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26 January 2010
The incidence of non-communicable diseases (NCD)in Malaysia is frightening. About 70% of the outpatient attendances in 2008 in the Health Ministry’s healthcare facilities are related to NCDs such as hypertension, diabetes, obesity, high cholesterol, and smoking. Do you have what it takes to commit to healthy behaviour?
BEHAVIOUR impacts significantly on every individual’s health. The vast majority of medical conditions are caused by poor diet, lack of exercise, tobacco smoking, substance abuse, and risky sexual practices. There is much evidence which shows that different behaviour patterns are rooted in the individual’s social and cultural circumstances.
One of the most daunting challenges for doctors and other healthcare professionals is to get patients to change their health behaviour, or if it is not possible, to modify it. Improvements to medical conditions, particularly chronic ones, are dependent not only on medical treatment, but also the change in patient behaviour.
There are numerous such situations in daily medical practice. Some examples are:
- Getting patients to cease smoking or to reduce it
- Getting obese and overweight patients to diet and exercise
- Getting patients with high blood pressure and coronary artery disease to modify their diet, exercise, and take medication
- Getting sexually active adolescents to use effective contraception and protection from sexually transmitted infections and more importantly, persuading adults not to ignore the surging hormones in the young
- Getting HIV/AIDS patients to adhere to safe sexual practices
It is difficult to change a person’s genetic predisposition to disease or his or her social circumstances, at least in the short to medium term. By contrast, it is easier to change the health behaviour of individuals and communities. Health behaviour interventions have the promise of altering or modifying current disease patterns, which will have an enormous impact on individuals and society.Health behaviour
There are many definitions of health behaviour. Parkerson defined it broadly as "the actions of individuals, groups, and organisations as well as their determinants, correlates, and consequences, including social change, policy development and implementation, improved coping skills, and enhanced quality of life." (Medical Care, 1993, 31, 629-637).
Gochman’s definition emphasised individuals. Health behaviour was defined as "those personal attributes such as beliefs, expectations, motives, values, perceptions, and other cognitive elements; personality characteristics, including affective and emotional states and traits; and overt behaviour patterns, actions, and habits that relate to health maintenance, to health restoration, and to health improvement" (Handbook of Health Behavior Research, Vol. I. Personal and Social Determinants. New York: Plenum Press, 1997).
Kasl and Cobb described three specific categories of health behaviour:
- Preventive health behaviour - Any activity undertaken by an individual who believes himself to be healthy, for the purpose of preventing or detecting illness in an asymptomatic state.
- Illness behaviour - Any activity undertaken by an individual who perceives himself to be ill, to define the state of health, and to discover a suitable remedy (Archives of Environmental Health, 1966a, 12, 246-266)
- Sick-role behaviour - Any activity undertaken by an individual who considers himself to be ill, for the purpose of getting well. It includes receiving treatment from medical providers, generally involves a whole range of dependent behaviours, and leads to some degree of exemption from one’s usual responsibilities (Archives of Environmental Health, 1966b, 12, 531–541)
Adherence to treatment
Adherence to treatment refers to "the extent to which patients follow the instructions they are given for prescribed treatments" (Cochrane Database Syst Rev 2002). The term is preferred to the commonly used term "compliance", which can be construed as judgmental.
Adherence to treatment impacts significantly on the individual and society. High blood pressure (hypertension) is a good example. Uncontrolled or poorly controlled hypertension increases the likelihood of heart attacks, strokes, and kidney disease. The National Health and Morbidity Survey (NHMS) III in 2006 reported that 35.8% of hypertensives were aware of their hypertension, of which 87.7% were currently on treatment.
Of those who were aware of their hypertension and currently receiving treatment, only 26.3% were found to have their hypertension controlled. The overall control of hypertension was a paltry 8.2%. There were more Indian (12.2%) and Chinese (11.5%) hypertensives whose blood pressure was controlled when compared to Malays (7.0%). The current prevalence of hypertension had risen by a third (33% vs 43%) when compared to NHMS II in 1996. There were slight improvement in the awareness of hypertension (33% vs 36%), and overall control rates (6% vs 8%). However, there was no difference in control rates among those treated (26%).
