Have you wondered over this period of social distancing and ‘lockdown’ why some groups appear to comply with public health messages more than others? Or perhaps you have been struck by the absence, in mathematical modelling approaches especially, of real insights into the ways in which people perceive and interpret risk differently and how this might impact on health-related behaviours.
The short answer: Policy makers, including government, setting out to change behaviour, often make errors. One of these is the assumption that greater knowledge on the part of the public leads to social change in one desired uniform direction. Another is the failure to appreciate the complexities of how risk is both socially constructed and then interpreted.
The impact of public health messages can be lessened by self-exempting beliefs. These beliefs can act as shields against the reality of net harms portrayed in public health campaigns, such as those around COVID19 or smoking and the links to cancer. A sporting parallel is brain injury and concussion. Let me elaborate further.
Sociologists have made important contributions to risk, especially its connections with health and pandemics, but also to many other aspects of the human condition, including modernity and uncertainty. Two main sociological approaches to risk began to emerge in the late twentieth century: one around Risk and Culture and the other on what came to be known as Risk Society.
These and other works broadened the debate: importantly, beyond technical considerations of environmental threats; beyond the financial hazards experienced by serial risk-takers and away from statistical aggregations, into the embodied realm. That is, how risk is constructed and interpreted.
Following on from this is how societies identify and manage new health conditions and diseases, for medical knowledge is never generated in a vacuum. It is created within social institutions with particular divisions of labour and various narratives. How these societies respond, notably via newer forms of media reporting, is not clear or predictable, nor is the various consequences.
In the socio-cultural approach, risk is intimately connected not just to cost-benefit analysis or to the frequency and types of social contact but also to less tangible factors such as identity, emotion, affect: ultimately, to human nature. Even in the face of scientific authority, rival risk narratives exist. In Northern Ireland, for example, and reminiscent of responses to HIV in the 1980s, one publicly elected councillor said that COVID19 was the judgement of God on the (unfavoured) legalisation of abortion and same sex marriage (Irish Post, 2 April 2020). There are competing views too about the seriousness of sports-related concussion.
Put simply: knowledge is a social process and humans are more than the sum of individually aggregated parts. Measuring the heart and associated risks of cardiovascular disease is one thing. It is altogether a different challenge to understand and measure heart and its impact on the ways in which people perceive risk, for example, those who see but ignore messages about the dangers of smoking, and sportspeople who normalise physical risks in the pursuit of competitive success, such that ‘playing hurt’ becomes second nature.
We continue to learn more about the ways in which people manage uncertainty and risk. Both COVID19 and concussion are life-threatening conditions but there is a fine balance between public concern that evokes collective self-protection or generates panic/alarm.
Common errors are often made in attempts to change health-related behaviour around the world (1), partly because of the imprecise impact of scientific modalities on uncertainty and risk. As those who have commented on anti-intellectualism and the denigration of expertise show, it is neither obvious nor agreed as to what needs to be done in the name of health promotion generally, not to mind the intricacies of virus transmission. But even if such responses were simply common sense, the actions of people are always and inevitably shaped by context: by culture, by tradition, by class, age and gender, by perceptions of risk. A useful analogy here is the ways in which athletes have responded thus far to education about concussion.
As we (2) have pointed out, incurring a potentially life-threatening injury or health condition cannot be understood as the actions of the ignorant or ill-informed who simply require better or more information about the associated risks. The same might also be said of the use of performance-enhancing substances or training methods. Indeed, given the culture of risk, which is present at all levels of sport, many athletes make choices and take action that are rewarded in and by this social context.
Athletes look upon ‘playing hurt’ or doping as an entirely rational choice of action, deriving from individual motivations and social drivers. From the perspective of those directly involved, such actions make sense because, within the cultural context of competitive sports, they generate personal and social rewards, especially identity affirmation. In these risk situations, knowledge pertaining to hazards is important and one might hypothesise that this affects intention to change behaviour. However, such rational decisions do not always flow from an appraisal of available scientific evidence. Consider what was said by one amateur female sportsperson to me in an interview:
“Well as I know, scientifically and logically, it’s very negative [to play with pain and through injury]. You should be looking after your body and health and you should be taking all the time out. You shouldn’t be risking anything that’s going to be a threat for you in the future. But as a player, it’s good [playing through pain and injury]. It makes you a stronger player and better in the future … It sounds so petty but what doesn’t kill you does make you stronger”.
Concussion is one of the more revealing examples of the most ‘problematic’ and idiosyncratic forms of risk behaviour when it comes to sports injuries. Health messages are therefore continually mediated.
