A scoping review of individual health responsibility: A context-base concept

Abstract

BACKGROUND:

Individual health responsibility plays an important role in maintaining and improving people’s health. There are controversial opinions related to this concept. This study aimed to investigate controversial opinions related to individual health responsibility and familiarize researchers and policy makers with the available evidence and gap of knowledge in the recent years.

MATERIAL AND METHOD:

This paper is a scoping review. The five-step approach of Arksey and O’Malley was used to review the relevant literature from the beginning of 2017 to the end of 2022. The search was done in the PubMed, Embase, Scopus, web of sciences, Cochrane databases, and Google Scholar search engine using the English keywords “health responsibility” AND “individual” OR “personal”.

RESULTS:

All articles and theses related to individual health responsibility, which were in English and had access to their full text, were included in the study. After a 2-stage screening for 1,412 articles and theses, 32 were included in the study. The findings indicated that most of the studies were conducted in developed European continent. The published articles included a wide range of quantitative, qualitative, and mixed research, and acute and chronic diseases have been considered in this field.

CONCLUSION:

Individual health responsibility is a multidimensional concept that is influenced by individual, social, and cultural factors, and emphasizing it can have both positive and negative effects on people’s health. To the concept be effective in health promotion, it is important to pay attention to individual and social context, health status, and community and health policy makers views about individual health responsibility.

Introduction

Evidence suggests that unhealthy behaviours play a major role in deaths in lifestyle-related diseases, and about 40% of premature deaths can be prevented by lifestyle changes.[1,2] This has made individual health responsibility one of the most important issues in the field of health and self-care in recent years.[2,3] Individual health responsibility is defined as a daily, gradual, and personalized process experienced by an individual and unique to each task related to self-care.[2] It involves people’s choices to accept, perform, and follow-up on actions regarding daily activities in helping to improve their health status.[4,5] Although the existence of individual health responsibility is one of the concepts discussed in the field of healthcare in this century, its dimensions and form are unclear and there are conflicting opinions about this concept.[2,6] Some researchers believe that individual health responsibility is an important factor in the promotion and maintenance of health.[2,7] In contrast, others believe that people can only be held responsible for activities they can freely avoid, and this does not include health-related issue.[8] Friesen (2018) believes that paying attention to health responsibility is an obstacle in implementing fair health policies.[9] Despite obstacles such as health costs, limited access to resources, and ethical issues, some believe that people’s level of responsibility is limited in the choices they make on their health path.[10,11,12]

Social change and civil liberties in recent decades have made people willing to choose different lifestyles and not just accept predetermined protocols and training. In recent centuries, people, as activists, have taken responsibility for their health and apply health-related behaviours to themselves according to the knowledge and facilities available in the society. It seems that in many situations, their performance in relation to their health plays a more important role than the actions of the responsible institutions in maintaining the health of the society.[4,13,14]

In the future, the world will need people who take responsibility for their health given the increasing prevalence of chronic diseases and the rising costs of health systems.[4,15] Governments will need to adopt approaches in which people are empowered to take responsibility for their health and actively play a role in choosing healthy lifestyles.[4,16] To achieve these goals, it is important to conduct further research on individual health responsibility. Because more evidence can help clarify the dimensions of this concept and resolve conflicts and help health policy makers to choose the best approaches to promote individual health responsibility.[9,10,11,12] Conducting scoping review research can be a good guide for researchers in conducting further research due to the identification of existing evidence and knowledge gaps. For this purpose, this study was conducted to investigate controversial opinions related to this concept and familiarize researchers and policy makers with the available evidence and gap of knowledge.

Materials and Methods

This scoping review was conducted to investigate opinions related to this concept of individual health responsibility and acquaint researchers and policy makers with the existing knowledge. Scoping review is one of the review studies that can investigate the extent, scope, and nature of research activities to determine the value of conducting a complete systematic review, summarizing and publishing research findings, and identifying research gaps in the existing literature. Arksey and O’Malley’s five-step approach was chosen to conduct this study. These steps include 1) identifying the research question; 2) identifying relevant studies; 3) study selection; 4) charting the data; 5) collating, summarizing, and reporting the results.[17,18]

• Step 1) identifying the research question

  Thus, in the first step, after discussing and exchanging opinions, the research team raised the following research question:

  “What knowledge is available in the field of individual health responsibility?”

