistical relationships between the belief dimensions and the behaviours was quite weak. They also show that amount of exercise correlates best with beliefs. This is well illustrated by the retired group. However, there were some marked variations in correlations between beliefs and behaviour between different economic groups. For example, amongst the self-employed group, there was a modest positive relationship between the internal dimension and cigarette smoking which was not replicated in any other group or in the sample as a whole. However, in the unemployed group, while many of the relationships between beliefs and behaviour were slightly stronger than in the sample as a whole, the strongest association was between beliefs about chance and exercise. A series of multivariate analyses were then carried out to examine further the relationship between beliefs and behaviour allowing for the influence of social structural position. Three separate stepwise multiregression analyses were carried out with each of the health-related behaviours acting in turn as the dependent variable. The independent variables were the same in each of the three analyses and these were the three belief dimensions of the MHLC and the index of social and economic position. The results of these analyses are presnted in Table 4. While accepting the limitations of this technique for the analysis of this type of data set, the pattern of results found previously was confirmed with the overall statistical relationships between the three dimensions of the MHLC and the three behaviours being weak, although of the three behaviours exercise was best predicted by the belief dimensions, particularly the powerful other dimensions. It must also be emphasised that the overall variance explained in each of the analyses even when the social position index was included was quite low, which appears to be a common finding in studies examining the relationship between beliefs and behaviour [14]. The amount of variance explained was still low when the three analyses were re-run replacing the social position index by its constituents and other social and demographic variables (gender, age, social class, education and employment status).
Health-related
behaviour
135
Table 4. Strongest predictors of three different forms of health-related kbaviour-stepwisc Independent variables step
I
Cum mrz MHLC
step 2
chance
0.004
Cum IrIG
B 0.063**’
Social position MHLC
-
multiple regression analysis
Alcohol use
Cigarette smoking
powerful
Exercise
B
Cum rnrl
-0.175’**
MHLC powerful other
0.016
-0.126***
0.043
-0.1 l2***
MHLC
internal
0.021
-0.075***
chance
0.027
-0.074**.
0.028
- 0.038.
other
step
3
-
-
MHLC
stea
4
-
-
Social
‘P c 0.06; ‘**f
8
0.031
wsition
< 0.001.
DISCUSSION
The evidence which emerged from this analysis showed that overall the strength of inter-relationships between the three dimensions of the MHLC and smoking, use of alcohol and level of physical exercise were weak. This pattern of statistical relationships was confirmed when social structural position was taken into account. One interpretation of this evidence is that beliefs about control over health have little influence on health-related behaviour, although it must be emphasised that this study was restricted to only three types of health behaviour. Certainly, evidence from other studies [14] has cast doubt upon the power of health beliefs for explaining health behaviour and suggested that a more fruitful area of investigation may involve focusing on beliefs about the behaviour itself. Thus, exercising or drinking alcohol may be influenced by concerns which have little to do with matters of health. Also, the weak relationship between beliefs about control over health and smoking might be explained by people perceiving smoking equally as enhancing health because of stress reduction as increasing health risks. Thus, the relatively low correlation for the relationship between the internal dimension of the MHLC and smoking and alcohol use might be related to these behaviours being seen as both harmful and beneficial. Alternatively, there may be weakness and faults in the way beliefs about control over health are being measured and in the way control over health is being conceptualised. The instrument is probably not measuring control over health [15] as it is tapping people’s beliefs about illness. Future research might build on ethnographic material [16] and develop an instrument which is more sensitive to lay beliefs about health and its control The MHLC as it stands may be more valuable for explaining use of curative or preventive services which are more concerned with the early detection of treatment of illness. However, recent evidence has suggested [17] that even in this context this general concept should be replaced by a more sensitive measure which would be an individual’s specific feelings of control over getting the disease in question. Certainly evidence from ethnographic research [16] shows that lay beliefs about control over diseases are complex and disease specific. In conclusion, the negative findings from this study might suggest the need to look elsewhere than beliefs about control over health to find an adequate explanation for patterns of health-related behaviour, although the analysis did only focus on a limited
