The World Health Organization (WHO) Constitution states: ‘the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being’. Reducing vulnerability to ill-heath implies human rights to the basic pre-requisites of health including access to information, education, nutrition and clean water1. Where these elements are in place, vulnerability to ill health is determined to an important degree by the choices of the individual. It is, of course, perfectly possible to be living without disease but leading an unhealthy lifestyle which makes future disease more likely or even inevitable.
This paper focusses on the responsibilities and even duties that healthy people have to maintain their own health, through self-care. Self-care for health has many elements including appropriate nutrition, sufficient physical activity and the avoidance of risks such as tobacco consumption2. Through self-care an individual can remain healthy into their seventh, eighth and ninth decades, prevent or delay ‘lifestyle’ diseases, and maintain mental health. Conversely, without successful self-care the emerging epidemic of lifestyle diseases threatens to swamp healthcare systems around the world.
The reasonable responsibilities of the average healthy citizen to care for themselves and help prevent lifestyle diseases are therefore of great interest, but have received relatively little attention. There is a substantial literature on the duties of healthcare professionals, rather less on the duties of the patient, and very little on the duties of the healthy individual3.
Individuals have a right to information and education on how to maintain good health but ultimately they bear the responsibility to take action. The environment in which we live and the support we receive from healthcare professionals can help determine our lifestyle choices, but we alone can make them. Therefore we propose that a manifesto for self-care is needed. This fundamental expression of the responsibilities of individuals to take care of their own health could serve as a touchstone to guide the development of enabling tools and policies.
SELF-CARE AND THE LIFESTYLE DISEASES CHALLENGE
The need for people to undertake self-care to prevent or delay ‘lifestyle’ diseases (also called non-communicable diseases) is particularly pressing. The incidence of these diseases – particularly heart attack and stroke, cancer, chronic lung diseases and diabetes – has reached epidemic proportions in most countries around the world. Worldwide, 63% of all deaths annually, an estimated 36 million people, are as a result of lifestyle diseases4. The proportion is much higher in the most developed countries – 88% of deaths in the UK and 87% in the USA for example5. Lifestyle diseases are projected to increase by 15% globally between 2010 and 2020. These diseases are often particularly costly to the individual and healthcare systems because of their chronic nature.
Lifestyle diseases are strongly associated with, and causally linked to, four behaviours: physical inactivity, unhealthy diet, tobacco use and the harmful use of alcohol. Up to 80% of heart disease, stroke and type-2 diabetes, and over a third of cancers could be prevented by modifying these behaviours4,6. If people were to undertake more self-care, the benefits to themselves, their families, and to the health systems that serve them would be enormous. However for this to happen there are significant challenges to be overcome.
Firstly people have to recognise what is healthy and unhealthy and, having recognised that they are at risk through their lifestyle choices, possess sufficient knowledge to know what action to take. With some behaviours (e.g. smoking) the risks are relatively well known and the action to be taken clear, however difficult. For others the judgements involved can be more difficult and influenced by evolving societal norms.
A warning lesson is provided by the trend towards the ‘normalisation’ of being overweight. A substantial proportion of overweight men and women think they are ‘about the right weight’7,8. Manufacturers of clothes have increased the space in clothes without changing the label size – ‘size inflation’ in clothing9. A recent study showed that 79% of parents of overweight children did not recognise that their offspring were overweight10, and of those who did, 41% did not perceive this to be a health risk.
The implication of evolving societal attitudes is that being overweight or even obese could become ‘normalised’, rather than approached as a serious but preventable personal and public health problem. People can only accept responsibility for their health if they can agree about what is unhealthy.
The medical consequences of being overweight are clear: the risk of coronary heart disease, ischaemic stroke and type 2 diabetes grows steadily with increasing body mass, as do the risks of cancers of the breast, colon, prostate and other organs. Chronic overweight contributes to osteoarthritis, a major cause of disability. Globally, 44% of diabetes burden, 23% of ischaemic heart disease burden and 7-41% of certain cancer burdens are attributable to overweight and obesity6.
Even when a problem is recognised, knowing how to deal with it can be demanding. People may recognise that they lead an unhealthy lifestyle through inactivity or an unhealthy diet, but may still struggle to know what action to take. Mixed messages in the mass media and the plethora of biased information online may contribute to lack of clarity about what constitutes a healthy lifestyle.