• Step 2) identifying relevant studies

  To find relevant studies, first a brief review of existing studies, MESH terms, and Emtree terms was done to select the best keywords for the search. Then, with the help of English keywords “health responsibility”, the search strategy was set. To find articles and theses in English, English databases PubMed, Embase, Scopus, Web of Sciences, and Cochrane were searched without time limit by two researchers separately. To complete the review, hand search of studies from Google Scholar search engine, review of the list of sources of highly relevant articles, and key journals was also done. Due to the large number of articles, of published articles and to identify gaps in the latest published knowledge, a time limit was applied from the beginning of 2017 to the end of 2022.

• Step 3) study selection

  In the third step, to select relevant studies, the titles and abstracts of all obtained articles were studied and related items were selected for full-text review. Oral presentations were excluded from the scope of the search. Then, English articles that focused on individual health responsibility that full text was available were included in the study. The disagreement of researchers regarding the selection of articles was discussed in the research team and a decision was made about them as a team Figure 1

• Step 4) charting the data

  In the fourth step, the data were extracted from the selected articles based on the table prepared by the research team and displayed in the form of a table.

• Step 5) collating, summarizing, and reporting the results

  In the last step, the findings were summarized and reported.

Figure 1.

PRISMA flow diagram for the scoping review process

Results

The result of the initial search in electronic databases and hand search was 1,412 articles and theses. After removing duplicate studies and reviewing the title and abstract of the texts based on the inclusion criteria, 33 articles were selected to full-text study and finally, 32 articles were chosen for reporting into study [Table 1].

Table 1.