range of behaviours. One possible direction may be to examine the relationship between beliefs about control over other, perhaps more important aspects of an individual’s life, and health-related behaviour. For example, activities at or associated with work may shape a large proportion of the population’s perceptions of the world; thus it might be useful to examine beliefs about control over work and healthrelated behaviour. Comwell’s study [8] showed a subtle relationship between beliefs about work and health. Evidence in this study showed some association between beliefs about control over health and employment status. Those who were self-employed felt in more control of their health and felt that health was either less a matter of chance or depended on the activities of professionals than those who were employees or who had another employment status. A more detailed investigation of the relationship between the working environment, beliefs about control and health-related behaviour might begin by focusing on the process or the way that the structure of the working environment actually influences beliefs about control. For example, Karasek [17] distinguishes between two elements of the work environment at the individual level which are the job demands placed on the worker and the discretion permitted the worker in deciding how to meet these demands. Thus the extent to which the individual feels job strain and control over his or her work will be influenced by the degree to which the conditions of work enable the management of job demands. This in turn might shape beliefs about control over other aspects of life such as health and will influence belief about health-related behaviour. The final issue to discuss concerns the practical implications for those involved in planning health education programmes aimed at influencing healthrelated behaviour. The initial stage in any campaign must be to find out what the various sets of salient beliefs are. The evidence presented here suggests that it is only in relation to physical exercise that beliefs about control over health as measured by the MHLC are salient and might be worth tapping. However, even with physical exercise the relationship was at most modest. It might be that if the MHLC is tied to illness rather than health it might be a better predictor of behaviour change in those with illnesses, e.g. suffered a coronary, than the ‘healthy’. However, if beliefs about health and its control are closely tied to and shaped by other aspects of people’s lives then changes in health beliefs and behaviour are not likely to occur unless changes are made in other spheres of life also [8].
MICHAEL. CALNAN
136
Acknowledgements-Thanks go to Lou Gpit and Ellen Annandale for their constructive comments and advice on the analysis, Barbara Wall for computing, Linda McDonnell for typing and the Maidstone DHA and Canterbury and Thanet DHA for supporting this study. REFERENCES
1. Pill R. and Stott N. Preventive procedures and practices
2. 3. 4. 5. 6. 7.
among working class women: new data and fresh insights. Sot. Sci. Med. 21, 973-984, 1984. Langlie J. K. Inter-relationships among preventive health behaviours: a test of competing hypothesis. Publ. Hlth Rep. 94, 216-220, 1979. Townsend P. and Davidson N. Inequalities in Health. Penguin, London, 1982. Blane D. Inequality and social class. In Sociology as Applied to Medicine (Edited by Patrick D. and Scambler G.), pp. 113-124. Balliere Tindall, Paris, 1982. Calnan M. Patterns of preventive behaviour: a study of women in middle age. Sot. Sci. Med. 20.263-268. 1985. Illsley R. Professional or public health? Sociology in Health and Medicine. NPHT. London. 1980. Blaxter M. and Paterson L.’ Mothers’ and Daughters:
A Three Generational Study of Health Atfitudes and Behauiour. Heinemann, London, 1982. 8. Comwell J. Hard-Earned Lives. Tavistock, London,
1984.
9. Graham H. Women, Health and the Family. Wheatsheaf Books, Sussex, 1984. 10. Calnan M. and Johnson B. Health, health risks and inequalities; an exploratory study of women’s perceptions. Social. Hlth Illness I, 55-75, 1985. 11. Williams R. Concept of health: an analysis of lay logic. Sociology 17, 185-205. 1983. 12. Wallston K. A., Wallston B. J. and De Veilra R. Development of the multi-dimensional health locus of control (MHLC) scales. Hlth Educ. Monogr. 6, 160-170. 1978.
