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Depending on the health challenge, adopting or maintaining particular health behaviours may be an appropriate approach to health management. Examples of this include dietary modifications or adhering to exercise regimes. For those who have demonstrated positive health behaviours throughout the life course, maintaining or upholding them may form their response to the health challenge. However, some individuals will be required to adopt new behaviours to manage their health in response to a new challenge. There is a gap in the literature assessing patterns of health behaviours across the life course in relation to health management. This thesis will address this gap by exploring associations between health behaviours in earlier adulthood and health management in later adulthood.

2.3.4.1 Adult health behaviours and health care utilisation

There is consistent research supporting an association between health behaviours and engagement with preventive health care. Individuals who attended a general health check - in a UK study of engagement with preventive health care - were more likely to report more positive health behaviours, such as not smoking, getting the recommended amount of sleep and participating in exercise (Pill et al., 1988). More recently, Dalton et al (2011) and Labeit et al (2013) also provided support for an inverse association between smoking and attending recommended health checks.

2.3.4.2 Pathways between health behaviours and health management

As indicated by life course models of health outcomes (Chandola, Clarke, Morris, &

Blane, 2006; Kuh et al., 1997), health behaviours are one of the factors in adulthood that influence individuals’ health in later life. They are also one of the potential mediators

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between other explanatory variables and health outcomes, as health behaviours are associated with education and SEP and other factors in adulthood.

Health status may mediate associations between adult health behaviours and subsequent health management. There is a large amount of longitudinal research demonstrating the relationship between poor health behaviours (including low levels of physical activity) across the life course and adverse health outcomes in later life (Andersen et al., 2000; Clennell, Kuh, Guralnik, Patel, & Mishra, 2008; Scarborough et al., 2011; Wang et al., 2014). Moreover, analysis of UK economic data has revealed that the diseases associated with poor diet, lack of exercise, smoking and alcohol consumption result in high levels of health care utilisation (Scarborough et al., 2011).

Certain health behaviours are associated with how individuals rate their health. Poor health behaviours, particularly smoking, low levels of physical activity and poor fruit and vegetable consumption are associated with poorer self-rated health in a sample of N=1691 British adults, using Office for National Statistics data (Wardle & Steptoe, 2003).

Self-rated health is likely to indicate how individuals interpret health events and whether they perceive them as a challenge or not, ultimately influencing how they will respond.

This suggests one possible pathway between health behaviours, adult health and health management in adulthood. Furthermore, Wardle & Steptoe (2003) also reported that smoking, low levels of physical activity and poor fruit and vegetable consumption were associated with lower likelihood of thinking about things to do to stay healthy, after adjusting for age, sex and self-rated health. Thinking about things to do to stay healthy is part of managing health and is one of the determinants of forming a response to a health challenge.

2.3.4.3 Women’s health behaviours and health management

Research shows that health behaviours demonstrated both throughout the life course and in midlife can impact how women experience and respond to the menopause. Health behaviours are particularly relevant to women’s health as the lifestyle habits a woman forms throughout her adult life have an impact on her reproductive health (Royal College of Obstetricians and Gynaecologists, 2011).

Health behaviours, particularly physical activity, are associated with menopause management. In the Melbourne Women’s Midlife Health Study (N=2001), Morse et al (1994) found that women who exercised weekly were more likely to utilise professional services throughout the menopause transition. However, in further analysis Morse et al (1994) differentiated between prevention related and problem related help-seeking and found that women who exercised were more likely to be prevention related utilisers,

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which involves attending health checks, such as cervical screening and mammogram.

This would suggest that women who exercise regularly may be more likely to take a proactive approach to managing their health, particularly regarding any potential future health risks.

2.3.4.3.1 Pathways between women’s health behaviours and management of symptoms in midlife

The pathway between health behaviours in earlier adulthood and women’s health management in midlife may be mediated by health-related factors, particularly symptomatology during the menopausal transition.

Findings on the impact of physical activity on symptoms during the menopause transition are mixed. Cross-sectional studies have reported the benefits of regular exercise for women during the menopausal transition. Women who exercise demonstrated higher levels of positive affect, lower negative affect, improved well-being (Dennerstein et al., 1994), improved mood (Slaven & Lee, 1997), better self-rated health (Dennerstein, 1996) and experienced fewer symptoms (Dennerstein et al., 1994). However, a review of the evidence concluded that results are mixed (Daley, Stokes-Lampard, & Macarthur, 2009), with one study reporting that physical activity actually increases the risk of severe vasomotor symptoms (Aiello et al., 2004). The logic behind this adverse effect on symptoms is plausible, as women are recommended to keep their body temperature cool to avoid bothersome hot flushes and avoid behaviours that raise the core temperature.

However, Daley et al's (2009) review concluded that there is a lack of high quality randomised controlled trials and that the findings of observational and cross-sectional studies are mixed and that results seem to vary according to sample size, many lacking statistical power, suggesting methodological limitations.

The literature is much more conclusive for the impact of smoking on women’s experience of the menopause. Cigarette smoking is consistently linked to the menopausal transition, which is likely to influence how women subsequently manage their symptoms. Smoking is associated with the timing of the menopause (Hardy et al., 2000; Torgerson, Thomas, Campbell, & Reid, 1997), symptom severity (Avis et al., 1997) and frequency (Dennerstein et al., 1993) and more erratic menstruation throughout the menopausal transition (Torgerson et al., 1997). Women who smoke are also more likely to use HRT during the menopausal transition (Torgerson et al., 1997), probably due to the impact smoking has on symptom severity. These results support the idea that the pathway between health-risk behaviours (ie, smoking) and management of symptoms in midlife is mediated by the experience of more bothersome symptoms.

