Elsevier

Social Science & Medicine

Volume 63, Issue 9, November 2006, Pages 2341-2353
Social Science & Medicine

Economic rationality and health and lifestyle choices for people with diabetes

https://doi.org/10.1016/j.socscimed.2006.06.007Get rights and content

Abstract

Economic rationality is traditionally represented by goal-oriented, maximising behaviour, or ‘instrumental rationality’. Such a consequentialist, instrumental model of choice is often implicit in a biomedical approach to health promotion and education. The research reported here assesses the relevance of a broader conceptual framework of rationality, which includes ‘procedural’ and ‘expressive’ rationality as complements to an instrumental model of rationality, in a health context.

Q methodology was used to derive ‘factors’ underlying health and lifestyle choices, based on a factor analysis of the results of a card sorting procedure undertaken by 27 adult respondents with type 2 diabetes in Newcastle upon Tyne, UK. These factors were then compared with the rationality framework and the appropriateness of an extended model of economic rationality as a means of better understanding health and lifestyle choices was assessed.

Taking a wider rational choice perspective, choices which are rendered irrational within a narrow-biomedical or strictly instrumental model, can be understood in terms of a coherent rationale, grounded in the accounts of respondents. The implications of these findings are discussed in terms of rational choice theory and diabetes management and research.

Introduction

The economist who truly believes in individual rationality is as much a fiction as homo economicus himself. (Krugman, 1998, p. 111)

Although the rationality principle is fundamental to economics, the familiar character of rational economic man—a maximising, consequentialist individual—has been frequently questioned by those in the profession (Hargreaves Heap, 1989; Hargreaves Heap, Hollis, Lyons, Sugden, & Weale, 1992; Renwick Monroe, 2001; Vanberg, 2004). Much of this critique has been either theoretical (Renwick Monroe, 2001; Zafirovski, 2000) or stemmed from experimental studies to determine whether individuals’ choices are consistent with an economic definition of rationality—usually the axiomatic definition represented by expected utility theory (EUT) (Schoemaker, 1982). Results commonly show such axiomatic models of rationality to be descriptively lacking with consistent violations of the underlying axioms (Schoemaker, 1982; Starmer, 2000; Sugden, 1991) (although some argue that they continue to have normative relevance (Baron, 1996)).

Hargreaves Heap (1992) uses the term ‘instrumental rationality’ to distinguish this tradition of rationality in economics from two others he describes; procedural rationality and expressive rationality. Whilst acknowledging the importance of instrumental rationality, he argues that this represents an incomplete picture. Choices are not only about achieving the best possible outcome but are often influenced by a range of other factors such as social norms and institutions, short cuts and rules of thumb, values and internal conflict.

The research reported in this paper uses Q methodology to examine the relevance of this alternative framework of economic rationality to choices made in a health context. The setting for this study is the health and lifestyle choices of people with type 2 diabetes.

The remainder of this paper is organised in six main sections: the rationality framework is described first and is followed by an introduction to the main characteristics of type 2 diabetes. A summary of Q methodology is then provided before presenting the main body of the paper in terms of the research methods, findings and discussion.

Section snippets

The rationality framework

Hargreaves Heap (1989) questions the consistent and exclusive allegiance to a model of instrumental rationality in economics. He presents an alternative, tri-part picture of rationality, incorporating procedural and expressive forms, drawing on areas of economic theory and literature in order to illustrate his arguments. As such the concepts are not new ones, but he provides a structure for those concepts, identifies differentiating features and commonalities, and supplies a terminology to

The research context: Type 2 diabetes

Type 2 diabetes is a common and growing health problem (World Health Organisation, 2002) Current treatment of type 2 diabetes focuses on the self management of health and lifestyle (Diabetes UK, 2003). Typically, self management programmes comprise advice about diet, exercise, smoking and alcohol consumption together with blood glucose monitoring and possible medication, in order to control blood glucose levels and delay or prevent adverse events (e.g. blindness, renal failure or death).

Methods: Q methodology

Q methodology (Stephenson, 1953) combines qualitative and quantitative methods (Brown, 1996) in the study of ‘subjectivity’. It is appropriate to questions about personal experience (McKeown & Thomas, 1988) and matters of taste, values and beliefs (Stainton Rogers, 1995). Whilst there are several applications in the health field (Eccleston, Willams, & Stainton Rogers, 1997; Risdon, Eccleston, Crombez, & McCracken, 2003; Stainton Rogers, 1991) it is little known in health economics (Baker,

Findings: the factors

A three factor solution emerged4 and factor loadings are shown in Table 3. Of 27 Q sorts, there are three ‘null’ cases (i.e. Q sorts which do not load significantly on any of the three factors) and five confounded sorts (loading significantly on more than one factor).

In the three subsections which follow, each factor

Rationality and diabetes management

This rationality framework has not been applied before in the area of health, and the concepts within it have enabled a new understanding of different types of lifestyle choices and the factors which are important to those choices. The application of rationality in a health context is interesting because the narrow biomedical approach to health choices has much in common with an instrumental rationale; relating cause and prevention, disease and cure in an outcome-oriented manner. This is, of

Acknowledgments

This study was funded by the MRC Health Services Research Collaboration as part of a doctoral studentship. This paper was written while the author was funded through an ESRC postdoctoral fellowship (Ref.: PTA-027-26-0107). I am indebted to the respondents who gave up their time to participate in this study; to my Ph.D. supervisors, Senga Bond and Linda Davies; to session participants at the 20th annual meeting of the International Society for the Scientific Study of Subjectivity 2004; and to

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