13. Winkfield H. R. Reliability and validity of the health locus of control. J. Person. Assessmr M&614-619, 1982. 14. Calnan M. and Rutter D. R. Do health beliefs predict health behaviour? Sot. Sci. Med. 22, 673-678. 1986. 15. Dean K. The influence of health beliefs on lifestyles: what do we know? Eur. Monogr. Hlth Educ. Res. 6, 127, 1984.
16. Calnan M. Health and Illness: The Lay Perspective. Tavistock, London, 1987. 17. King J. The impact of patients’ perceptions of high blood pressure on attendance at screening. Sot. Sci. Med. 16, 1074-1080, 1982. 18. Karasek R. A. Job demands, job decision, attitude and mental strain: implications for job redesign. Admin. Sci. Q. 285-307,
1979.
Copyright
CONTROL OVER HEALTH AND PATTERNS HEALTH-RELATED BEHAVIOUR
0277-9536189 %3.00+ 0.00 C 1989 Pcrgamon Press plc
OF
MICHAEL CALNAN Health Services Research Unit, Cornwallis Building, University of Kent at Canterbury, Canterbury, Kent CT2 7NF, England Abstract-This paper empirically examines the relationship between position in the social structure, beliefs about control over health and three different types of health-related behaviour. The data are drawn from two large scale community surveys (N = 4224) carried out in southern England. The results show that the relationship between the Multi-dimensional Health Locus of Control (MHLC) and exercise, cigarette smoking and use of alcohol was never more than modest even within different social and economic contexts. Doubts are cast upon the value of the MHLC for explaining variations in health-related behaviour and more fruitful areas for research are suggested. Key
words-health
behaviour, health beliefs, locus of control, inequalities
INTRODUCITON Evidence from empirical research has shown that the strength of statistical relationships between types of health-related behaviours are at best modest [ 1.21, which has suggested that health-related behaviour cannot be conceptualised as a uni-dimensional phenomenon. Evidence has also shown [3,4] that certain socio-demographic factors such as social class, age, gender and educational background are strongly associated with patterns of health-related behaviours. One interpretation of these two pieces of evidence is that while individual beliefs about health-related behaviour or its consequences [5] may influence the decision to adopt the behaviour in question, socioeconomic circumstances may provide a setting which can act to enable or constrain the practice of healthrelated behaviour. Social and economic factors may act in a variety of ways. For example, studies have shown how people’s general beliefs about health and the extent to which they feel they have control over their daily activities are shaped by their position in the social structure [6]. Blaxter and Paterson [7] have shown how ‘low’ norms about health are adopted by those living in circumstances of social or economic disadvantage due to the relatively greater experience of ill-health suffered by this group. Such definitions of health are claimed to be antithetical to the adoption of health-related behaviour. Cornwell [8] in her ethnographic study amongst working class people in London showed how living and working conditions shaped not only beliefs about health but also beliefs about other aspects of social life. She found that the set of moral philosophical assumptions which underlay beliefs about work almost replicated those which underlay beliefs about health and illness. Differences or inequalities in occupation were believed to reflect the natural order of things and most people do the work that naturally suits them which is itself influenced by gender and natural abilities such as level of intelligence. Thus it was felt that people had little control over the job that they did, although they did have
some control or responsibility for how they went about their work. Similar dual theories were prevalent in her subjects’ accounts about health and illness. While ‘being healthy’ depended on whether or not one was naturally endowed with a good ‘constitution’, good health also had to be earned through leading a life of moderation, virtue and hard work. In this respect, people had little control over their health because it depended on differences in constitution, but they could control or have ‘responsibility for’ their health by having the right attitude. Alternatively, there is an approach that places greater emphasis on the direct impact of the circumstances in which people live and work. This approach is well illustrated in the work of Graham [8] who examined the patterns of health-related behaviour within families living in conditions of social and economic adversity. She showed that, although mothers were