Characteristics of the included articles

Methodology	Country	Study questions/objectives/assumptions	Year	Author
Content and thematic analysis	New Zealand	Analysis of Media Framework cause and solution to attribute responsibility in diabetes discourse	2017	Gounder and Ameer
Phenomenological study	Sudan	Investigating the nature of fateful beliefs among Coptic Christians and Sunni Muslims, and how these beliefs affect the health of diabetic patients.	2017	Hamed and Daniel
Cross-case analysis	Denmark	Determining how health management is applied to body weight management in three welfare institutions with a look at traditional social intervention and neoliberal ideology	2018	Vitus et al.
Mixed method	Sweden	Applying quantitative approaches to understand people’s views on health and responsibility at different ages	2018	Kjellström and Hudson
Mixed method	Netherlands	To focus on a downside of workplace health promotion programs, due to a focus on individual health responsibility.	2018	täuber et al.
Argument	Australia and UK	Satisfying the epistemic conditions for taking responsibility	2018	Levy
Argument	Netherlands and USA	How does the structure of society affect health and what is the responsibility of the community to deal with health inequalities?	2018	Ismaili M’hamdi et al.
Anthropological examination	USA	To discuss about hiv/aids care policy in relation to Indiana’s alternative Medicaid expansion plan	2018	O’daniel
Argument	Canada	Consideration of health inequalities fairness caused by individual ’s choices by opposing Rawlsian and luck-egalitarians views of responsibility	2018	Kniess
Argument	Denmark	Evaluates the acceptance of personal responsibility from the look of luck egalitarianism	2019	Albertsen
Novel approach	UK	1- To discuss how different approaches to health promotion through behaviour change highlights the role of individual responsibility 2- To investigate philosophical and ethical aspects of allocations of responsibility.	2019	Brown et al.
Survey	Australia	To assess relationship between participants’ political orientation, personal responsibility, and their physical health	2019	Chan
A multi-phase development method	Finland	Documentation of the preliminary testing of a scale to measure adolescents’ rights, duties, and responsibilities in relation to health choices.	2019	Moilanen et al.
Cross-sectional	Norway	Examination of the public’s attitudes towards personal and social health responsibility	2019	Traina et al.
Special section: argument	Sweden	Description of qualifications and the restriction of individual and population centered sensitive theories of distributive justice	2020	Bognar
Special section: argument	UK	To what extent there is a need to hold patients accountable for their health and to discipline them accordingly.	2020	Clavien and Hurst
Descriptive	Malaysia	Investigation of the relationship between active aging and health promotion among orders	2020	Loke et al.
Semiotic approach	UK	A semiotic and thematic analysis of a British medical reality show to investigate whether it may contribute to the anthropological understanding of oral health and social status	2020	Holden et al.
Qualitative interview study	Norway	Contribute to knowledge about the empirical relevance of personal responsibility for clinical prioritization.	2020	Traina and Feiring
Mixed method	China	The use of top Chinese media organizations and mental health organization of a social media platform, to define responsibilities of depression with a causal and problem-solving approach.	2020	Zhang et al.
Survey	Norway	Exploration of people’s attitudes toward responsibility in the allocation of public health care resources.	2020	Cappelen et al.
Perspective	USA	An investigation on Universal health coverage, oral health, equity and personal responsibility	2020	Wang
Argument	USA	Examine the extent to which deeply rooted cultural stories about “free choice” and “personal responsibility” permeate policy making, advertising, media, social norms and personal attitudes toward health	2020	Hook and Markus
Descriptive qualitative	Iran	Explore the experiences and views of colorectal cancer survivors and health care providers regarding health promotion among colorectal cancer survivors.	2021	Ramezanzade Tabriz et al.
Interview study, Phenomenographic analysis	Sweden	To analyse general practitioners’ perceptions of the concept of Individual health responsibility	2021	Björk et al.
Content analysis	Iran	To recognize adolescence’s components of a healthy lifestyle	2021	Khosravi et al.
Mixed methods	Poland	Identify the role of health responsibility in predicting risk driving style in a group of young adults.	2021	Kulik et al.
Argument	South Africa	Exploring the emphasis on taking Individual health responsibility by examination of the south African government’s response to covid-19	2021	Patel and Graham
Systematic review	Germany	To show an overview of the current state of research on responsibility frames	2021	Temmann et al.
Mix method	Macao	To Explain how audiences’ perception of Individual health responsibility is formed by COVID-19 information consumption on social media and to analyse the leavening role of health orientation in the relationships between COVID-19 information consumption on social media, personal responsibility, and preventive behaviours	2021	Liu
Thematic analysis	Norway	Investigating how Individual health responsibility is framed and rationalized priority setting in Norwegian key policy documents	2022	Traina and Feiring
Thesis survey	USA	To determine the relationship between causal attributions for COVID-19, emotional responses, and related policy support of COVID-19	2022	Cox

• Findings by Location

  The issue of individual responsibility for health in the European continent has been considered more than the rest of the world, so that more than half of the studies are devoted to European countries. Norway with four articles and Sweden and the United Kingdom with three articles have the highest number of articles in this field. A total of five papers have been published in the continental United States, with four articles ranked first in the continent on individual health responsibility. Five papers have been published in China, Malaysia, Macau, and Iran on the Asian continent, two of which belong to Iranian researchers. Africa and Oceania each have two published articles.

• Findings based on Human Development Index

  The Human Development Index (HDI) is a summary measure of average progress in key dimensions of human development: living a long and healthy life, knowledge, and having a decent standard of living.[19] Considering the important role of individual health responsibility in having a healthy life,[3] as well as the highlighting of developed countries in dealing with this concept in results, the HDI was used in the report of the results of this study. Developed countries have dealt with health responsibility more than other countries in the world, so that 25 studies have been conducted in countries with very high levels of human development. Two papers relate to countries with high indexes, one in countries with low indexes. Three articles relate to countries not included in the HDI index rankings.

• Findings based on the study methodology

  The findings indicate that addressing the issue of individual health responsibility has been done through quantitative, qualitative, and mixed approaches. In some studies, the type of methodology has not been clearly stated and seven articles have been published as arguments. Among the papers, five papers have been devoted to mix method and multiphase development method.

  Quantitative research has been done through surveys and descriptive correlational studies. Among the published qualitative studies, the variety of methodology is more and the design of this research was anthropological examination, phenomenological study, cross-case analysis, exploratory, cross-sectional, phenomenographic analysis, content analysis, and thematic analysis. A systematic review article has also been done in the field of health responsibility.