There is no shortage of sound, practical, evidence-based advice on healthy lifestyles11,12,13, but this guidance is often assumed to be aimed primarly at those with responsibility for supporting individuals to change behaviours, rather than to the individuals themselves. To be effective at a population level, these initiatives have to change societal attitudes to what is accepted as normal and this necessarily involves everyone11.
We suggest that an important part of this change is attitudinal and involves people accepting responsibility for their own lifestyle rather than devolving responsibility for their future health to health care professionals or the government.
ACCEPTING RESPONSIBILITY FOR SELF-CARE: THE MORAL GROUNDING
The moral imperative to keep healthy through self-care is based in part on responsibility to others, primarily:
1. Other users of public healthcare services i.e. to current and future patients, and
2. Future generations, including one’s own children.
Current and future patients.
In a resource-constrained healthcare system, medical treatment offered to one patient represents an opportunity cost to other patients with potentially more pressing healthcare needs. We have a duty to others whenever our choices impact on them. People leading healthy lifestyles and practising self-care for self-limiting conditions will consume fewer healthcare resources, leaving more capacity to treat those requiring those resources most.
People readily accept responsibilities that recognise the needs of others in many spheres of society. Cars and properties have to be maintained so as to be at least minimally safe with regard to others as well as to the primary user. Smoking bans in public spaces are now ubiquitous and widely accepted public health measures. The excessive consumption of alcohol, tobacco smoking, an inactive lifestyle or an unhealthy diet may all appear to be purely personal choices but as the cause of lifestyle diseases which consume a large proportion of constrained healthcare resources, their impact on others should be similarly recognised.
Parents have a major influence on the lifestyle habits of their children, making parents suitable agents for change14. Children of parents who engage in physical exercise such as sports, who try to eat ‘5-a-day’ fruit and vegetables and who do not smoke are more likely to be aware of, and adopt, healthy habits when they are adults (and parents) themselves.
There is also a need to improve parental self-awareness of their children’s health determinants. As mentioned, it is well documented that parents are often unaware that their child is overweight10,15, or that their child’s weight poses a risk to their health16,17. Parents are, at least initially, primarily responsible for the lifestyle choices of their offspring and therefore for the consequences of those choices.
POTENTIAL OBJECTIONS TO THE IDEA OF PERSONAL RESPONSIBILITY FOR HEALTH
The ‘nanny state’ argument.
One possible objection to governments (local or national) encouraging more individual responsibility for health is that this implies some interference with personal choice. However, the healthy person who takes no steps to avoid lifestyle diseases will ultimately consume more healthcare resources than someone leading a healthy lifestyle. These resources are not just scarce but are also commonly held, being publicly funded. It does not seem unreasonable for society as a whole to expect individuals to behave responsibly when they have the opportunity to do so.
Popular opinion seems to support this approach – in 2004, The King’s Fund, an independent think tank, conducted a survey of more than 1,000 people and found that most favoured policies that combatted behaviour such as eating a poor diet and public smoking18. The ‘nanny state’ argument may have lost some force given the positive results of self-care enhancing policies such as public place smoking bans, mandated vehicle seatbelt and motorcycle helmet use.
The budget argument.
Some critics have suggested that promotion of self-care is driven by the vested interest of governments to curb their healthcare budgets by shifting responsibility to the individual. But even if healthcare resources were abundant, people would still benefit personally from self-care. Within a financially constrained system, responsible use of resources is intrinsically important and has ethical weight. The disadvantaged in society may need more support to achieve self-care, but whatever their socio-economic status, giving the healthy the means and responsibility to take care of themselves frees resources to constantly improve the care of those that become ill. The moral imperative to conserve shared resources remains, irrespective of the size of those resources. And the moral imperative towards the next generation is much more than an issue of funding.
Objections on societal grounds.
There is a practical objection that placing duties or responsibilities upon people should take into account the societal context and external environment in which the individual lives. It is more difficult for an inner-city tower block resident to take exercise than it is for a person living near green spaces. There is a positive association between the density of unhealthy food outlets in a neighbourhood and the prevalence of overweight and obesity in children19.
It is clear that there may be structural circumstances that inhibit positive self-care behaviours, but these difficulties do not dissolve the responsibility for self-care. The disadvantaged in society may have particular difficulties in adopting a healthy lifestyle and will require more support from the community, and from the healthcare system, than those with more physical or financial resource available to them. Giving people the means to make healthy choices is a legitimate obligation for govenments and their agents. However this does not change the priniciple that ultimately the individual is responsible for the choices that they do make.
