Thursday, April 24, 2008

Motives and risk perception

As I wrote in a previous post, What does it mean to understand a risk?,lay people often don't understand risk. In large part, this is due to simple lack of knowledge about statistics. However, there are also important psychological motives involved, particularly when people appear to know the facts about risk but act in ways that demonstrate that they are ignoring what they know.

In Motives, Health Risk Perception, and Decision-Making, Klein and Cerully seek to identify these motives. Their discussion of the desire for self-enhancement is particularly relevant to understanding the self congratulatory nature of homebirth advocacy.
An extensive literature suggests that most people desire to hold positive views of themselves on a wide variety of dimensions, and many of these views are distorted. The motive of self-enhancement can be seen in many places when one looks at health beliefs and decisions. People tend to be unrealistically optimistic about their chances of experiencing a wide variety of health events and view their own health behaviors as superior to those of their peers.
We certainly see that at work in homebirth advocacy. While some homebirth advocates have literally no idea of the risks that they are undertaking, others know that there is a risk, but don't believe that it could happen to them. Of note, homebirth advocates are uniformly convinced that their own health behaviors are superior to those of other women, when the evidence is precisely the opposite. Homebirth advocates are constantly prattling about avoiding the "risks" of epidurals while simultaneously exposing their own babies to an increased risk of death.
When their self-favoring views about their behaviors and their future are challenged, people engage in a variety of strategies to preserve these views ... People are quite capable of finding fault with threatening health messages, suggesting that they endeavor to maintain positive views of their health.
Homebirth advocates react very angrily when it is pointed out to them that they are willingly exposing their babies to an increased risk of death. The most common reaction is flat out denial. However, homebirth advocates also strike back at the warnings of obstetricians by claiming that obstetricians are only trying to increase business for themselves, when this is obviously false.

Klein and Cerully point out that self enhancing health beliefs are often accompanied by illusory positive beliefs:
... [R]esearch in the health domain has been instrumental in testing a key theory introduced by Taylor and Brown, which argued that positive illusions (e.g., unrealistic optimism, illusion of control, and overestimations of ability) were adaptive. Although there is a fair amount of evidence that positive beliefs such as optimism are related to favorable health outcomes, there is also growing evidence that illusory positive beliefs are associated with negative health outcomes such as ineffective health decision-making and poor processing of health information... The distinction between positive beliefs and positively biased beliefs is a crucial one that has been blurred in many tests of positive illusions theory, and has been highlighted by research in a health context.
All three types of positive illusions are fundamental to homebirth advocacy. Homebirth advocates are unrealitistically optimitistic about their incidence of childbirth complications. They believe that health behaviors like good nutrition can prevent childbirth complications, and they grossly overestimate their ability to manage complications when they happen.

The bottom line is that even homebirth advocates who demonstrate intellectual awareness of the increased risk of preventable neonatal death at homebirth, act in ways that indicate they do not really appreciate the risks. One of the most important motives for treating the risks of homebirth so cavalierly is the desire for self-enhancement. It is difficult to feel superior about the choice of homebirth when the risks are taken into account. Since feeling superior is so important, the only logical alternative is to discount the risks.


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