Aim, objectives and hypotheses

The aim of this thesis is to investigate how study members from the MRC National Survey of Health and Development (NSHD) manage their health at various points in the life course and identify the health and social factors associated with different health management approaches.

The results presented in this thesis will meet this aim by investigating the health and social factors from childhood and adulthood associated with i) health professional consultation for health conditions and symptoms reported at age 43, ii) women’s management of symptoms in midlife (between ages 47 and 54), iii) women’s self-management of general health in midlife and iv) health check attendance at age 68.

These health management approaches will be collectively referred to as proactive health management in the objectives described below.

The objectives of this thesis and hypotheses tested throughout the chapters are shown below.

Objective 1

Describe NSHD study members’ management of health in adulthood and later life, specifically:

 Health professional consultation for health conditions and symptoms at age 43

 Women’s consultation for and self-management of symptoms in midlife (between ages 47 and 54)

 Women’s self-management of general health in midlife

 Attendance for recommended health checks at age 68

The thesis will also assess whether rates of consultation differed between different types of symptoms at age 43 and in midlife for women.

Hypothesis 1

It was hypothesised that rates of consultation would differ between different types of symptoms at age 43 and, in women, age 54.

This hypothesis was based on the assumption that symptom type would be associated with the likelihood of consulting. This assumption was informed by the literature describing the ‘illness iceberg’ (Hannay, 1980) that suggests that individuals do not consult for most symptoms, which could indicate that consultation occurs more for some

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symptoms than others. Furthermore, previous literature has reported that women’s experience of symptoms in midlife is associated with the likelihood of consultation (Avis et al., 1997), demonstrating the role of symptoms in health management, thus ‘health challenge’ (including health symptoms) was included in the conceptual framework as a correlate of health management. There is also evidence to suggest that psychological symptoms are often under-reported (Aneshensel, Estrada, Hansell, & Clark, 1987;

Bwtvelt & Van Dam, 1991; Lyness et al., 1995), suggesting that symptom type may influence reporting and subsequent symptom management.

Objective 2

Describe the associations between socioeconomic factors - including lifetime social class and educational attainment - and management of health.

Hypothesis 2

It was hypothesised that socioeconomic advantage - ie, higher social class, both in childhood and adulthood, and higher educational attainment - would be associated with more proactive management of health. Moreover, it was hypothesised that any associations between childhood social class and health management in adulthood would be attenuated by adult health and social factors.

There was some mixed evidence for the association between socioeconomic position (SEP) and proactive health management, particularly regarding adult social class and consultation (see section 2.3.1.1). However, there was fairly consistent evidence for a positive association between socioeconomic advantage and more self-management, screening attendance and health check attendance (Goldman & Smith, 2002; Pill et al., 1988; Rockwell & Riegel, 2001; Waller et al., 2009). Given that this thesis will consider only consultation in symptomatic study members, this was considered to be proactive health management, thus socioeconomic advantage was hypothesised to be associated with more consultation, more self-management and higher health check attendance.

Objective 3

Describe the associations between health in childhood and adulthood and management of health.

Hypothesis 3

It was hypothesised that those with poorer health in childhood and adulthood would be more likely to proactively manage their health. Also, it was hypothesised that any associations between worse health in childhood and proactive management of health would be explained by adult health and social factors.

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The evidence regarding the association between adult health status and health management was mixed and there was very little evidence for the role of childhood health (see sections 2.3.2 and 2.2.1 respectively). However, given that there was some evidence for an association between worse health in adulthood and more proactive health management (in the form of primary health care access and health check attendance) this informed the hypothesis (Glynn et al., 2011; Labeit et al., 2013).

Moreover, specific to women’s health, the literature consistently supported an association between adverse health experiences in earlier adulthood and more proactive management of women’s symptoms in midlife (Avis & McKinlay, 1990; Guthrie et al., 1996; Morse et al., 1994).

Objective 4

Describe the associations between health care utilisation in earlier adulthood and management of health.

Hypothesis 4

It was hypothesised that accessing health care services in earlier adulthood would be associated with a higher likelihood of proactive management of health in later adulthood.

This hypothesis was informed by consistent evidence for associations between previous attendance to professional health services and engagement with health checks (Labeit et al., 2013; Pill et al., 1988; Thorogood et al., 1993) and between women’s prior utilisation of professional health care services and medicalised management of symptoms in midlife (Anderson & Posner, 2002; Avis & McKinlay, 1990; Egeland et al., 1991; Kuh et al., 2000).

Objective 5

Describe the associations between health behaviours in adulthood and management of health.