well aware of the health links associated with activities such as smoking, these activities provided a means of coping with pressures created by the conflicts between responsibilities for family care and the shortage of resources. In these situations, the social benefits of activities such as smoking may outweigh the known costs, and even if some of these women would like to give up smoking, changing their behaviour is difficult. Such evidence described above suggests that each form of health-related behaviour is a product of an inter-relationship between specific beliefs associated with a behaviour and more general conditions and ideologies associated with a particular location in the social structure. This paper explores further this inter-relationship between socio-demographic factors, health beliefs and health-related behaviour. Previous research has tended to concentrate on the way concepts of health are shaped by social structural position [7] which can also influence patterns of health-related behaviour. The analysis presented here aims to extend this approach by examining the possible relationship between social structural position, beliefs about control over health and healthrelated behaviours exploring the proposition that 131
132
MICHAEL CALNAN
those in relative weak positions of social or economic power are more likely to feel that they are not in control of their own lives. One manifestation of this self-perceived lack of control could be in their health. If furthermore it is assumed that health beliefs are precursors of health-related behaviour, then these feelings of low control over health might be antithetical to the observance of certain health-related behaviours. Evidence from ethnographic research has begun to show that lay conceptions of health include many dimensions such as health as being strong, health as being fit and active and health as the absence of illness [lo, 1I]. These conceptions of health will influence beliefs about control over health but quantitative measures based on this ethnographic research have yet to be developed. Thus, in this study we are confined to measuring beliefs about control over health through the Health Locus of Control which focuses solely on health as the absence of illness and the extent to which there is dependence on medical professionals to manage health problems. The general principle behind the Health Locus of Control is that those who feel they have control over their own health are also more likely to carry out health-related behaviour, whereas those who feel powerless to control their own health will be less likely to comply with officially recommended health actions. Since its original formulation, the general model of the Health Locus of Control has been modified and the approach which is now favoured is the Multi-dimensional Health Locus of Control (MHLC) [12]. The MHLC consists of three distinct dimensions which are called internal, powerful other and chance. Those who score high on the internal scale are more likely to believe that health is the result of their own behaviour, whereas high scores on the other two suggest either that health is dependent on the power of doctors or that health is a matter of chance, fate or luck. It is unclear, as yet, which, if any, of these dimensions is the most powerful predictor of healthrelated behaviour, although the limited evidence that is available suggests that the internal/external characteristic may have the most powerful explanatory value [13] (Fig. 1). The specific aims of this analysis are first to examine the inter-relationships between the three dimensions of the MHLC and different types of health-related behaviour. Cigarette smoking, alcohol use and level of physical exercise were the three behaviours included in the analysis. Evidence [2] has suggested that while health-related behaviour may not be uni-dimensional, it might be conceptualised along the lines of direct risk behaviour such as smoking and alcohol and indirect risk or avoidance behaviour such as exercise. This is a proposition that can be further examined in this study. The second aim is to examine the relationship between structural positions, MHLC and the three types of health-related behaviour. Social class, educational background, age, gender, marital status and employment status were included in the study as indices of social structural position. The aim was to develop a specific scale or index to measure the social and economic power of the individual. One of the problems with the traditional
Mean rmre
9
+
Internal
rangs
24.87
0
Chance
range
19.00
0
POwerfUL
range
q9.23
otnsr
Distibution
Fig. 1. Distributions
of scores
of scores
on the three MHLC
scales.
