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Introducing Health Baseline Comparison Theory

The term ‘health baseline comparison’ (HBC) refers to the baseline or comparison point which is used by people to evaluate their current health status. To determine whether health is ‘good,’ ‘bad’ or ‘indifferent,’ a comparison with a baseline is necessary. This baseline can be influenced by past health, social representations of health obtained from the media, comparisons with other people, or alternatively, consideration of current personal circumstances. All of these factors at any one time may play a role in the health baseline invoked. HBCs can be ‘accurate’ or ‘inaccurate’ (AHBC and IHBC, respectively). Comparisons between present and past health or with social idealisations of health may be less accurate, whereas consideration of current circumstances is more likely to produce perceptions of health status that might be more realistic. For example, changes in functional ability could be due to illness or ageing; therefore health baselines should naturally change throughout the lifespan and in accordance with any contracted illness or disability. Adapting HBCs in accordance with such inevitable changes could facilitate acceptance of uncontrollable health deteriorations; it could subsequently encourage individuals to behave according to actual health status, rather than to a possibly less realistic health status. To clarify the basis of HBC theory, an accurate health baseline is taking into consideration changes to health and adapting to these changes so as to enhance acceptance, adjustment and well-being. An AHBC may further contribute to informed decisions regarding health behaviours and potential treatment plans, which could be particularly important when patients are provided with a number of possible treatment options, as is the case with prostate cancer.

HBC theory has primarily been explored with participants who have Rheumatoid Arthritis (RA) (Davies and Kinman, 2006). The results revealed HBCs to have a significant influence on inconsistencies between subjective and objective health status, with IHBCs being linked to higher levels of depression and AHBCs to better psychological status. Individuals with AHBCs were subsequently better adjusted to RA, as was demonstrated through scores on the Arthritis Impact Measurement Scale (AIMS). These findings suggest that HBCs have significant implications for adjustment to illness, since the level of accuracy accounts for inconsistencies between perceived and actual health and therefore any subsequent psychological adaptations. HBC theory may therefore have applications in the quality of care provided to individuals with more chronic conditions that require permanent psychological adaptation, such as is the case with heart disease, fibromyalgia, and cancer.

The HBC approach is unique when compared to other quality of life research in that it encompasses both physical and psychological adjustment to illness, with an AHBC creating a more realistic perception of health circumstances and thus equipping an individual to make the appropriate physical and psychological adaptations.


THE RELEVANCE OF HBC TO ONCOLOGY


Due to an increase in the elderly population, changes in risk factors (e.g. smoking), and improvements in cancer screening and detection, there has been a gradual increase in the incidence of cancer. This group is therefore of high priority in the realms of health research. Further, earlier cancer detection and more effective treatments have led to a better five year survival rate for most cancers. Improvements in quality of cancer treatment have improved quality of life for cancer patients, yet they may still experience severely disabling, disfiguring and painful side-effects while receiving cancer treatment (Jacobsen et al., 1998). With this increase in incidence and survival rates, quality of life research is fundamental and it is believed that at the core of patient quality life lies HBC issues. Cancer patients may be confronted with permanent changes to their body image and energy levels, as well as impaired bowel, bladder and sexual functioning (Passik et al. 1995). With such a sudden and unexpected confrontation with a life threatening illness and its treatment, individuals may find that their emotional homeostasis is disturbed. AHBCs may play a key role in adjusting to the physical changes outlined above, as well as to achieving and maintaining emotional homeostasis.

A major problem in the assessment of long-term adjustment to cancer is distinguishing the physical and psychological effects of cancer from those that are due to ageing and comorbidities (Gotay and Muraoka, 1998). Many cancer patients are in the age range of 60 years or above when they receive their cancer diagnosis; they are also at an age when they are more likely to suffer from other physical problems, such as limited energy or mobility, and chronic diseases. This indicates the ideal application of HBC to cancer, where natural physical and mental changes due to age may be hidden by the diagnosis of cancer and its treatment. For example, a unique component of prostate cancer is that men are more likely to die with prostate cancer than from it. HBC theory addresses this component, with AHBCs having the potential facilitate the recognition of those changes that are due to age and those that are due to cancer or its treatment. This could subsequently enable the individual to adjust appropriately to both types of change they are confronted with. AHBCs could further enable individuals to distinguish between symptoms resulting from treatment and those that are cancer symptoms, potentially making treatment side-effects more tolerable and easing any anxieties and fears produced by these treatment side-effects.

