Article Text

Download PDFPDF

Applying social theory to understand health-related behaviours
  1. Daniel Holman1,
  2. Erica Borgstrom2
  1. 1Department of Sociological Studies, University of Sheffield, Sheffield, UK
  2. 2Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Dr Daniel Holman, Department of Sociological Studies, University of Sheffield, Northumberland Road, Sheffield S10 2TU, UK; daniel.holman{at}sheffield.ac.uk

Abstract

Health-related behaviours are a concern for contemporary health policy and practice given their association with a range of illness outcomes. Many of the policies and interventions aimed at changing health-related behaviours assume that people are more or less free to choose their behaviour and how they experience health. Within sociology and anthropology, these behaviours are viewed not as acts of choice but as actions and practices situated within a larger sociocultural context. In this paper, we outline three theoretical perspectives useful in understanding behaviours that may influence one's health in this wider context: theories of social practice, social networks and interactionism. We argue that by better understanding how health-related behaviours are performed in people's everyday lives, more suitable interventions and clinical management can be developed.

  • Anthropology
  • Health policy
  • Public health
  • Social science
View Full Text

Statistics from Altmetric.com

Health-related behaviours are a concern of contemporary health policy and practice given their association with a range of illness outcomes.1 Behaviour change programmes often focus on individual autonomy in decision-making. Such approaches may have limited effect and receive criticism for neglecting the wider social context in which behaviours take place.2 ,3 In this paper we explore three social theories which are useful in helping to understand behaviours that are associated with health: (1) social theories of practice, which focus on people's social and cultural background and circumstances, (2) social networks, which explore interpersonal relationships and (3) interactionist approaches, which consider the meaning-making, performativity and roles implicit in social interaction. We discuss the relevance of these theories for medical research and practice as a potential way forward for help better understand the social aspects of behaviour, leading to more suitable interventions and clinical management.

The concept of ‘health behaviour’ originates from psychology and describes actions that are considered to be associated with developing, or preventing, particular diseases or conditions.4 These actions are conceptualised as discrete, categorical and belonging to the individual. Health behaviour categories include diet, alcohol/drug consumption, physical activity and medication adherence. It is assumed that behaviours are causally linked to health outcomes which can be improved by altering or eradicating particular behaviours. This approach has furthered the understanding of the cognitive processes implicit in how people's lifestyles impact their health over the life course.5 However, such conceptualisations do not explain how or why people behave beyond the individual level or have much to say about the differing ways in which behaviour is articulated by people, for example, across time, gender, ethnicity and place. We have used the term ‘health-related behaviours’ to indicate the importance of context and downplay the causal link assumed in many behaviour–change interventions.

Theory of practice and collective patterns

Practice theory is receiving increasing attention within the social sciences,6–8 and although it has taken off in some fields such as environment sciences,9 it has yet to do so to the same extent in public health. A classic paper by Williams10 on the potential of Bourdieu to help understand class, health and lifestyles was pivotal in inspiring further work in this area, for example in health lifestyle theory11 and the collective lifestyles approach.12 The health focus of practice theory has therefore centred on lifestyle, with diet and exercise being two of the behaviours receiving most interest. This may be because lifestyle entails everyday behaviours which are closely bound up with sociobiography.

Practice theory posits that who people are—their personalities, ways of seeing the world, ways of talking, thinking and feeling—is rooted in and expressed through the situations and circumstances they have experienced, especially in the formative early years in life.13 The mental categories which orientate or dispose people to act in certain ways—known as habitus—are therefore influenced more widely by the structure of society, which gives rise to the situations and circumstances characterising society. For example, growing up in an area with scarce employment opportunities might lead one to develop a fatalistic orientation towards life, where personal choice is seen as having little relevance, which has implications for a variety of health behaviours, including those implicit in smoking,14 talking treatment use15 and physical activity.16 Another important aspect of practice theory is centred on the resources—or capital—that people have available to act in certain ways. Having a healthy diet, for example, is not just a matter of choosing to be healthy but is made easier by having the money to afford healthy foods (economic capital), the know-how to shop for and cook them (cultural capital) and being within a social setting where healthy eating is the norm (social capital).17 Eating also entails certain meanings (eg, cultural conventions), materials (eg, tools) and tacit and explicit competences (eg, embodied skills).7