measures such as social class is it tends to misrepresent or neglect the current position of the retired, those not in paid work and many married women. Thus, an attempt was made to build up an index which represented both current social and economic status. This was done through a combined index of employment status and educational background. METHOD
The information on which these analyses are based are taken from a study examining the Health Locus of Control and Health-Related Behaviour of Adults (aged 18 and over) who in the spring of 1985 were residing within two health districts in southern England. A 1 in 75 sample was selected from the electoral registers which covered the population of adults living in District A. Three thousand and twenty-seven names were selected from the register and a mail questionnaire was sent to each. Two thousand and ten completed questionnaires were returned after two further follow-up contacts, giving a response rate of 70%. A 1 in 50 sample was selected from the electoral registers which covered the population of adults living in District B, 2905 names were selected and a mail questionnaire was sent to each. Two thousand, one hundred and fourteen completed questionnaires were returned after two follow-up contacts giving a response rate of 73%. The two surveys were carried over the same period of time. The background characteristics of the responders in the two studies were compared with their respective background populations and showed that overall the respondents were repreientative of the adult populations of both districts. Because the distributions of the background characteristics of the populations in the two districts were similar, as were the distributions of the measures of smoking, alcohol and
Health-related Table
I,
133
bchaviour
Distribution for the three types of health-related bchaviour %
Cigarefle smoking Never smoked
37 31 13 12 6 I N = 4224 Mean score 2.2
Ex-smoker Smoker, 10 or less cigarettes a day Smoker, I I-20 cigarettes a day Smoker, 21+ cigarettes a day No answer
Alcohol
use (frequency
and number
ofdrinks)
19 48 18 6 6 3 N = 4224 Mean score 2.3
Don’t drink Less than 3 days per week and less than 5 drinks 3 days, >everyday and less than 5 drinks Less than 3 days per week and 5+ drinks 3 days, >everyday and 5+ drinks No answer
Exercise
Low
Pts 0
I Level of physical exercise
High No answer
exercise and scores on the MHLC, it was decided to combine the two data sets giving an overall achieved sample size of 4224. Data were gathered on cigarette smoking, alcohol use and exercise, the patterns of health-related behaviour being derived from respondents self-reports. The questions which elicited this information had been extensively piloted and used in previous surveys. An index for each of the different types of healthrelated behaviour was constructed through combining responses to a number of different questions. The index of smoking behaviour was made up from two questions about current smoking status and number of cigarettes smoked. This was a five category item and it is shown in Table 1 along with the distribution of responses for both surveys. An index of alcohol use was also made up from two different questions about the frequency and level of drinking. This was also a five category item which is shown in Table 1. The third and final index of health-related behaviour was on levels of exercise. The index ranged from 0 to 7 points, and was constructed from responses to two different questions. The first one asked about the level of activity in the respondents daily work or other daytime activity. Those whose work or daytime activity involved a lot of exercise (lifting or
Table 2. Rclationshios
Internal Chance Powerful Smoking Alcohol ‘P
< 0.05;
l**p
carrying loads, heavy work etc.) were allocated 1 point and those who had more sedentary daily activities were given 0 points. In addition to this, respondents were given one point each for the number of times in the last few weeks that they had undertaken vigorous sport or recreational activities which had made them breathless or made them sweat. The distributions are presented in Table 1. The three dimensions of the MHLC were each measured by six items and the scores were constructed following the method previously prescribed [12]. The scores ranged from 6 to 36 and the distributions of each are shown in Table 1, along with mean scores. RESULTS
The relationships between the three dimensions of the Health Locus of Control and the health-related behaviours were examined using both bivariate and multivariate statistical techniques. Table 2 shows the overall statistical relationships and inter-relationships between alcohol use, cigarette smoking and the level of exercise and the three belief dimensions. It must be emphasised that the large sample increased the likelihood of even weak relationships being statistically significant. The table shows that none of the
between dimensions of MHLC and health-related behaviour (Swarman’s
Internal
Chance
Powerful other
-
-0.0090 -
0.1033*** 0.2391*** -
< 0.001.
2 3 4 5 6 7+
43 12 7 5 s 3 12 4 8 N = 4224 Mean score 3.0
correlations1
Smoking
Alcohol
Exercise
0.0372’ o.o5g2*** 0.0198 -
-0.0034 -0.0701*** -0.1424*** 0.1923*** -
o&535*** -0.1152*** -0.1522*** -0.0790*** 0.1492***
MICHAEL
134 Table 3. Employment
Self-employed Employed and left school at l6+ Employed and left school at I5 or less Housewife Retired Student Unemployed Whole sample
status and inter-relationships
between health beliefs and health behaviour significant correlations)
Internal
Internal
Internal
by smoking
by alcohol
by exercise
Chance by smoking
0.1672..