Goverments may try to ‘enforce’ self-care responsibilities.
An important question arises as to whether fulfilling self-care responsibilities will come to be seen as an expectation (assuming that monitoring behaviours is even possible).
Denying provision of healthcare services to people who have neglected to lead a healthy lifestyle would be highly contentious, and in the context of societal inequalities that skew the ability to adopt such a lifestyle, morally indefensible. Nevertheless, there are clearly adverse consequences for the individual who adopts an unhealthy lifestyle, apart from ultimate ill-health. Those that smoke or drink heavily pay considerable taxes in the process. If one seeks health insurance, smoking, drinking alcohol to excess and evidence of being overweight will all have a marked effect on the level of premium paid.
Disincentives to an unhealthy lifestyle therefore already exist, and are a legitimate tool of government policy.
DEVELOPING PUBLIC POLICY APPROACHES
Establishing the principle of individual responsibilities in health leads to the question of what mechanisms and supports could be provided to help people with a potentially challenging objective.
Some general policy directions are clear. Policies which focus on supporting positive behaviours in healthy people are more appropriate and useful than those which penalise sick people. Policies which are universal in their application are also likely to be better accepted than those that appear to target individuals. For example, if the evidence continues to mount for the role of sugar in causing obesity and diabetes, then a general ‘sugar tax’ has clear advantages compared with penalising the obese.
The influence of public policies on the ability of people to self-care is extensive. Self-care may be substantially outside the reach of health and social systems, but many government policy decisions have a bearing on the practice. The UN 2011 resolution on Noncommunicable Diseases, Article 3620 illustrates this:
…(We) recognize that effective non-communicable disease prevention and control require leadership and multisectoral approaches for health at the government level, including, as appropriate, health in all policies and whole-of-government approaches across such sectors as health, education, energy, agriculture, sports, transport, communication, urban planning, environment, labour, employment, industry and trade, finance, and social and economic development…
Many programmes and policies which impact on self-care and lifestyle behaviours have already been implemented around the world. However, the results of these programmes have not been assessed and organised systematically. A consolidation of programme documentation and outcomes would provide a valuable reference database for policymakers and programme managers, and provide the basis for planning a comprehensive, articulated research strategy. In addition to providing evidence for policy-makers, a systematic review of such data could help to identify practical ways and means which could help individuals to undertake lifestyle changes.
THE SELF-CARE RESPONSIBILITIES OF HEALTHY PEOPLE
We suggest that healthy people should aim to preserve and promote their own health and wellbeing so far as it is reasonably open to them so to do. They should follow a healthy lifestyle through being aware of, and following, health promotion guidelines. This means that they should eat a healthy diet and avoid inactivity. They should not put their health at risk, for example, through smoking or consuming excess alcohol. They should seek to understand the risk factors for chronic diseases particularly relevant to them, and address them as far as possible.
The healthy person should not put at risk the health and safety of others when this can be avoided. Examples include not smoking in spaces shared with others, good hygiene practices in hand washing, in food preparation and when coughing or sneezing.
It is the responsibility of a healthy person to consume healthcare resources in a responsible way and therefore to self-care whenever possible for self-limiting illnesses.
People should also promote health and wellbeing in their families, not least their own children. Examples include encouraging their children to exercise, teaching them about healthy and unhealthy foods, and having them vaccinated.
There are clearly many qualifications and reservations in these proposed responsibilities. Questions obviously arise as to the meaning of ‘aim to’, ‘avoidable’ and so on. However, these are questions of scope and extent, which are open to debate, rather than matters of principle.
Figure 1: A Self Care Manifesto: Responsibilities and Expectations in Self-Care.
A MANIFESTO FOR SELF-CARE
Taken together, the responsibilities of the individual can be seen as defining a ‘manifesto’ for self-care (Fig. 1). These responsibilities interact with, and are interdependent on those of healthcare professionals, and society as a whole, through government policy at a national and community level. This manifesto is proposed as an agenda and framework for discussion. There are gaps in our knowledge of what works in changing behaviour at the level of the individual and thus a clear need for research to underpin future policy within this conceptual framework.
The Declaration of Alma-Ata, the International Conference on Primary Health Care in 197821 stated that ‘The people have the right and duty to participate individually and collectively in the planning and implementation of their health care’.