It is interesting to contrast habitus with recent discussions from within behaviour change theory of what causes behaviour to become habitual,18 which centre on the immediate context of behaviour. Similarly, the recently popular nudge theory focuses on the immediate built environment, such as where products are placed on the shelf or how they are packaged.19 Combining insights from the sociobiographical and socioeconomic context of orientations and behaviour with psychological work on the context of habit formation and the influence of the built environment may be a fruitful area of inquiry. Psychological constructs can be viewed as mediating the relationship between the wider social context and individual behaviours; social theory allows for conceptualising the causal chain, and without it an important ‘layer’ of behaviour is ignored. Using these models to understand health behaviour in research and clinical practice involves looking at issues such as how behaviour is patterned across the population and within individuals over time, cultural interpretations of risk factors, the resources available for behaviour, environments where people behave in certain ways and how people perceive health behaviour and how this may affect their desire to engage in certain activities.

Networks

Social network analysis is used to identify agents and their relationships and the structure of systems. Originating in sociology, network analysis centres around the fundamental idea that social action and meaning-making are contingent on people (and other phenomena) being related to one another in a multitude of ways.20 Although methodological approaches vary, they share the idea that networks can be analysed in terms of the number of connections, the distribution of ties and the position and influence of actors in the network.20 Interest in social network analysis has grown massively in recent years21 and is also now a relatively popular approach in understanding health behaviour. A recent influential application is Christakis's and Fowler's22 work on how obesity ‘travels’ in social networks, which for example showed that a person's chance of becoming obese increased by 57% if they had a friend who became obese. In addition, connections of the same sex had a greater effect on each other, suggesting that people are more readily influence by those similar to themselves. Studies using social network analysis have focused on smoking,23 ,24 drug-taking25 and sexual behaviour,26 perhaps because these are relatively contingent on peer interactions. In these studies, the types of explanations that emerge for health behaviour—including peer selection, influence of parents versus friends, geographical location of network influences, clustered behavioural patterns, interaction of educational background and social network—are at odds with highly individualised explanations of health behaviour.

Another useful example of network analysis is the Network Episode Model (NEM), which aims to explain help-seeking behaviour—an important concern for medical practice. Rather than viewing help-seeking behaviour as a one-time action influenced solely by social psychological constructs such as self-efficacy or knowledge of services, NEM aims to systematically account for the role of networks in healthcare outcomes.27 NEM posits that people have an ‘illness career’ across the life course, and fluctuate between different health problems ranging in type and severity and also fluctuate in terms of how they respond to these problems, whether by using individual coping strategies, social support or by formal healthcare. In this sense, different types of networks interact with patterns of illness across the life course.

Actor-network theory (ANT) focuses on inanimate actors, such as technological systems (eg, health records systems),28 discourses or other phenomena. The idea behind ANT is to explore the multiple networks between multiple human and non-human actors, including how they are established, evolve, interrelate and move.29 ,30 ANT has been used to conceptualise alcohol as an ‘actor’ in teenage drinking behaviour,31 to analyse the complex and messy interactions that characterise change tobacco use management32 and to examine the effects of the built environment on behaviour change.33 Since ANT is a theory through which the materiality (ie, material objects as well as people) of social life can be conceptualised, it widens the analytical lens to allow for a more complex and thorough understanding of how networks influence health.