-
0.0996.
-
-
0.0748’
-0.0894 0.0372’
‘P < 0.05; l*P < 0.01: ***p
<
-
0.043 I -
CALNAN
0.0585. 0.0938. 0.1441’ 0.1117 0.0635***
0.1013** 0.1579 0.0582***
Chance
Chance
by alcohol
by exerc*se
(Spearman’s Powerful other by smoking
-0.0712’ -0.0713 -0.0701***
-0.0740*
-0.0747.
- 0.0998 -0.0945.. -0.1381’** -
-0.1041** -
-0.2545** -0.1152***
-0.0658 -
only starlstxally
Powerful other by alcohol -
-
correlatrons:
-0.1118 -0.1424***
Powerful other by exercw -0.12w -0.0732. -0.1200* -0.0928.’ -0.139F3*** - 0.07Gu -0.1522***
0.001
statistical associations between any of the three belief dimensions and the behaviours were strong. The statistical relationship between the internal dimension and the three behaviours was weak as was the relationship between the chance dimension and the behaviours. The statistical relationships between the powerful other dimension and the behaviours were at best of modest strength with those who tended to believe that their health depended on the actions of medical professionals being less likely to be heavy drinkers and to carry out regular exercise. The table also shows that the overall strength of the relationships between the behaviours was no more than modest with drinkers being also likely to be smokers and exercisers more likely to be drinkers. The relationship between smoking and exercise was a negative one and was much weaker than the other associations between the behaviours. The interrelationships between the belief dimensions are also shown in Table 2. While the internal and chance dimensions were not associated, there was a positive association between both these dimensions and the powerful other dimension. The second stage of the analysis examines the inter-relationship between beliefs and behaviour taking into account social structural position. It is possible that within certain social groups the relationship between beliefs and behaviour might be stronger or weaker than the relationships between beliefs and behaviour in the sample as a whole. For example, the statistical relationship between the powerful other dimension and alcohol and exercise, although at best modest in strength might be a spurious one. The powerful other dimension varies with a range of socio-demographic characteristics particularly age, as does alcohol use and the taking of exercise. Thus, the powerful other dimension and the two other dimensions of the MHLC may be acting as confounding variables between aspects of social structure and the health-related behaviours. The index of social structural position was based on employment status in an attempt to take into account the position of those not in paid work such as housewives, retired, students and the unemployed. However, the employed group were too heterogeneous and thus they were divided into those who left school before 16 and those who left at or after they were 16. The aim was to divide the employed group into those with relatively high and low social status. The index of economic and social power is
shown in Table 3 and the groups are ordered in terms of imputed economic power with self-employed at the top and unemployed at the bottom. The table shows the strength of the inter-relationships between beliefs and behaviour within each economic group. The results confirm the overall trends shown before that the statistical relationships between the belief dimensions and the behaviours was quite weak. They also show that amount of exercise correlates best with beliefs. This is well illustrated by the retired group. However, there were some marked variations in correlations between beliefs and behaviour between different economic groups. For example, amongst the self-employed group, there was a modest positive relationship between the internal dimension and cigarette smoking which was not replicated in any other group or in the sample as a whole. However, in the unemployed group, while many of the relationships between beliefs and behaviour were slightly stronger than in the sample as a whole, the strongest association was between beliefs about chance and exercise. A series of multivariate analyses were then carried out to examine further the relationship between beliefs and behaviour allowing for the influence of social structural position. Three separate stepwise multiregression analyses were carried out with each of the health-related behaviours acting in turn as the dependent variable. The independent variables were the same in each of the three analyses and these were the three belief dimensions of the MHLC and the index of social and economic position. The results of these analyses are presnted in Table 4. While accepting the limitations of this technique for the analysis of this type of data set, the pattern of results found previously was confirmed with the overall statistical relationships between the three dimensions of the MHLC and the three behaviours being weak, although of the three behaviours exercise was best predicted by the belief dimensions, particularly the powerful other dimensions. It must also be emphasised that the overall variance explained in each of the analyses even when the social position index was included was quite low, which appears to be a common finding in studies examining the relationship between beliefs and behaviour [14]. The amount of variance explained was still low when the three analyses were re-run replacing the social position index by its constituents and other social and demographic variables (gender, age, social class, education and employment status).