The only consolation is the major improvement in the treatment rates among those who were aware of their hypertension status (23% vs 88%). This trend is disturbing with its serious human, social, and economic costs.
Another example is that of HIV/AIDS, which prevalence in Malaysia is high compared to other countries with similar population size. HIV/AIDS has also contributed to the resurgence of tuberculosis (TB).
Both conditions present particular challenges to adherence to treatment as they are chronic diseases affecting many of the disadvantaged. Their treatments involve complex regimes with potentially serious side effects. For HIV/AIDS treatment, drug resistance is also an issue.
The NHMS III reported that 35.8% of respondents had knowledge about the symptoms of sexually transmitted infections (STI) and 49.6% were knowledgeable about HIV transmission through sexual intercourse. 63% of the sexually active perceived that condoms protect against HIV when used correctly every time during sexual intercourse.
Although 94.5% of the study population knew about high risk practices that lead to the acquisition of HIV and STI, only 16.7% of those who had sex with prostitutes took safe sexual practices. The interaction of these factors makes adherence to treatment for these diseases a complex public health issue.Behaviour change
The incidence of non-communicable diseases (NCD) in Malaysia is frightening. About 70% of the outpatient attendances in 2008 in the healthcare facilities of the Health Ministry are related to NCD. The prevalence of diabetes has increased from 8.3% in 1986 to 14.9% in 2006 for adults, aged 30 years and above, an increase of 80% within a decade.
Yet only 11.4% of the patients attending the Health Ministry’s facilities had good diabetic control. (Mohd Ismail Merican, Berita MMA, November 2009)
Hypertension, diabetes, obesity, high cholesterol, and smoking, all NCD, and communicable diseases like HIV/AIDS and TB, are the main contributors to an increasingly unhealthy Malaysia. Yet all these conditions can be prevented and/or controlled by behavior change.
The Nuffield Council of Bioethics 2007 reintroduced the concept of an "intervention ladder" as a framework for consideration of the acceptability and justification of different policies for behaviour change to improve public health viz:
- Eliminate choice, e.g. compulsory isolation of patients with infectious diseases.
- Restrict choice, e.g. removing unhealthy ingredients from foods, or unhealthy foods from shops or restaurants.
- Guide choice through disincentives, e.g. taxes on cigarettes or discouraging the use of cars in inner cities through charging schemes or limitations of parking spaces.
- Guide choices through incentives, e.g. tax breaks for purchase of bicycles as a means of travelling to work.
- Guide choices through changing the default policy e.g. changing menus to provide a more healthy option as standard
- Enable choice - Enable individuals to change their behaviours, e.g. participation in "stop smoking" programme.
- Provide information - Inform and educate the public, e.g. campaigns to encourage people to walk more or eat five portions of fruit and vegetables per day.
- Do nothing or simply monitor the current situation.
The first and least-intrusive step is to do nothing, or at most monitor the situation. The most intrusive is legislation that restricts freedoms significantly, either for some population groups or the whole population. The higher the rung on the ladder the intervention is, the more effective it may be.
However, as the potential loss of liberty is greater, there is greater need for justification of the intervention in terms of evidence, benefits, harms, and costs.
The National Institute for Health and Clinical Excellence (NICE) published its guidance on behavior change in 2007 after reviewing the literature. The principal conclusions were:
- Interventions to bring about behaviour change can be at the population, community, or individual level. The outcomes are not necessarily at the same level as the intervention. It is important there be clarity about the levels involved.
- The causal links from intervention to outcome are complex.
- Behaviour change takes place in a social context.
- Psychological evidence about self-efficacy is a sound basis on which to develop individual interventions. Popular, non-evidence based models should be discarded.
- Policy level interventions should be synchronised with local interventions and vice versa.
- There should be precision about the content of the intervention.
- Implementation must involve proper planning and training, careful delivery, and evaluation.
- Some behaviour change interventions can sometimes increase health inequity.
- Commentators have observed that there is evidence to support the effectiveness of social marketing approaches, i.e. the systematic application of marketing techniques and approaches to achieve specific behavioural goals, to improve health, and reduce health inequalities.