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2.3.5 Personality, health beliefs and attitudes and adult health management

2.3.5.1 Personality and health management

Although there is a lack of literature describing a direct link between personality and health management approaches, it is plausible that certain domains of personality are related to an individual’s approach to managing their health. For instance, neuroticism and extraversion are associated with coping behaviours (such as appraisal of stressful events and coping resources) (Carver & Connor-Smith, 2010) and this may be particularly relevant for individuals who are required to manage chronic conditions, where coping with the demands of a condition is necessary for effective self-management. It is more likely that personality is associated with health management via a number of other adult health and social factors, some of which are included in this thesis. Personality is associated with health in adulthood through several mechanisms, including the relationship between personality and health behaviours, such as drinking and sexual activity (Cooper, Agocha, & Sheldon, 2000) and smoking (Munafo & Black, 2007).

2.3.5.2 Health beliefs and health management

The Health Belief Model (Rosenstock, 1974) predicts health behaviours (including responses to health challenges) depending on health beliefs including: the individuals’

perceived susceptibility to an illness; perceived severity of an illness; the perceived cost and benefits of a health behaviour, health motivation and self-efficacy. Health beliefs have been directly associated with several approaches to managing health, including self-management of chronic conditions (Berman & Iris, 1998), utilisation of health care services (Andersen & Newman, 2005) and adherence (Gherman et al., 2011). Moreover, health beliefs are associated with social class (Wardle & Steptoe, 2003), demonstrating one possible pathway by which health beliefs might be associated with health management. Individuals’ health beliefs may also be associated with the other factors discussed in this chapter as potential explanatory variables, particularly health behaviours, health status and health care utilisation, in terms of influencing health and health management.

2.3.5.3 Personality, health beliefs and attitudes and management of women’s health

Given that women’s experiences of health challenges and their subsequent management of health are different to that of men’s, it is worth considering the role of

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women’s personality, health beliefs and attitudes, concerning women’s health, including the menopause.

2.3.5.3.1 Personality and women’s experience of the symptoms in midlife A small amount of research has reported an association between particular personality traits, namely neuroticism, and women’s experience of symptoms and coping styles during the menopausal transition, which could contribute towards the pathway between personality and women’s health management. In an American randomised controlled trial, bivariate associations showed that neuroticism is strongly correlated with psychological symptoms (r=0.68), moderately correlated with somatic symptoms (r=0.33) and weakly correlated with sexual and vasomotor symptoms (r=0.18 and r=0.21 respectively) (Elavsky & McAuley, 2009); as discussed previously, women’s experience of symptoms is associated with how symptoms are managed, thus symptomatology may form part of the pathway between personality and management of symptoms in midlife.

A study of 170 American women found that finding the menopausal transition a stressful experience was weakly but significantly correlated with neuroticism (r=0.26) and although personality, on the whole, was not strongly correlated with most coping techniques, neuroticism was moderately associated with avoidance coping (r=0.41) (Bosworth, Bastian, Rimer, & Siegler, 2003).

2.3.5.3.2 Attitudes towards the menopause and management of symptoms in midlife

Women’s attitudes towards both the menopause and ageing are likely to influence the experience of the menopause and women’s response to symptoms throughout the menopausal transition. Attitudes are particularly relevant to the menopause as, for many women, the menopause is symbolic of the end of their reproductive life and signifies ageing. There is also a social stigma around the menopause and for many women the issue is a taboo subject, which may be reflected in negative beliefs and attitudes.

Attitudes towards the menopause are related to how women manage the menopause, as negative attitudes towards the menopause significantly predicted consulting a professional regarding menopausal symptoms and HRT use (Anderson & Posner, 2002).

Attitudes towards the menopause are likely to reflect an individual’s approach to managing the menopause, as taking a medicalised approach to treating menopausal symptoms or taking a holistic approach to coping with the menopausal transition using more behavioural techniques will depend on how the menopause is perceived.

There may also be an additional pathway between women’s attitudes towards the menopause and subsequent management of symptoms via experience of symptoms.

The evidence consistently supports the relationship between negative attitudes towards

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the menopause and more severe symptoms. This was demonstrated by a systematic review including studies from a wide range of cultures from Europe, North America, Central America and Asia, which reported that 10 out of the 13 studies reviewed found that negative attitudes towards the menopause were associated with higher prevalence of menopausal symptoms (Ayers, Forshaw, & Hunter, 2010).

Negative attitudes towards the menopause do not only predict vasomotor symptoms, but, in a large population based study, a higher prevalence of up to 22 self-reported menopausal symptoms were associated with both negative attitudes towards the menopause and towards ageing (Dennerstein et al., 1993). A similar list of 22 midlife symptoms was also used in NSHD. However, in cross-sectional studies, women’s attitudes towards the menopause may be influenced by their experience of symptoms, therefore it may not be possible to infer a causal association in one particular direction.

This is a limitation in the literature that this thesis aims to address by measuring attitudes before/at the beginning of the menopausal transition.

There are also sociodemographic differences in attitudes towards the menopause as negative attitudes towards the menopause have been associated with higher educational attainment (Avis & McKinlay, 1991), demonstrating an additional potential pathway (ie, higher educational attainment is associated with negative attitudes, which is associated with more symptoms) between women’s attitudes towards the menopause and how it is experienced and managed.

2.3.5.3.3 Health beliefs and women’s health management

Women are exposed to routine screening procedures throughout their adult lives; there is a large amount of research exploring the factors associated with mammogram and cervical screening attendance. Previous research has reported an association between women’s health beliefs and attendance to preventive health care procedures, specifically cervical screening. In a study exploring the barriers to cervical screening attendance, embarrassment, worrying about the pain involved and worrying about the possible results of the procedure were frequently cited reasons for non-attendance (Waller et al., 2009).

2.3.6 Family circumstances and adult health