When evaluating personal health status after a diagnosis, taking into consideration personal factors such as diet, lifestyle, mental well-being, and like, would be more ‘accurate’ than making comparisons with the health status of other people or those represented in the media. An example of why health evaluations based on social or media representations has been termed ‘inaccurate’ can be illustrated in Saywell et al.’s (2000) analysis of media representations of cancer in Britain. This analysis revealed that breast cancer was featured seven times more often than lung cancer, even though lung cancer kills approximately the same number of women as breast cancer. Representations of breast cancer featured young women more often than older woman, even though it is experienced more often by older women. Breast cancer was further represented by a focus on sexuality and maternity, regardless of statistics that indicate breast cancer is more common in post-menopausal women. Media images were also inclined to show women as martyrs who were struggling on for the sake of their husband and children, this being a potential detriment to the acquisition of natural coping processes relevant to the individual experiencing breast cancer. Health baselines influenced by such media images have implications for the development of more realistic perceived health status or adjustment to the illness. It is also not productive to the meanings individuals attribute to the cancer experience, this being important in the context of the breast cancer (Collie and Long, 2005); nor to necessary health baseline adjustments after diagnosis and throughout the treatment process.

A recent example of the dangers of IHBCs based on media representations can be seen in the way the singer, Kylie Minogue’s, battle with cancer has been portrayed. Individuals who turn to Kylie Minogue for comparative purposes may expect themselves to bounce back from their treatment quickly, as has been represented in Kylie Minogue’s quick return to the stage (BBC News, 2006). Even if Kylie Minogue had not made such a rapid recovery, this could have become a baseline for individuals to believe that if someone famous and wealthy is faced with such illness difficulties, then they surely will. Although the media surrounding Kylie Minogue’s experience of cancer was beneficial in raising awareness, when employed for comparative purposes there is the potential for many implications. Whatever image is represented in the media, positive or negative, if adopted as a HBC it is unlikely be productive to individual adjustment to personalised experiences of cancer.

Another HBC termed ‘inaccurate’ is comparisons with other cancer patients. Such comparisons could be viewed as a positive way of finding a sense of identification or of gaining a better understanding of how to cope with the illness. However, upward and downward comparisons (Hagopian, 1993), making comparisons with those who are better or worse off respectively, raises doubts as to the effectiveness of such methods of evaluating personal health status. For example, radiation patients may make a downward comparison with chemotherapy patients and believe they are ‘better off’ because chemotherapy represents a more severe cancer. Alternatively, they may make such comparisons and become fearful of what the future holds. In this instance they are not taking into consideration that they are not their comparator and they do not have the same health baseline as their comparator. Factors such as severity of illness, susceptibility to illness, consequences of illness, and other illness perceptions included in Leventhal et al.’s (1980) self-regulatory model, as discussed further in the literature review, need to be considered when creating a HBC. They are also factors that are likely to be less accurately assessed when comparisons with other patients are taking place.

Further reasoning for why it is important for cancer patients to be encouraged to use their own health baselines rather than looking to others for health evaluations is that lay persons and medical professionals have been found to overestimate the degree of psychological distress associated with cancer treatment (Buick et al., 1996). Further, physicians have been found to overestimate levels of anxiety in patients. This illustrates that if patients were to look to others for a baseline of how they should be feeling, coping or experiencing the illness, they could be confronted with stigmatised baselines that could hinder their adjustment to the illness and its treatment by possibly making them feel pressure to be more anxious than they are.

Comparisons with others, both those with and those without cancer, are a real concern within oncology. Crisis Theory (Moos, 1986) supports the notion that people are especially receptive to outside influences at times of change and uncertainty, making the experience of cancer a likely time when social comparisons and other IHBCs are likely to take place. It could be that the greater the crisis, the greater the outside influences. Cancer is most certainly a time of significant crisis. This is not only a crisis in regards to heightened awareness of mortality, but also in regards to necessary changes in goals and meanings attached to life. It is also likely to be a unique experience to the individual in that it is new and no baseline is available for it. When confronted with an experience that has not been encountered before, an individual may search for a sense of familiarity via the development of a baseline for the monitoring of this unique experience. This is another way in which the cancer experience can increase vulnerability towards IHBCs in the form of comparisons with others.

IHBCs may interfere with an individual’s ability to interpret and understand the illness and treatment experience, promoting emotion-focused disengagement-style coping (Tobin et al., 1989). This style of coping has been found to be related to more anxiety and depression in breast cancer patients (Osowiecki and Compas, 1999) since it often results in social withdrawal and self-criticism. In contrast, AHBCs may enhance an individual’s ability to interpret and understand the illness and treatment experience, equipping an individual with a more realistic idea of what is being contended with and what action needs to be taken physically and emotionally in order to cope with and adjust to the illness. Whether an AHBC results in a positive or negative interpretation of personal health circumstances, the interpretation is more realistic and therefore more likely to be coped with via acceptance. Acceptance coping has been found to be a strong and consistent predictor of positive outcomes (Park, Cohen, and Murch, 1996; Pruchno and Resch, 1989), especially when a stressor cannot be changed and must be accommodated (Carver et al., 1993). In fact, one if the most difficult decisions a person can be confronted with is the choice of not having treatment in order to maintain quality of life. When such decisions are available, an AHBC may facilitate the making of such a decision by enhancing an individual’s ability to more accurately contemplate their future with and without treatment.


