Saturday, October 8, 2011

Healthful Behaviors: Why do people adopt them? Or not?

While I am not a psychologist or psychiatrist, I am both a family physician and a person. As such, I have observed human behavior for a long time. I have noted some psychological behaviors seem to be very common in the people that I have met both personally and professionally.  I won’t say that they are “human nature”, since this phrase almost always refers to something that the speaker believes in or finds dominant in his/her environment, and is usually very culturally bound. However, they are common. One of these is the tendency to deny the magnitude of risk inherent in the risky things we do (or the risks we take because of things we don’t do). At the same time, we magnify the degree of risk inherent in the things we pride ourselves on not doing (or doing, when we see doing them as if beneficial, and not doing them as risky). As a corollary, we are likely to criticize those who adopt the risky behaviors that we do not, or do not adopt the beneficial behaviors that we do. That is, judging others is easy.

Perhaps because many of these potential risks are to our health and safety, these attitudes are common in health care and public health workers. Health professionals who do not smoke, and have never smoked, often severely condemn those who do. But alcohol? A little wine is good for you, right? Maybe, but it depends on who you are. If you have a tendency towards alcoholism, or are pregnant, or are going to drive, it is not good for you. Or for others. Public health workers can strongly advocate for wearing bicycle and motorcycle helmets, and using infant car seats, but it is just possible that once or twice they were late for something and drove too fast or too carelessly. And hopefully didn’t have an accident, but could have, and certainly increased their risk for it. From a risk/benefit point of view (fire trucks and ambulances and police aside), being late for work is NEVER a reason to drive faster or more carelessly; in fact, because there is a natural temptation to do so, conscious governance of that temptation is the beneficial behavior.

The utility of adopting a healthful, or not adopting an unhealthful, behavior is complex. It depends on the likelihood of something bad happening, how bad that thing is, and how many people it affects. So eating unhealthful food and not exercising is bad, but mainly for the person (and their immediate family) if they get sick or die. Smoking in public places, and even more, driving less than carefully or under the influence of alcohol or drugs potentially affects more people. Not immunizing your children because it allows you prevent a common but unpleasant effect (getting a lot of shots) and possibly a bad but extraordinarily rare long-term effect (whether real, like Guillain-Barre from swine flu shots or not, like autism[1] must be balanced against both the risk of their acquiring the disease and its sequelae, as well as the impact on the overall population that results if lots of children, not just yours, are unimmunized.

Not long ago I saw a patient in her early 30s who was pretty obsessed with getting breast cancer. She had no particular risk factors (no first-degree female relatives with it), but had previously talked a physician into ordering a mammogram when she was just 28 (it was normal), and wanted another one. We discussed the risk, but she was pretty fixated on breast cancer. We also talked about other risks, of much more concern to me than to her: smoking 2 packs of cigarettes per day, having 3 different sexual partners and rarely using condoms, and having untreated hypertension. I suggested, strongly but I hope appropriately, that all of these were much greater risks to her health than was breast cancer. I don’t know that I got through.

I imagine that it is pretty easy for health professionals to agree with me about the relative risks for this woman. Why she was so concerned about breast cancer rather than her real risks is another question. Some obsessive neurosis? Excessive effectiveness of breast cancer awareness advertising? I’d suggest that in large part it is about personal responsibility, about whether she would have to take action to prevent a bad outcome. If she were really worried about the risk from blood pressure, from smoking, from unprotected sex with multiple partners (and she should be), she would have to do something, take some action to change her life, to take medicine, to give up an addiction. This would be hard. On the other hand, since there are no clear behaviors she would need to change to avoid breast cancer, this is a safer – that is, less challenging – thing to be concerned about, to be fixated on.

Are the rest of us so different? Even those of us who have almost no dangerous or risky habits or behaviors (are there such? If we apparently have none, there is a fair chance that we might be suffering from obsessive-compulsive disorder, also a potential risk!) Besides, some of us may always take care to wash our hands when using the restroom (and even use our elbows to turn off the water, as I saw a very young man do in a public place the other day), but take the risk of riding our bicycles on public thoroughfares. Or we may practice what we believe to be healthful eating, and may regularly ingest herbs and give our children vitamins that there is little or no data to support doing, but not give them immunizations.

Reducing health risk is also impacted by societal memory, or the lack thereof. This has been examined in the case of abortion rights, where younger women who have grown up during a period when abortion was legal (if increasingly unavailable, largely resulting from the campaign of terror from violent anti-abortion forces) do not see the urgency of fighting to continue it. It also often true in the case of HIV/AIDS, where young people who did not grow up seeing all their friends die of the disease before effective treatment was available may find themselves adopting the same high-risk behaviors. Or for those who never saw the devastation of epidemics of pertussis or diphtheria, or of measles, or of awful outcomes from Hemophilus influenza infections, to not see immunizing their children as critically important.

In addition, when we as individuals have good outcomes (or don’t have bad ones) we may tend to think it is deserved rather than attributing it to good fortune. We haven’t had car accidents because we are good drivers, not because we are lucky. We think we are healthy because we bike to work, or “eat right”, not because we are young and in a low-risk group. When we are older, we may believe that we are less ill than our friends because we do healthful things like yoga or take certain herbs, not because we lucked out in not getting cancer (or being born into a family with resources who could feed us well and educate us and provide us with other advantages) See also Social Determinants, Personal Responsibility, and Health System Outcomes, Sept 10, 2010).

I am not going to say “let s/he who is without sin cast the first stone”. I would, rather, ask all of us to recognize that an honest appraisal of our own risk behaviors is a first step to understanding those of others, and to helping them, and helping our society, achieve greater health.

[1] Data on vaccines presented at the recent American Academy of Family Physicians (AAFP) meeting suggest the chance of an adverse vaccine outcome is approximately equal to the chance of winning the lottery, and that of dying from a vaccine about equal to spontaneously having quadruplets.

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