Interactionism and performativity

Interactionist approaches propose that behaviour reflects social meaning, which derives from how people make sense of social reality within their social and cultural contexts.34 People ascribe meaning to people, events and situations through interacting with them. Persons’ subjective position, or worldview, filters their understanding of their environment, and identity is formed by and through this interactive meaning-making process. From this perspective, behaviour can be understood as a social performance centred around constructing social identity—these performances often tied to social roles with particular expectations. This perspective has been most influential in the form of Goffman's work on stigma—the situation where a person is reduced from being ‘a whole and usual person to a tainted, discounted one’.35 Stigma first became significant in the public health field in explaining the AIDS epidemic,36 and in recent years, efforts have been made to stigmatise smokers in campaigns seeking to ‘denormalise’ tobacco consumption.36 The concept has also been hugely influential in mental health, in part owing to the sometimes fuzzy boundaries between behaviour, illness and deviance.37

Roles provide a basis for the response of others in social interaction and are a key part of a person's identity. Parsons’s widely used concept of the sick role describes how being sick carries certain rights and responsibilities,38 which might take on new significance in relation to the recent focus on changing people's ‘unhealthy’ behaviours. Research on gender roles has examined men's reluctant help-seeking behaviour,39 unhealthy eating patterns40 and sunscreen use.41 One recent intervention encouraging men to lose weight drew on understandings of gender roles by basing the intervention in a traditional preserve of masculinity, the football club.42 Taking into account social roles allows for an appreciation of how behaviour is strongly shaped in terms of pre-existing and patterned norms, values and expectations.

Another aspect of the interactionist perspective is how people construct their identities through social performativity. The body is often a focus in this perspective, as it is a visible marker of social identity, which can be shaped, for example, by going to the gym or dieting. Notions of performativity have been drawn on to understand the focus of sport and fitness testing within schools.43 Plumridge et al explained adolescent smoking by focussing on the ‘coolness’ factor surrounding it.44 Buus used an interactionist approach to consider interviewees’ performances in explaining their ‘medicine-taking careers’, focussing on their changing and often frustrated relationships with healthcare professionals as their medicine use changed.45 In sum, interactionist approaches can be used to help understand how health behaviour is imbued with meaning and identity-making as part of everyday life.

Discussion

Health behaviour is incredibly complex and cannot be reduced to individual psychological factors. Social theories are systems of thought that acknowledge and attempt to disentangle the complex interplay between social and individual factors over time. The theories discussed in this paper have particular relevance to studying health-related behaviours. They look at these behaviours from the perspective of the actions being performed, who is involved, the social contexts in which they are conducted and how these influence the practices that can be conceptualised as lifestyles. Importantly, by shifting the focus onto practices and locating these within their social context, rather than focusing on behaviour as solely a function of cognitive phenomena, one can begin to unpick the role these practices have in people's lives, the meanings they hold and the ways in which such actions serve to express and are formed by a person's situations and circumstances. Such knowledge in turn can be used in the development of future interventions and clinical management programmes. In addition, social theories often overlap. For example, social networks can be conceived as a type of capital in practice theory, and as constituted by individuals with particular roles. The habitus can be used to understand how social interaction is socially patterned. Given this overlap, each theory can be considered to provide a different lens to investigate the issue. In order to produce informed accounts of health behaviour within research, we suggest collaborative working between health psychologists and health professionals with those with the expertise in social theory, from the conceptualisation to the evaluation stages of a research project. From a policy and practice perspective, the use of social theory enables researchers to outline the processes informing health-related behaviours and provides a more comprehensive and grounded understanding of the experiences of patients and professionals in everyday life. This presents numerous challenges in itself but is a necessary step if we are to make progress at the interface of medicine and health behaviour. Without social theory, it is evident that crucial pieces of the puzzle of health behaviour are missing.

Acknowledgments

The authors would like to thank Felix Naughton for his feedback on an earlier draft of this paper. This paper was inspired by discussions held within the Social Analysis of Health Network in Cambridge.

References

View Abstract

Footnotes

  • Contributors Both authors contributed to the ideas and writing of the text. DH is the guarantor and corresponding author.

  • Funding EB is currently funded by the Foundation for the Sociology of Health and Illness Mildred Blaxter fellowship.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.