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By Dr. Maddie Swannack and Dr. Ben Appleby
Next Lesson - Beliefs of the Public
Core
The World Health Organisation (WHO) defines health as 'a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity'. (source)
This means that to be ‘healthy’, one should be well physically, mentally and socially.
There are three ways to interpret this definition of health. They are important to understand how a patient (especially those with chronic illness) view themselves and their health.
- Positive – a state of well-being and fitness.
- Functional – the ability to perform the tasks needed.
- Negative – the absence of illness.
Chronic illness is defined as a long-term condition that has a significant impact on sufferers and has many co-morbidities. Manifestation may vary day to day, and the disease may or may not be able to be controlled and may or not be able to be cured. It is also important to note that living with chronic conditions can have a profound effect on the life of the patient, regarding social interaction, mental health, and general day to day life.
There are numerous studies that have shown a link between deprivation (or poverty) and ill health. There are many theories as to why this is. The Black Report identified a number of explanations for health inequalities.
- Social Selection – this theory states that health determines socio-economic status. If a patient is chronically ill, they cannot work, and this will increase the chances of them entering poverty or having a lower socio-economic status.
- Behavioural – patients in deprived areas are more likely to engage in behaviours damaging to health (negative health behaviours), like smoking and drinking and partake in fewer positive health behaviours such as good diet and regular exercise.
- Psychosocial – the stress of working in poorly paid, poor quality, low skilled/status jobs can cause biological changes, and this can lead to poor health.
- Material – the direct effects of poverty such as poor access to food or poor access to quality housing.
- Artefact – this is the theory that states that no true association exists between poverty and poor health, but that this link is a by-product of methods used to measure both health and deprivation.
It has been theorised that the largest cause for increases in life expectancy in the UK in the last 100 years, is likely due to social improvements such as improved housing conditions, sanitation and diet rather than medical advances.
There are two prevailing models of health: The Biomedical Model and The Biopsychosocial Model. Their differences are highlighted in the table below.
Table - The differences between the Biomedical Model and the Biopsychosocial Model
SimpleMed original by Maddie Swannack
A 2019 report by the King’s fund states:
‘In 2015–17, males living in the least deprived 10 per cent of areas in England could expect to live almost a decade (9.3 years) longer than males living in the 10 per cent most deprived areas, and for females the gap was 7.5 years. Much of this inequality is caused by higher mortality from heart and respiratory disease, and lung cancer, in more deprived areas.’
This can be colloquially compared by thinking about the relative life expectancies of those related to Prince William compared to those related to the Peaky Blinders.
This is a very complex area with a large degree of debate over the causes and contributing factors.
An important theory to be familiar with is the Inverse Care Law. This is the situation in which individuals who are more in need of care have less opportunity to access care and those with the least need of care use health services more.
Living with Chronic Conditions
Living with chronic illness can be very hard work. There are numerous types of ‘work’ that those living with chronic illness have to expend:
- Illness Work – this is the day to day effort of managing symptoms and dealing with things like medications.
- ‘Everyday Life’ Work – this is the effort of going about day to day tasks, like walking or preparing food and the adjustments required to routine to facilitate these tasks.
- Emotional Work – this is the effort that it takes every day to overcome the emotionally draining effects of the illness. This also involves the impact on the emotions of those around the patient.
- Biographical Work – when suffering with a chronic illness, a patient can feel as though they have lost their identity for various reasons. This is the work that goes into reassessing and re-establishing a new or different sense of self.
Individuals with chronic conditions can also be the victims of stigma. Stigma can be classed into 4 categories:
- Discreditable stigma – discrimination which is aimed at nonvisible conditions such as mental health.
- Discredited stigma – discrimination which is aimed at visible illness.
- Enacted stigma – the real direct experience of prejudice and discrimination as a result of illness.
- Felt stigma – the fear of experiencing stigma, shame or abuse. This can lead patients to conceal their condition from others.
Health related behaviours are anything that promotes either good health or leads to illness. This means that both smoking and exercise count as a health related behaviour, even though they lead to different outcomes.
Classical conditioning
This was first explored in the work of Ivan Pavlov, where one stimulus becomes paired with another. Pavlov famously explored this phenomenon with dogs. When the dogs were presented with food they began to salivate and a bell was rung. By repeating this process many times, the dog began to associate the sound of the bell with food. This meant that hearing the sound of the bell began to salivate even in the absence of food. This can be seen in addictive behaviours. For example if an ex-smoker used to smoke after lunch whilst at work they may crave a cigarette after lunch as they have come to associate lunch with cigarettes. This can be a very tricky hurdle in combatting any addiction and be a trigger for relapse.