Health behaviour decay
The benefits of behaviour change can be realised only if the healthy behaviours are continued. When there is cessation of the healthy behaviours, the health benefits usually end. There is often a predictable pattern shown by patients following the adoption of new behaviours.
Initially, there is marked adherence and obvious behaviour change. However, this is not uncommonly followed by a gradual return to previous behaviours over the ensuing months and years. The gradual migration away from the newly adopted healthy behaviours to the previous, less healthy behaviours is called health behaviour decay.
Weight reduction is a classic example of health behaviour decay. The initial period of weight loss is characterised by consistent efforts at dieting and exercising. After some time, this is followed by a period of health behaviour decay, when the new, healthy behaviours are replaced with the previous less healthy behaviours, leading to weight gain.
Similar examples are seen in interventions that lower blood pressure and raised lipids. The initial health benefits are reduced in the course of time as the previous, less healthy behaviours return.
The problem of health behaviour decay can be avoided with the assistance of doctors and other healthcare professionals.Healthy living for every individual
Many in the population depend on the authorities for the maintenance of their individual health. Whilst the authorities, particularly the health authorities, have an important role to play, the individual’s responsibility for his or her own health is even more important.
For example, the authorities can increase the prices of cigarettes and require manufacturers to have gory pictures printed on the cigarette packs, but the crucial determinant of the effectiveness of these interventions is the individual who makes the decision whether to smoke or not.
There is much that an individual can do to improve one’s health status. The interventions are very inexpensive as compared to the costs of treatment of ill health.
Healthy eating does not mean one has to do without one’s favourites. It is important to eat the right food and not to over consume. Regular daily meals should consist of a combination of food that is based on the food pyramid. It is vital that the food is low in sugar, salt, and fat.
Physical activity involving movements of the various parts of the body can be done at work or at recreation. The lack of exercise increases the risk of obesity, hypertension, and cardiovascular disease. There should be at least 30 minutes of light to moderate physical activity daily, or if not possible, at least, every alternate day. Any physical activity that is suitable for the individual would do.
It is best not to start smoking, but if one is already a smoker, efforts should be taken to cease smoking. Tobacco smoke contains more than 200 toxic chemicals, of which more than 60 cause cancer. It increases markedly the risk of many diseases including lung cancer, obstructive airway disease, and cardiovascular disease.
Smoking cessation is challenging, but with the advice and assistance of doctors and other healthcare professionals, it can be done.
Safe sexual practices prevent unintended pregnancies and sexually transmitted infections (STI) including HIV/AIDS. There are various methods available that will suit an individual’s cultural and religious needs. Saying no to sex is insufficient.
Accessible and user friendly sexual health services and wider dissemination of knowledge about the prevention of unintended pregnancies and STI, particularly to youths and young adults, will go a long way to reducing the number of STIs, including HIV/AIDS, and babies left by the road side.
The avoidance of drug abuse, particularly intravenous ones, will reduce not only the incidence of drug addiction but also that of HIV/AIDS.
The boundary between normal and abnormal mental health is often blurred. It is helpful to periodically consider one’s feelings, thoughts, and self esteem. Stress is part and parcel of life.
As such, everyone should learn how to cope with it. If one is unable to do so, help can be sought from one’s doctor, who may make a referral to a specialist.
Staying healthy at the workplace is vital.
It may mean attention to office space ergonomics or attention to work hazards. One should consider various means of improving job satisfaction and work-life balance.
Much time, effort, and money have been expended by the Health Ministry in its Healthy Lifestyle campaigns for more than a decade. Yet there is a paucity of reports of its success or otherwise.
The data from the NHMS III does not indicate that Malaysians have become healthier, but rather the opposite appears to be the case.
Perhaps it is time for a review of the campaign, evaluate its successes and failures, and then re-strategise, which would certainly include research into gap areas.
Behaviour impacts significantly on individual and community health. Whilst the authorities have their responsibilities, they can only do so much.
The ultimate responsibility rests on each and every individual. Interventions are available for behaviour change from less healthy behaviours to healthier ones leading to health benefits for the individual and community. In this respect, assistance from doctors and other healthcare professionals would be helpful.
Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.This article was first published in www.thestar.com.my on 3 January 2010.
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