• Findings based on types of diseases

  Some studies have been conducted in the field of a specific disease. HIV virus infection, chronic diseases including heart and respiratory diseases, diabetes, obesity, depression, cancer, oral and dental health, and COVID-19 infection are some of the issues discussed in individual health responsibility.

Discussion

The purpose of this study is to investigate the existing knowledge in the field of individual health responsibility and knowledge gaps. The findings indicate that the existing literature in the field of individual health responsibility have focused more on two areas. A group of these studies have focused on health responsibility as a personal belief in people and a group have also examined this concept in terms of ethical, social, media, and health policy maker’s aspects.

Some studies have investigated the relationship between different personal or social characteristics of people with the level of individual responsibility for their health. With the aim of determining the effectiveness of various personal beliefs and characteristics as well as the social actions and reactions of people, these studies try to determine the dimensions related to people’s adherence to individual health responsibility.

In terms of age, adults and young-olds were more willing to talk about individual health responsibility than other age groups. This shows that engaging children, adolescents, and seniors in taking individual health responsibility is a challenge that needs to be addressed.[20,21] In Iran, Khosravi has concluded that individual responsibility for health is one of the components of a healthy lifestyle for teenagers.[22] As Loke et al. concluded, there is a significant relationship between work and individual health responsibility in the seniors. In this way, although less than a quarter of the seniors showed positive individual health responsibility, nevertheless active seniors (seniors who go out or are employed) are more likely to have individual health responsibility.[23] On the other hand, if the responsibility of young people’s health is transfered to another person (doctors, nurses, teachers, or family), their risky driving behaviours will decrease.[24] These results indicate that young adults have difficulty at taking individual responsibility for their health.[4] There is also a special emphasis on women’s health responsibility.[25]

Teman et al. believe that individual health responsibility is often discussed in the case of noncommunicable diseases and is divided into controllable and uncontrollable cases. In this regard, the most important health challenges that have been addressed were diabetes, oral and dental diseases, depression, cancer, and especially obesity or behaviours related to weight control.[25,26,27,28,29,30,31] In a study conducted during the COVID-19 pandemic, people’s understanding of the responsibility of individual health in the face of COVID-19 was also high.[14]

Hamed and Daniel 2017 have discussed this issue from the perspective of religion and the meanings of fatalism among Coptic Christians and Sunni Muslims. They concluded that although the view of religious fatalism leaves everything in the hands of God, but consider people responsible for their health behaviours.[29] Regarding political orientation, Chen’s study found that politically conservative individuals have more individual health responsibility and exhibit more health behaviours compared to their liberal counterparts.[32]

For most people, individual health responsibility is an abstract ideal concept that makes them more willing to take responsibility for social health. But this issue does not negate the desire to have individual health responsibility.[33] As in Cappelen et al.’s study, most of the participants believed that if they choose an unhealthy lifestyle, they should accept responsibility for it.[34] Physicians also believe that the source of individual responsibility for health can be within the patients themselves, formed in relation to their relatives or doctors, or seen as part of their civil duties. Also, the form of expression or action based on it is also different, so that it includes a spectrum from the attitude of “ownership of the problem” to actions that indicate the acceptance of help and support in health.[26] Patel and Graham also believe that health risks are never objective and are considered a kind of subjective experience. For this reason, the type of encountering people with it is very different.[35] During the COVID-19 pandemic, people were significantly angry and unsympathetic toward people who had low individual responsibility for their health and considered themselves less similar to these people in terms of personality traits.[14]

Creating health habits and feeling good, thinking about health and wanting to improve it, and adopting explicit normative attitudes to take care of one’s health are mentioned as three dimensions influencing individual health responsibility.[20] For example, people who avoid fast driving and have low-risk driving habits show greater individual health responsibility.