Concerns about head injuries have waxed and waned over the twentieth century but unlike COVID19 however, concussion has been ‘hiding in plain sight’. Mitigating this has been many powerful organisations and interests (3). In the collective approach to concussion, also labelled a public health crisis by some, the injury remains under reported and hidden, especially in amateur sport. This is even when athletes have undertaken education designed to boost their knowledge and understanding of the associated risks.
From a socio-cultural perspective, a culture of risk is deeply embedded within modern sport that values risks and rewards those who exhibit the right attitude: the players that take one for the team, those that carry on despite injured, the player that takes a known risk because the coach and team needs him/her. Being socialised into this culture, from a young age, leads to a set of beliefs that interact with the growing knowledge about the risks of partaking in competitive sports.
One might assume that knowledge of such hazards might lead to more sensible risk-taking but some beliefs, though they may not weather rigorous scrutiny, function still as a means of avoiding an issue, even rationalising the status quo. Several will influence intention to change; yet others might inhibit a decision to enact or mitigate enactment itself. All of these are mediated by cultural norms, values and attitudes.
Of the self-exempting beliefs likely to be more important in mitigating changes in health behaviour (4), there are those who think they have a personal immunity to health risks and compromises – they are bulletproof as it were, until a serious injury or health event might force them to re-evaluate. Even in this scenario, they might not see what experts describe as serious in the same way. And they may continue to regard themselves as bulletproof after what is framed by them as a one-off event.
There might be those who simply do not believe medical evidence about risk. This applies especially to the longer-term health effects of partaking in competitive sports. These are sceptics, partly for understandable reason. Consider the scientific uncertainty that yet surrounds COVID19 and why youths appear to be less affected by COVID19. Selected others might take the ubiquity of risk to its logical conclusion. Life itself is risky.
Before this pandemic, acclamations about risk and its perceived value were given perhaps only to sportspeople and one other occupation – the military – who, through their ordinary pursuits, become injured, maimed or worse, killed, and go on to be celebrated for their dedication and sacrifice. Medical/ health professionals and those in essential work during this pandemic are also now ‘in the frontline’.
Several key issues need to be addressed therefore in order to make policy and education more effective, not only in relation to concussion, but that apply to COVID19 and its longer-term management:
- Determining the attitudes towards, and knowledge of, risk, as it applies to virus transmission, on the part of various target groups. Who are most likely to deceive themselves concerning risk or who are under/ill informed? What are their sources of information and how reliable are they?;
- Determining the medium or combination of media (text, audio-visual, apps, face-to-face messages and so on) appropriate for these different groups;
- Determining the voice best suited to these, for example, doctors, celebrities, family, role models, trained peers, experts in training and development and so on;
- Agreeing on the tailored message or combination of messages, likely to be most effective.
The practical challenge here is one of context management; more specifically to develop different frames of reference that can become new habits, which also need to endure as we move through the phases of this COVID19 pandemic. If this is to be done, then we need to know more about the different contexts, around the world – in nation-states and local communities, within which different ethnic and cultural groups, and those younger, older and in various socio-economic conditions, live and interact with one another – in order that public health messages can be made more consistent with the constraints and values of those contexts.
As the sociology of risk shows us, changing behaviour in a way that encourages people away from risk, towards greater caution and more ‘sensible risks’ cannot be resolved simply or quickly. The central problem is that risk is more than mathematical calculation or cost-benefit analysis: it is always and inevitably framed by institutional structures and cultural values, and by conformist beliefs some of which normalise risk taking, and even position it on the elevated platform of individual liberty, choice and freedom.
 Kelly, M. and Barker, M. (2016) ‘Why is changing health-related behaviour so difficult?’, Public Health. 136: 109-116.
 Liston, K., McDowell, M., Malcolm, D., Scott-Bell, A. and Waddington, I. (2018) ‘On being “head strong”: The pain zone and concussion in non-elite rugby union’, International Review for the Sociology of Sport. 53 (6): 668-684.
 Liston, K. and Malcolm, D. (2019) ‘Sports-Related Brain Injury: Concussion and Chronic Traumatic Encephalopathy’, in Young, K. (ed) The Suffering Body in Sport (Research in the Sociology of Sport) Vol 12. Emerald Publishing, pages 89-104.
 In the context of smoking, see, for example, Oakes, W., Chapman, S., Borland, R., Balmford, J. and Trotter, L. (2004) ‘“Bulletproof skeptics in life’s jungle”: which self-exempting beliefs about smoking most predict lack of progression towards quitting?’, Preventive Medicine. 39: 776-782.
Katie Liston is a senior researcher and sociologist in the Sport and Exercise Sciences Research Institute at Ulster University, Northern Ireland. Twitter @kliston14
Image Credit: Simon Wilson, Flikr, CC-BY-2.0