Chapter 3  Seeking Health Care

Adopting Health-Related Behaviors Although health is highly valued, people do not always behave in ways that promote their health.

Theories of Health-Protective Behaviors Several theories attempt to explain health-related behaviors.

The Health Belief Model The health belief model includes four factors that should combine to predict health-related behaviors: perceived susceptibility to disease or disability, perceived severity of the disease or disability, perceived benefits of health-enhancing behaviors, perceived barriers to health-enhancing behaviors.

The Health Belief Model Although the health belief model appears to conform to common sense, it does not consider such factors as ethnic background, having a regular place to go for health care, self-efficacy, intentions to behave, and social norms.

The Health Belief Model The Irrational Health Belief Scale is an attempt to improve the health belief model by including measurements of unrealistic optimism and irrational beliefs about the risk of health-care. More research is necessary to establish reliability and validity of this scale.

The Theory of Reasoned Action The theory of reasoned action assumes that people are quite reasonable and make systematic use of information when deciding how to behave.

The Theory of Reasoned Action A person's intention to act is the immediate determinant of behavior intentions are shaped by one's attitude toward the behavior as well as one's subjective norm; [that is, one's perception of the social pressure to perform or not perform the action] (see Figure 3.1).

Figure 3.2 Theory of planned behavior

The Theory of Reasoned Action A person's attitude toward the behavior is determined by beliefs that the behavior will lead to positively or negatively valued outcomes.

The Theory of Reasoned Action The subjective norm is shaped by the perception of the evaluation that a particular individual (or group of individuals) places on that behavior and the motivation to comply to the norms set by that individual (or group of individuals).

The Theory of Reasoned Action In predicting behavior, the theory of reasoned action also considers the relative weight of personal attitudes measured against subjective norms. This theory has shown some success in predicting safe and unsafe behaviors such as using condoms obtaining mammograms.

The Theory of Planned Behavior The theory of planned behavior is an extension of the theory of reasoned action, adding the component of perception of how much control people have over their behavior (see Figure 3.2).  

The Theory of Planned Behavior Perceived behavioral control is the ease or difficulty of achieving desired behavioral outcomes and reflects both past behaviors and perceived ability to overcome obstacles. This factor acts both directly and indirectly to affect behavior. Research has supported the value of this added component.

The Precaution Adoption Process Model Neil Weinstein’s precaution adoption process model assumes that when people begin new and relatively complex behaviors aimed at protecting themselves from harm, they move through as many as seven stages of belief about their personal susceptibility (see Figure 3.3).

The Precaution Adoption Process Model In Stage 1, people are unaware of the hazard. In Stage 2, they are aware of the hazard but believe that they are not at risk but others are; that is, they have an optimistic bias.

The Precaution Adoption Process Model Stage 3 acknowledge their personal susceptibility and accept the notion that precaution would be personally effective. Action occurs Stage 4, whereas in the parallel Stage 5, people decide that action is unnecessary.

The Precaution Adoption Process Model Stage 6, people have already taken the precautions aimed at reducing risks, Stage 7 involves maintaining the precaution. Much research has supported the notion of optimistic bias, and the authors of the text report on some of these studies in subsequent chapters.

Figure 3.3 Weinstein’s seven stages of the precaution adoption process model

Research on other aspects of Weinstein's model generally supports the hypothesis that people adopt a precaution only after they see that they are personally susceptible to a hazard.

Critique of Health-Related Theories Useful health-related theories should: (1) generate significant research, (2) organize and explain observations, and (3) help the practitioner predict and change behaviors.

Critique of Health-Related Theories The older models (such as the health belief model) have produced a great deal of research, and the newer models show promise of doing so. None of the models explain all of the complexities of health-related behavior, but the concept of intention and optimistic bias have supporting research.

Critique of Health-Related Theories Several factors not included in these theories may lessen the theories effectiveness. These include poverty, public policy, ethnic background, legislation, and lack of medical and health information, institutional factors, and community factors. The variety of these circumstances poses a substantial problem for any such theory

Seeking Medical Attention How people determine their health status when they don't feel well depends on their social and cultural background, their interpretation of symptoms, and their concept of what constitutes illness.

Illness behavior consists of those activities taken by people who feel sick and are directed toward determining health status before an official diagnosis. Sick role behavior consists of those activities exhibited by people after they have been diagnosed and are aimed at trying to get well.

A. Illness Behavior Many people experience symptoms that may signal illness; some seek help for these symptoms and others do not. Six possibilities explain how people respond to symptoms.  

1. Personal factors include people's way of viewing their own body, their level of stress, and their personality traits. Stress affects people’s readiness to seek care, that is, people who experience a great deal of stress are more likely to seek health care than those under less stress, even with equal symptoms.

2. Gender also plays a role in seeking health care, with women more likely than men to seek treatment. Women are more likely than men to be sensitive to their bodies and also to report more non-life threatening symptoms. In addition, women's gender role allows them to seek assistance more readily than men’s gender role permits.