Hypothesis 5

It was hypothesised that reporting healthier behaviours (specifically, not smoking and higher levels of physical activity) would be associated with more proactive management of health and, conversely, reporting poorer health behaviours (such as smoking and lower levels of physical activity) would be associated with less proactive management of health.

The literature indicated that positive health behaviours were associated with greater health check attendance (Dalton et al., 2011; Labeit et al., 2013; Pill et al., 1988) and, in women, with engagement with preventive health care, including screening (Morse et al., 1994). Although there was no evidence to suggest an association between positive

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health behaviours and health professional consultation, the hypothesis that positive health behaviours would be associated with all forms of proactive health management was formed in light of this evidence for associations with preventive health care engagement.

Objective 6

Describe the associations between personality and attitudes towards to health and management of health.

Hypothesis 6

It was hypothesised that higher levels of self-organisation in adolescence would be associated with more proactive management of health and that this association would be explained by other childhood and/or adult health and social factors. It was hypothesised that higher levels of extraversion and neuroticism would be associated with more proactive management of health. For women who experienced symptoms in midlife, it was hypothesised that those who reported more negative attitudes towards the menopause would be more likely to proactively manage symptoms.

Although there was not any evidence to suggest that higher self-organisation was associated with proactive health management, previous literature reported that higher self-organisation was associated with positive health behaviours (Moffitt et al., 2011;

Nishida et al., 2016). As positive health behaviours were shown to be associated with some forms of proactive health management, as discussed above, it was hypothesised that an association between adolescent self-organisation and proactive health management would operate through adult health behaviours and perhaps other health and social factors from across the life course.

There was also a lack of literature assessing the role of extraversion and neuroticism in health management. However, previous literature suggested that higher levels of extraversion and neuroticism were associated with several other factors likely to be associated with health management, namely health behaviours (Cooper et al., 2000;

Munafo & Black, 2007), in women, symptoms in midlife (Bosworth et al., 2003; Elavsky

& McAuley, 2009) and, although not measured in this thesis, coping behaviours (Carver

& Connor-Smith, 2010), thereby demonstrating a number of pathways by which extraversion and neuroticism might be associated with proactive health management.

Objective 7

Describe the associations between family circumstances (particularly marital status and, where possible, family-related stress) and management of health.

Hypothesis 7

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It was hypothesised that being married would be associated with more proactive health management and that, for women, lower levels of family related stress in midlife would be associated with more proactive management of health.

There was some consistent evidence demonstrating an association between married status and more health care utilisation (Dunlop et al., 2000; Thorogood et al., 1993), including access to preventive health care, and with more health self-management (Jerant et al., 2005; Jowsey et al., 2014; Rosland et al., 2010) to inform the hypothesised association between being married and proactively managing health.

Although there was no previous literature describing associations between family related stress and health management, it was hypothesised that experiencing more family related stress would be associated with less proactive health management, as this would lead to greater burden for women and make caring for and managing their own health less of a priority.

Objective 8

In women who reported symptoms in midlife, describe the associations between symptom experience (severity and duration) and management of symptoms and investigate whether symptom experience mediates associations between childhood and adult health and social factors and management of symptoms.

Hypothesis 8

It was hypothesised that women who reported more bothersome symptoms and experienced symptoms for a longer duration would be more likely to proactively manage symptoms. Additionally, it was hypothesised that the experience of more bothersome, enduring symptoms would mediate the associations between exposures from childhood and adulthood described above.

This hypothesis was informed by the evidence for an association between symptom frequency and severity and health professional consultation (Avis et al., 1997). Moreover, as previous literature demonstrated the role of various health and social factors in women’s experience of symptoms in midlife (Avis et al., 1997; Dennerstein et al., 1993;

Kuh et al., 1997; Mishra & Kuh, 2012; Smith & Waters, 1983), illustrating the potential pathways by which various health and social factors might be associated with management of women’s symptoms via the experience of bothersome symptoms.

Objective 9

Finally, this thesis will describe the associations between health management approaches in adulthood and later life (ie, consultation at age 43, women’s management

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of symptoms and self-management of general health in midlife and health check attendance at age 68). The analysis will assess whether health management differs across adulthood (between ages 43 and 68) and if the approaches to managing different types of health conditions vary.

Hypothesis 9

It was hypothesised that proactive management of health would be consistent throughout adulthood and into later life, thus consultation at age 43 would predict consultation and self-management in midlife in women and health check attendance in later life and, for women, consultation and self-management in midlife would predict health check attendance at age 68.

There was no existing research to inform or support this hypothesis as this was a gap in literature that this thesis aimed to address, using a novel approach to health management research by investigating different approaches to health management and assessing whether or not they were associated at different stages in adult life.