THE POTENTIAL BENEFITS OF HBC TO ONCOLOGY


Much of the literature surrounding cancer highlights the negative aspects of the experience, but there is a growing realisation that cancer may have positive consequences. For example, in such a period of uncertainty, patients may search for meaning and reconsider their priorities and values (Taylor, 1983). This could lead to positive life changes prompted by and attributed to cancer. As was shown in the BBC4 documentary ‘Bosom Buddies’ (2006), one lady admitted that before breast cancer all she used to do was work; after breast cancer she started to enjoy life. HBC theory aims to strengthen this new positive perspective by illustrating that cancer can be accepted and adjusted to from this grounded baseline, and that this can further enhance quality of life in what can be viewed as a new era in one’s life.

The personal accounts outlined at the beginning of the introduction are experienced by the majority of cancer patients, yet there are those individuals who do not experience cancer as being this distressing and who don’t feel overwhelmed by it. This is where HBCs may play a role in improved quality of life. The images described were patient’s expectations, often based on publicity and social comparison, of how cancer will be experienced. With the adoption of personal interpretations implicit to the individual, a cancer patient may be more likely to experience some of the following attitudes:

“I just wasn't reacting in this 'shock, horror' way that most people anticipate.” (Interview 19, Dipex).

“I just sort of thought: ‘Well, you've got it girl. Let's just get on with it. Let's get this sorted, get the next 12 months over with and then get back on with your life,’ really.” (Interview 23, Dipex).

-- 17:15, 14 May 2007 (UTC)


REFERENCES


BBC News (2006) Kylie returns to stage in Sydney. ''http://news.bbc.co.uk/1/hi/entertainment/6135564.stm.''

Buick, D.L., Petrie, K.J. & Probert, J. (1996) Illness beliefs, coping and emotional distress: How do healthy women and medical staff perceive women with breast cancer? In ''Perceptions of health and illness: Current research and applications'' by Petrie, K.J. and Weinman, J. (1997), 379-404, Published by Psychology Press.

Carver, C.S., Pozo, C., Harris, S.D., Noriega, V., Scheier, M.F., Robinson, D.S., Ketcham, A.S., Moffat, F.L., & Clark, K.C. (1993) How coping mediates the effects of optimism on distress: a study of women with early stage breast cancer. ''J Pers Soc Psychol'' 65: 375-390.

Collie, K. and Long, B. (2005) Considering ‘meaning’ in the context of breast cancer. ''Journal of Health Psychology'', Volume 10, No. 6, pp. 843-853.

Davies, N. and Kinman, G. (2006) Health baseline comparison theory: Adjustment to rheumatoid arthritis. ''Health Psychology Update,'' Vol. 15, Issue 3, pp. 31-36.

Gotay, C.C., Muraoka, M.Y. (1998) Quality of life in long-term survivors of adult-onset cancers. ''JNCI'' 90(9): 656-667.

Jacobsen, S.J., Bergstralh, E.J., Katusic, S.K., Guess, H.A., Darby, C.H., Silverstein, M.D., Oesterling, J.E., Lieber, M.M. (1998) Screening digital rectal examination and prostate cancer mortality: a population-based case-control study. ''Urology'' 52(2):173–9.

Moos, R.H. (1986) ''Coping with Life Crisis: An Integrated Approach.'' Plenum Press: New York.

Osowiecki, D. M. and Compas, B.E. (1999) A prospective study of coping, perceived control and psychological adaptation to breast cancer. ''Cognitive Therapy and Research'', Vol. 23, No. 2, pp. 169-180.

Park, C.L., Cohen, L.H. and Murch, R. L. (1996) Assessment and prediction of stress-related growth. ''Journal of Personality,'' 64, 71-105.

Passik, S.D., Newman, M.L., Brennan, M., Tunkel, R. (1995) Predictors of psychological distress, sexual dysfunction and physical functioning among women with upper extremity lymphedema related to breast cancer. ''Psycho-Oncology,'' 4:255–63.

Taylor, S.E. (1983) Adjustment to threatening events: a theory of cognitive adaptation. ''Am Psychol'' 38: 1161-1173.

Tobin, D.L., Holroyd, K.A., Reynolds, R.V., & Wigal, J.K. (1989) The hierarchical factor structure of the Coping Strategies Inventory. ''Cognitive Therapy and Research'', 13, 343-361.