3. Age is another factor in seeking treatment, with young and middle-age people being most reluctant to check out symptoms. Older adults must decide if their symptoms are the result of aging or disease. In many situations, this attribution is difficult to make, and their uncertainty may delay seeking health care.

4. Socioeconomic and cultural factors People in high socioeconomic levels are less likely than others to have symptoms, but when they do experience pain and discomfort, they are more likely to go to a health care professional. Knowledge of the implications of symptoms is similar in all groups, but access to care varies with socioeconomic status.

5. Symptom characteristics often influence how people respond to illness. People are most likely to seek medical care when: (1) their symptoms are quite visible to themselves and to others, (2) they view the symptoms as severe, (3) their symptoms interfere with usual lifestyle, and (4) their symptoms recur or persist.  

6. Conceptualization of disease is a sixth factor that may help explain why some people seek health care, whereas others with the same symptoms do not. Howard Leventhal and his colleagues identified five components in the conceptualization of illness.

(1) People need to label their symptoms, and a non-threatening label seems to alleviate symptom anxieties. (2) When people receive a diagnosis, they think about the time line of both the disease and the treatment. (3) Most people feel less anxious when they can attribute some cause to their symptoms

. (4) People think of the consequences of their disease, and some overestimate or underestimate the mortality rates of certain diseases. (5) People who believe that they can control their own disease process (for example, through diet or exercise) are less likely than others to seek health care

B. The Sick Role After people become convinced that they are ill, they adopt the sick role, which allows them both privileges and responsibilities.

Their privileges include: (1) the right to make decisions concerning health-related issues, (2) the right to be exempt from normal duties, and (3) the right to become dependent on others for assistance.

Their three responsibilities are (1) the duty to maintain health as well as get well, (2) the duty to perform routine health care management and, (3) the duty to use a range of health care resources.

III. Receiving Health Care By the time most people in the United States have reached their 21st birthday, they have had multiple experiences of receiving health care. Those experiences vary according to economic factors, which may limit access to health care.

A. Limited Access to Health Care Hospitalization and other complex medical treatments are so expensive that most people cannot afford these services. People who can afford health insurance do so, but about 17% of people do not have insurance.

A. Limited Access to Health Care In an attempt to rectify this condition, the U.S. Congress created two programs in 1965 to provide health care—Medicare, which pays hospital expenses for most Americans over the age of 65 and Medicaid, which provides health care based on low income and physical problems, such as disability or pregnancy.

B. Choosing a Practitioner Sick people have a wide choice of health care providers, including midwives, nurses, physical therapists, psychologists, osteopaths, chiropractors, dentists, nutritionists, and herbal healers. The recent growth of alternative medicine has come mainly from well-educated people who are dissatisfied with traditional medical care.

For many poor people, their most common experience of receiving health care is going to a hospital emergency room, giving them very little choice of practitioner. People with choices have developed a more consumer-oriented attitude, and many choose female physicians, who tend to spend more time with their patients.

C. The Rise of Managed Health Care Health maintenance organizations (HMOs) originated with the concept that prevention is preferable to treatment. HMOs hire health care workers, including physicians, and pay them salaries for their services.

Because HMO physicians cannot dictate their salaries and because they can manage the amount of health care available, patients have more difficulty seeing a medical specialist or receiving additional treatment.

C. The Rise of Managed Health Care Many insurance plans now have lists of preferred or exclusive providers whom members may consult. If members wish to choose a practitioner not on the list, they will have a greater financial burden.

Managed care changed health care in the United States in at least three important ways. (1) People do not usually have a choice among health care providers, (2) solo practitioners are becoming rare, and (3) the power and authority of physicians have diminished.  

D. Being in the Hospital The experience of being in the hospital has changed during the past 25 years. Hospitalization has become less common for many types of surgery and tests, and hospital stays have become shorter, but those who are hospitalized tend to be sicker. An array of technology for diagnosis and treatment adds to the depersonalization and stress of hospitalization.

Part of the sick role is to be a patient, and being a patient means conforming to the rules of the health care institution, complying with medical advice, and being a good patient, that is, a "non-person" who tolerates lack of information and loss of control.

Hospitalized patients become part of hospital routine, which allows them limited information concerning their illness and little control over their situation. This situation adds to the stress of being ill, but hospitals have become more technology-oriented and more impersonal, so this situation is not likely to improve.

Children are especially vulnerable to persistent fears as a result of receiving medical treatment. Reassuring children that they have nothing to fear is not effective, but allowing children to tour the premises to become familiar with the treatment they will receive can decrease fears.

Observing a model deal with a similar procedure is another approach to preparing children to cope with hospitalization. Unfortunately, costs, not effectiveness, are the main problem with children's interventions to reduce children's stress.