Health-related
behaviour
135
Table 4. Strongest predictors of three different forms of health-related kbaviour-stepwisc Independent variables step
I
Cum mrz MHLC
step 2
chance
0.004
Cum IrIG
B 0.063**’
Social position MHLC
-
multiple regression analysis
Alcohol use
Cigarette smoking
powerful
Exercise
B
Cum rnrl
-0.175’**
MHLC powerful other
0.016
-0.126***
0.043
-0.1 l2***
MHLC
internal
0.021
-0.075***
chance
0.027
-0.074**.
0.028
- 0.038.
other
step
3
-
-
MHLC
stea
4
-
-
Social
‘P c 0.06; ‘**f
8
0.031
wsition
< 0.001.
DISCUSSION
The evidence which emerged from this analysis showed that overall the strength of inter-relationships between the three dimensions of the MHLC and smoking, use of alcohol and level of physical exercise were weak. This pattern of statistical relationships was confirmed when social structural position was taken into account. One interpretation of this evidence is that beliefs about control over health have little influence on health-related behaviour, although it must be emphasised that this study was restricted to only three types of health behaviour. Certainly, evidence from other studies [14] has cast doubt upon the power of health beliefs for explaining health behaviour and suggested that a more fruitful area of investigation may involve focusing on beliefs about the behaviour itself. Thus, exercising or drinking alcohol may be influenced by concerns which have little to do with matters of health. Also, the weak relationship between beliefs about control over health and smoking might be explained by people perceiving smoking equally as enhancing health because of stress reduction as increasing health risks. Thus, the relatively low correlation for the relationship between the internal dimension of the MHLC and smoking and alcohol use might be related to these behaviours being seen as both harmful and beneficial. Alternatively, there may be weakness and faults in the way beliefs about control over health are being measured and in the way control over health is being conceptualised. The instrument is probably not measuring control over health [15] as it is tapping people’s beliefs about illness. Future research might build on ethnographic material [16] and develop an instrument which is more sensitive to lay beliefs about health and its control The MHLC as it stands may be more valuable for explaining use of curative or preventive services which are more concerned with the early detection of treatment of illness. However, recent evidence has suggested [17] that even in this context this general concept should be replaced by a more sensitive measure which would be an individual’s specific feelings of control over getting the disease in question. Certainly evidence from ethnographic research [16] shows that lay beliefs about control over diseases are complex and disease specific. In conclusion, the negative findings from this study might suggest the need to look elsewhere than beliefs about control over health to find an adequate explanation for patterns of health-related behaviour, although the analysis did only focus on a limited
range of behaviours. One possible direction may be to examine the relationship between beliefs about control over other, perhaps more important aspects of an individual’s life, and health-related behaviour. For example, activities at or associated with work may shape a large proportion of the population’s perceptions of the world; thus it might be useful to examine beliefs about control over work and healthrelated behaviour. Comwell’s study [8] showed a subtle relationship between beliefs about work and health. Evidence in this study showed some association between beliefs about control over health and employment status. Those who were self-employed felt in more control of their health and felt that health was either less a matter of chance or depended on the activities of professionals than those who were employees or who had another employment status. A more detailed investigation of the relationship between the working environment, beliefs about control and