Operant Conditioning
A behaviour is consciously learnt by its consequences. For example; if a young child puts their hand on a hot stove and burns themselves they learn that putting their hand on the stove is a bad idea and will not do it again. This cycle of action, consequence and change in future behaviour is also applicable in addiction. Many unhealthy behaviours are immediately rewarding. For example if a patient uses illicit drugs the positive high they get from the use of the drug will encourage further use. Further use is also strengthened by the negative effects of withdrawal which will discourage stopping use of the drug. This can lead to addiction and dependency.
Social Learning Theory
People learn through observed behaviours and seek to copy these behaviours to gain the same praise. (Or to put it simply, monkey see, monkey do.) For example if an individual sees others drinking alcohol and as a result are having fun, they may then copy this behaviour in an attempt to also have fun/ achieve the positive result.
This can be compounded by peer pressure: if it is accepted by a group that drinking alcohol is necessary to have fun, for an outsider with the desire of acceptance into that group, will drink alcohol to fit in and to gain praise.
However, it is worth considering that these theories are deterministic – this means that according to the three theories, no one should ever be able to escape bad behaviour, and the individuals in the examples would never be able to recover. Of course, this can’t be true, it is possible to break from these negative health behaviour patterns however as a result of their structure this can be difficult and may take multiple attempts and concerted effort. But this is possible, so it must mean that these three theories are not completely and only true.
The COM-B model discusses the factors that contribute to a behaviour. Take for example a patient who is diagnosed with Type 1 Diabetes Mellitus and is now required to inject insulin before a meal.
This patient must have the capability to perform the injections. This means that they must understand the process of how to safely inject insulin and have the ability to do so.
They must also have the opportunity to do so, through having insulin available and the time to perform the injections before each meal.
These both contribute to the patient having the motivation for performing the injections. The patient must also understand why they need to perform the injections, and the consequences if they choose not to.
These all contribute to their behaviour, and whether they choose to inject or not.
Diagram - The COM-B Model
SimpleMed original by Maddie Swannack
Applying Models to Substance Misuse and Abuse
It is possible to apply different treatment models to substance abuse and misuse. For this part of the article, substance abuse is assumed to be either IV drug use or alcohol abuse so specific treatment examples can be given, but these models can be applied to any form of addiction.
There are three main treatment models when considering substance abuse:
- Medical – this model treats the physical symptoms of addiction with pharmacological interventions rather than treating the underlying addiction. It can involve treating symptoms such aswithdrawal, vitamin deficiency (like vitamin B12 which is often deficient in alcoholism), and tolerance (especially in addiction to prescribed painkillers).
- Disease – this model views avoidance as the only reliable treatment for addiction, because addiction is a genetically predetermined illness with ‘loss of control’ as the primary symptom. This model uses programs like the 12 Step Program for alcoholism to put into place avoidance tactics as treatment.
- Behavioural – this model views addiction not as a disease, but a series of poorly learned behaviours that form a negative coping mechanism. This means that the best way to treat addiction is to address the past experiences that have encouraged this behaviour and teach more positive coping mechanisms.
It is important to note though that a combination of all three treatment models is often the most effective. For example, an IV drug user needs medical treatment to treat the symptoms of withdrawal, help in avoiding situations where they might be exposed to drugs, and counselling to teach alternative coping mechanisms.
There are also two themes of treatments offered alongside the key themes of the treatment model based on whether the patient is interested in changing or not.
- Harm Reduction – this occurs to maintain the health of the patient while they work towards being able to combat their addiction. It is important to advise these things alongside any other treatment to help reduce the lasting damage of addiction.
- Alcoholism – given vitamin B supplements to avoid malnutrition associated with liver damage.
- Opiates – Naloxone given in overdose to block the negative effects of the overdose (see Pharmacology unit).
- For those injecting drugs – needle exchanges and blood borne virus screenings to encourage safer needle practice and prevent sharing of needles and transmission of blood borne diseases.
- Relapse Prevention – this is for patient who are willing to change but need a helping hand to avoid slipping back into their addiction.
- Disulphiram – alcohol deterrent through increasing hang over symptoms (for more information, check out the Metabolism unit, especially the article on Alcohol Metabolism).
- Methadone – used to combat heroin addiction because it can be reduced slowly and accurately, reducing the amount of withdrawal symptoms.
Reviewed by: Dr. Thomas Burnell
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