Socialisation and the making of health behaviour

The mechanism by which external rules become personal identity was worked out in detail by the American social psychologist George Herbert Mead, whose lectures were published after his death in 1934 as Mind, Self and Society. Mead argued that the self is not present at birth but emerges from social interaction. In the earliest stage the child merely imitates the gestures of those around it. In the play stage the child takes the role of one other person at a time — today the mother, tomorrow the driver, the following day the nurse — and speaks to itself in that voice. In the game stage the child must hold several roles at once and anticipate what each participant expects of the others. It is this step that produces what Mead named the generalised other: the internalised standpoint of the organised community, heard as the voice that comments on one’s own conduct even when nobody is present. Charles Horton Cooley had described the earlier part of the same process in 1902 as the looking-glass self: we imagine how we appear to others, imagine their judgement, and feel pride or shame accordingly. Put the two together and the practical point becomes clear. When a patient says “I am not the kind of person who goes to hospital”, he is not being stubborn; he is reporting the generalised other of his community, which he has carried inside him for decades. Telling him that he is wrong does not change that inner audience, because the audience is made of real people whose approval he still needs. Change happens when the people he actually listens to begin to expect the new behaviour, or when he enters a group whose generalised other already approves of it. This is why support groups, peer educators, church health teams and community health workers change behaviour that a clinic leaflet cannot: they change the audience a person carries in his head. A nurse can use the same principle deliberately by asking who the patient would have to answer to, and by recruiting that person into the plan with the patient’s consent.

Resocialisation is not a polite word for learning new facts; it describes the loss of one world and the acquisition of another, and the classic study of how institutions achieve it is Erving Goffman’s essay on total institutions (1961). A total institution is a place where people live, work and sleep under one authority, cut off from the outside, and Goffman showed that admission begins with what he called mortification of the self: personal clothes, possessions and sometimes a name are removed, the newcomer is batched with others on a common timetable, and he learns a privilege system in which small rewards are earned by compliance. The patient learns to wait, to ask permission, to be a case rather than a person. Some of this is unavoidable in a ward and much of it is intended for safety, but it leaves a mark: patients institutionalised for weeks may afterwards act less freely, and the dependency can outlive the illness. In parallel, Robert Merton described anticipatory socialisation through reference groups — the process by which a person adopts the values of a group he hopes to join — which explains why a student nurse behaves like a nurse months before qualifying, and why a patient told he will need lifelong dialysis may begin to learn the habits and language of the renal unit in advance. Chronic illness produces a different and longer resocialisation. Michael Bury argued in 1982 that it arrives as biographical disruption: it breaks the assumptions on which a life was built — that the body is reliable, that life follows a known timetable, that the future belongs to one’s plans. Anselm Strauss and Juliet Corbin described the work that follows as three simultaneous lines: illness work (managing symptoms, medicines and appointments), everyday life work (keeping a household and a job going) and biographical work (rebuilding a self that can live with the condition). Kathy Charmaz added that people protect a “preferred self”, the version of themselves they want to remain, and that the practical task of chronic illness is to keep that self recognisable. Nursing consequences follow directly: assess what the patient’s previous life required of him, teach the new routine as a set of skills rather than as information, and plan discharge so that hospital habits do not become permanent ones — restoring control rather than removing it.

Every health system invests in information — posters, radio spots, counselling cards — on the assumption that the public behaves badly because it does not know better. The numbers say otherwise. The WHO 2020 guidelines on physical activity recommend at least 150 to 300 minutes of moderate-to-vigorous aerobic activity each week for all adults, including those living with chronic conditions, and an average of 60 minutes a day for children and adolescents; WHO also reports that one in four adults and four out of five adolescents do not meet them. For infant feeding, WHO and UNICEF recommend breastfeeding within one hour of birth, exclusive breastfeeding for the first six months and continued breastfeeding up to two years or beyond, yet only about 47% of infants aged 0–6 months were exclusively breastfed over 2018–2025. In both cases the recommendation is public, repeated and free, and the gap remains. The sociological explanation was given by Pierre Bourdieu, whose concept of habitus names the durable set of dispositions a person acquires from childhood — how to stand, eat, speak, use time and treat the body — together with cultural capital, the knowledge and manners that make a person competent and respected in a particular setting. Habitus is learned in a specific social position and feels like second nature; wanting to change a habit therefore asks a person to move away from the group whose judgement formed it. The same facts produce the social gradient in health described by Michael Marmot and the Whitehall studies and emphasised by the WHO Commission on Social Determinants of Health: behaviour is not randomly distributed but follows income, education and occupation, because those positions supply different habitus, different means and different constraints. A useful nursing rule follows from this. If a behaviour is a practice, it will not yield to a message; change the condition instead. Make the desirable action the easy default — water available and formula expensive, a place to wash, tablets in a single monthly pack, an appointment at a time that suits work. Then link the new practice to a group whose opinion the patient values, and reinforce it repeatedly, because a habit that took twenty years to settle will not be reset by one brave conversation.