health-related behaviour might begin by focusing on the process or the way that the structure of the working environment actually influences beliefs about control. For example, Karasek [17] distinguishes between two elements of the work environment at the individual level which are the job demands placed on the worker and the discretion permitted the worker in deciding how to meet these demands. Thus the extent to which the individual feels job strain and control over his or her work will be influenced by the degree to which the conditions of work enable the management of job demands. This in turn might shape beliefs about control over other aspects of life such as health and will influence belief about health-related behaviour. The final issue to discuss concerns the practical implications for those involved in planning health education programmes aimed at influencing healthrelated behaviour. The initial stage in any campaign must be to find out what the various sets of salient beliefs are. The evidence presented here suggests that it is only in relation to physical exercise that beliefs about control over health as measured by the MHLC are salient and might be worth tapping. However, even with physical exercise the relationship was at most modest. It might be that if the MHLC is tied to illness rather than health it might be a better predictor of behaviour change in those with illnesses, e.g. suffered a coronary, than the ‘healthy’. However, if beliefs about health and its control are closely tied to and shaped by other aspects of people’s lives then changes in health beliefs and behaviour are not likely to occur unless changes are made in other spheres of life also [8].
MICHAEL. CALNAN
136
Acknowledgements-Thanks go to Lou Gpit and Ellen Annandale for their constructive comments and advice on the analysis, Barbara Wall for computing, Linda McDonnell for typing and the Maidstone DHA and Canterbury and Thanet DHA for supporting this study. REFERENCES
1. Pill R. and Stott N. Preventive procedures and practices
2. 3. 4. 5. 6. 7.
among working class women: new data and fresh insights. Sot. Sci. Med. 21, 973-984, 1984. Langlie J. K. Inter-relationships among preventive health behaviours: a test of competing hypothesis. Publ. Hlth Rep. 94, 216-220, 1979. Townsend P. and Davidson N. Inequalities in Health. Penguin, London, 1982. Blane D. Inequality and social class. In Sociology as Applied to Medicine (Edited by Patrick D. and Scambler G.), pp. 113-124. Balliere Tindall, Paris, 1982. Calnan M. Patterns of preventive behaviour: a study of women in middle age. Sot. Sci. Med. 20.263-268. 1985. Illsley R. Professional or public health? Sociology in Health and Medicine. NPHT. London. 1980. Blaxter M. and Paterson L.’ Mothers’ and Daughters:
A Three Generational Study of Health Atfitudes and Behauiour. Heinemann, London, 1982. 8. Comwell J. Hard-Earned Lives. Tavistock, London,
1984.
9. Graham H. Women, Health and the Family. Wheatsheaf Books, Sussex, 1984. 10. Calnan M. and Johnson B. Health, health risks and inequalities; an exploratory study of women’s perceptions. Social. Hlth Illness I, 55-75, 1985. 11. Williams R. Concept of health: an analysis of lay logic. Sociology 17, 185-205. 1983. 12. Wallston K. A., Wallston B. J. and De Veilra R. Development of the multi-dimensional health locus of control (MHLC) scales. Hlth Educ. Monogr. 6, 160-170. 1978.
13. Winkfield H. R. Reliability and validity of the health locus of control. J. Person. Assessmr M&614-619, 1982. 14. Calnan M. and Rutter D. R. Do health beliefs predict health behaviour? Sot. Sci. Med. 22, 673-678. 1986. 15. Dean K. The influence of health beliefs on lifestyles: what do we know? Eur. Monogr. Hlth Educ. Res. 6, 127, 1984.
16. Calnan M. Health and Illness: The Lay Perspective. Tavistock, London, 1987. 17. King J. The impact of patients’ perceptions of high blood pressure on attendance at screening. Sot. Sci. Med. 16, 1074-1080, 1982. 18. Karasek R. A. Job demands, job decision, attitude and mental strain: implications for job redesign. Admin. Sci. Q. 285-307,
1979.