There is also a strong correlation between the lack of individual health responsibility and the development of dental diseases, which can be related to the habit of taking care of the teeth.[4,28] In this regard, people who were more used to using information published on social media about COVID-19 had a better and greater understanding of individual health responsibility.[36] It is important to note that individual responsibility for health is a spectrum that is constantly changing throughout each person’s life and can be influenced by factors beyond people’s understanding.[33,37] Creating and publication scientific knowledge about the effect of these factors creates responsibility for other parties such as health institutions in the public and private arenas.[37] In fact, researches emphasize that every person has prudent and rational reasons for taking care of their health and assigning this responsibility to people can play a good role in improving their health.[11] Nowadays, it is not logical to emphasize only the concept of individual responsibility for health. Rather, it is necessary to pay special attention to the establishment of laws and ethical frameworks related to this issue to balance the responsibility toward people in terms of health.[38,39] This discussion has become more important since the priority of receiving care and treatment costs have been raised as a challenge.[25] Awareness of the fact that chronic and progressive diseases are the main burden of global health challenges and also, awareness of theories sensitive to individual responsibility for health in the justice of distribution and allocation of health facilities play a special role in finding the importance of this discussion.[12] Some researchers believe that the positive and preventive role of individual health responsibility should be emphasized more than its role in contracting diseases or getting stigmatized due to not taking care of one’s health.[37] Doctors in Traina and Firing’s study also confirmed individual responsibility for health as a principle in people’s health, but they did not want to introduce it as an official criterion that would play a role in determining priorities for receiving care. Because they believed that despite the fact that holding patients accountable for their behaviour helps the efficient use of healthcare resources, using it as a determining factor in receiving health services is a harsh, unfair, and stigmatizing practice and leads to avoidance of people to receiving care.[38] This matter has been raised in the field of occupational health of people in the same way.[40] In the study by Cappelen et al., few participants gave the healthcare system the right to boycott people for voluntary behaviours that increase the risk of developing the disease.[34] Egalitarian theories also believe that to hold people responsible for their health, different ways should be used and not only emphasizing the concept of health responsibility.[10] The issue of individual health responsibility seems to be an element that policymakers cannot fully address outside of distributive justice in healthcare, but it is even more controversial to include in prioritization of health services.[14,33,41] In the COVID-19 pandemic, when the provision of health services was faced with problems, individual responsibility for health did not play a role in the allocation of health services.[14]

Media and social networks, as another determinant of health in today’s world, have influenced the concept of individual responsibility for health. Although a small part of the content produced by users in social networks is about individual responsibility for health, but different media, especially news, often attribute health responsibility to individuals and generally about chronic and noncommunicable diseases. Researchers believe that this emphasis is somewhat distorted and causes the role of individual responsibility for health to be exaggerated.[25,30] This misplaced emphasis also affects health norms and policies. In China, for example, both media organizations and mental health institutions primarily attributed the responsibilities of depression to the individual. State-controlled media organizations were more likely than market-oriented media organizations to hold individuals responsible for solving the depression problem.[42] Wong states in 2020 that although having individual health responsibility is a key factor in oral and dental diseases, the role of social determinants of health and the possibility of having or not having healthy choices for people should not be ignored. For example, misperceptions of individual responsibility for health endanger the health of vulnerable populations who have limited lifestyle choices.[27] Because unequal socioeconomic situations affect the ability to choose and follow it, and if these choices are made under unfair conditions, we should not hold people responsible for poor health choices.[13,43] It should be noted that the state of health depends on both individual choices and physical, social, and cultural environments.[44] As much as individual responsibility for health can be a strong rationale for health promotion, it is done in a broader sociocultural context and is not separate from it.[13,44]

Conclusion

Individual health responsibility is a multidimensional concept that is influenced by individual, social, and cultural factors and can never be separate from the context. This concept can have both positive and negative effects on people’s health. As much as it encourages people to have a healthier lifestyle, it can intensify the feeling of inefficiency, powerlessness, and unfairness in facing health challenges. To be able to benefit from the concept of individual health responsibility paying attention to the role of social determinants of health and the type of health challenge, which is effective on the possibility of attributing responsibility to people, is strongly emphasized by the articles. Based on this, the studies recommend that health policy makers treat this concept with caution and do not consider it as a separate basis for health policies. Also, this concept is not only related to noninfectious diseases but it can be considered as a concept affecting infectious diseases, such as the recent COVID-19 pandemic and any health challenge that is related to the individual and social choices of humans. The conflicting opinions about individual responsibility for health require more studies in this field.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.