To a large extent the maintenance of good health is not a ‘gift’ of a government or a healthcare system, but a ‘purchase’ that each individual makes by expending some effort. There is an urgent need to accept the duty we owe to ourselves and each other to maintain our health through self-care. A world in which we believe that we have important duties in this regard, even where they are difficult to achieve, will differ materially from a world in which we continue to delegate the responsibility for our health to others.
We propose the ‘Self-Care Manifesto’ as a conceptual framework to consider a new alignment of responsibilities, whereby the healthy assume the principal responsibility for maintaining their own health, and other agencies and resources work to enable this to happen.
Correspondence to: David Webber, International Self-Care Foundation (www.isfglobal.org),
Acknowledgements: The authors are grateful to Professor H. Martyn Evans for comments.
Statement of Interests: The authors have no conflict of interest relating to the publication of this paper.
Funding: The International Self-Care Foundation is a charity registered in the UK.
- The WHO constitution: http://www.who.int/governance/eb/who_constitution_en.pdf Accessed December 2014
- David Webber, Zhenyu Guo, Stephen Mann. Self-Care in Health: We can define it, but should we also measure it? SelfCare 2013;4(5):101-106.
- Evans HM. Do patients have duties? Journal of medical ethics. 2007;33(12):689-94.
- World Health Organisation. Global status report on noncommunicable diseases 2010. WHO 2011a. http://www.who.int/nmh/publications/ncd_report_full_en.pdf Accessed December 2014
- World Health Organisation. Noncommunicable Diseases Country Profiles 2011. http://www.who.int/nmh/publications/ncd_profiles_report.pdf Accessed December 2014
- World Health Organisation. Global health risks: mortality and burden of disease attributable to selected major risks. WHO 2009. http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf Accessed December 2014
- Duncan DT, Wolin KY, Scharoun-Lee M, Ding EL, Warner ET, Bennett GG. Does perception equal reality? Weight misperception in relation to weight-related attitudes and behaviors among overweight and obese US adults. The international journal of behavioral nutrition and physical activity. 2011;8:20.
- Johnson F, Beeken RJ, Croker H, Wardle J. Do weight perceptions among obese adults in Great Britain match clinical definitions? Analysis of cross-sectional surveys from 2007 and 2012. BMJ open. 2014;4(11):e005561.
- The Economist, daily chart, Size inflation 4th April 2012: http://www.economist.com/blogs/graphicdetail/2012/04/daily-chart-1 Accessed December 2014
- Saxena S, Laverty AA. Confronting child obesity in primary care. The British journal of general practice : the journal of the Royal College of General Practitioners. 2014;64(618):10-1.
- Public Health England: Everybody active, every day: a framework to embed physical activity into daily life. http://www.gov.uk/government/publications/everybody-active-every-day-a-framework-to-embed-physical-activity-into-daily-life Accessed December 2014
- NICE Guidance ph 49: Behaviour change: individual approaches. https://http://www.nice.org.uk/guidance/ph49 Accessed December 2014
- Knowledge and attitudes towards healthy eating and physical activity published May 2011. http://www.noo.org.uk/NOO_about_obesity/lifestyle Accessed December 2014
- Birch LL, Davison KK. Family environmental factors influencing the developing behavioral controls of food intake and childhood overweight. Pediatric clinics of North America. 2001;48(4):893-907.
- Rietmeijer-Mentink M, Paulis WD, van Middelkoop M, Bindels PJ, van der Wouden JC. Difference between parental perception and actual weight status of children: a systematic review. Maternal & child nutrition. 2013;9(1):3-22.
- Lampard AM, Byrne SM, Zubrick SR, Davis EA. Parents' concern about their children's weight. International journal of pediatric obesity : IJPO : an official journal of the International Association for the Study of Obesity. 2008;3(2):84-92.
- Park MH, Falconer CL, Saxena S, Kessel AS, Croker H, Skow A, et al. Perceptions of health risk among parents of overweight children: a cross-sectional study within a cohort. Preventive medicine. 2013;57(1):55-9.
- Coote A. Prevention rather than cure : making the case for choosing health. London: King's Fund; 2004.
- Cetateanu A, Jones A. Understanding the relationship between food environments, deprivation and childhood overweight and obesity: evidence from a cross sectional England-wide study. Health & place. 2014;27:68-76.
- United Nations General Assembly. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. 2011. Document A/66/L.1. http://www.un.org/en/ga/ncdmeeting2011/pdf/NCD_draft_political_declaration.pdf Accessed December 2014
- Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. http://www.who.int/publications/almaata_declaration_en.pdf Accessed December 2014