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CHAPTER 4

Social and Behavioral Sciences and Public Health

LEARNING OBJECTIVES

By the end of this chapter, the student will be able to:

• explain relationships between the social and behavioral sciences and public health.

• illustrate how socioeconomic status affects health.

• illustrate how culture and religion affect health.

• describe the relationship between income and socioeconomic status.

• describe key categories of social determinants of health.

• describe the role of theory in health behavior.

• identify the three levels of influence in which theories and models are categorized and provide examples of theories and models that correspond to these levels.

• explain the principles of social marketing.

• identify the steps of the PRECEDE-PROCEED planning framework.

You travel to a country in Asia and find that this nation’s culture affects most parts of life. From the food the people eat and their method of cooking, to their attitudes toward medical care, to their beliefs about the cause of disease and the ability to alter it through public health and medical interventions, this country is profoundly different from the United States. You ask: How does culture affect health?

You are working in a country with strict Islamic practices and find that religion, like culture, can have major impacts on health. Religious practices differ widely—from beliefs about food and alcohol; to sexual practices, such as male circumcision and female sexual behavior; to acceptance or rejection of interventions aimed at women’s health. You ask: How does religion affect health?

You are trying to help your spouse quit smoking cigarettes and prevent your kids from starting. You know that gentle encouragement and support on a one-on-one basis are essential, but often not enough because cigarette smoking is an addiction that produces withdrawal and long-term cravings. You wonder what other factors in the social system influence behavior and how they can be addressed.

Your efforts to convince your friends to avoid smoking (or stop smoking) focus on giving them the facts about how cigarettes cause lung cancer, throat cancer, and serious heart disease. You are frustrated by how little impact you have on your friends. You wonder what tools are available to better explain and predict health behavior.

Your classmate, who is first in her family to attend college, received word that her father lost his job at the local factory and she needs to take a leave from school because her family can no longer afford tuition. You wonder how this will affect her and her family.

Your town board just approved extending public transportation services to a wider geographic area. Although there are several opponents to the plan, you learn that a group of public health professionals supports this extension of services. You wonder what this transportation plan has to do with health.

You are in the checkout line at the grocery store, and a pregnant mother is ahead of you. You glance at the sugary cereals, snacks, and sodas she is purchasing and happen to notice that she is using an EBT card from the Supplemental Nutrition Assistance Program (SNAP), formerly known as the Food Stamp program. You wonder what could be done to encourage the consumption of healthy food options.

One of your friends asked for your assistance in helping his aunt move from her farm in the rural part of the state into the city center. He explained that his aunt was recently diagnosed with cancer and required regular chemotherapy treatments. You wonder why this diagnosis necessitates a move from a rural to an urban area.

Every day on your way to work, you pass the same homeless man on the same corner. He does not look very old—you guess he is about 25 years of age. You notice that over the past few weeks, he has been coughing, and you figure he must have a cold. Today when you walk by his usual place on the corner, he is not there, but someone has left a sign that reads, “Rest in peace, Ramón.” You are surprised, especially because he was so young. You wonder whether there was anything that could have been done to prevent his death.

As a new parent, you hear from your pediatrician, nurses in the hospital, and even the makers of your brand of diapers that babies should sleep on their backs. They call it “Back-to-Sleep.” You are surprised to find that it is part of the class on baby-sitting given by the local community center and a required part of the training for those who work in registered day care centers. You find out that it is all part of a social marketing campaign that has halved the number of deaths from sudden infant death syndrome. You ask: Why has the Back-to-Sleep campaign been so successful?

Each of these cases illustrates ways that an understanding of social and behavioral sciences can contribute to an understanding of public health. Let us explore these connections.

HOW IS PUBLIC HEALTH RELATED TO THE SOCIAL AND BEHAVIORAL SCIENCES?

The development of social and behavioral sciences in the 1800s and 1900s is closely connected with the development of public health. These subject areas share a fundamental belief that understanding the organization and motivation behind social forces, along with a better understanding of the behavior of individuals, can be used to improve the lives of individuals, as well as society as a whole. 1

The 19th century development of social and behavioral sciences, as well as public health, grew out of the Industrial Revolution in Europe, and later in the United States. It was grounded in efforts to address the social and economic inequalities that developed during this period and provided an intellectual and institutional structure for what was and is now called social justice. Social justice implies a society that provides fair treatment and a fair share of the rewards of society to individuals and groups of individuals. Early public health reformers advocated for social justice and saw public health as an integral aspect of it.

The intellectual link between social and behavioral sciences and public health is so basic and so deep that it is often taken for granted. For students with opportunities to learn about both social sciences and public health, it is important to understand the key contributions that social sciences make to public health. It is not an exaggeration to view public health as an application of the social sciences, or in other words, as an applied social science. Table 4-1 summarizes many of the contributions that the social sciences make to public health.

HOW ARE SOCIAL SYSTEMS RELATED TO HEALTH?

Complex Interactions

As humans, we are constantly interacting with our surroundings. Those surroundings include social systems comprised of interactions we have with other people, institutions, communities, and policies. The relationship between individuals and social systems is reciprocal, meaning we influence our social systems and our social systems influence us.

Due to our constant interaction with our surroundings, efforts aimed at improving population health require an understanding of the complex relationship between social systems and health. Medical care is only a piece of the puzzle, considering its focus is to treat disease without addressing the conditions in the social system that contributed to the illness in the first place.

To assist in pulling apart the complex social characteristics that impact health, it is useful to consider different levels of influence within the social system. Socio-ecological models are often employed to gain an understanding of the various social influences on health as well as to assist in identifying points at which to intervene. In general, the levels of influence include:

TABLE 4-1 Examples of Contributions of Social and Behavioral Sciences to Public Health

Social science discipline a	Examples of disciplinary contributions to public health
Psychology	Theories of the origins of behavior and risk-taking tendencies and methods for altering individual and social behaviors
Sociology	Theories of social development, organizational behavior, and systems thinking; social impacts on individual and group behaviors
Anthropology	Social and cultural influences on individual and population decision making for health with a global perspective
Political science/public policy	Approaches to government and policy making related to public health; structures for policy analysis and the impact of government on public health decision making
Economics	Understanding the micro- and macroeconomic impact on public health and healthcare systems
Communications	Theory and practice of mass and personalized communication and the role of media in communicating health information and health risks
Demography	Understanding demographic changes in populations globally due to aging, migration, and differences in birth rates, plus their impact on health and society
Geography	Understanding the impacts of geography on disease and determinants of disease, as well as methods for displaying and tracking the location of disease occurrence

a A similar list of contributions of the humanities could be developed including the contributions of literature, the arts, history, philosophy, and ethics. These contributions of the social sciences are in addition to contributions of the sciences, mathematics, and humanities. Biology, chemistry, and statistics underpin much of epidemiology and environmental health. Languages and culture, history, and the arts provide key contributions to health communications and health policy. Thus, a broad arts and sciences education is often considered a key part of preparation for public health.

• Individual lifestyle factors: Characteristics of the individual, including knowledge, attitudes, beliefs, and personality traits, as well as age, sex, and hereditary factors.

• Social and community networks: Points at which interaction with other individuals occurs. This sphere of influence can further be divided into the following levels:

Interpersonal: Family, friends, and peers who shape social identity, support, and roles.

Institutional/organizational: Rules and regulations of institutions, such as schools and places of employment, that may limit or promote healthy behavior.

Community: Comprises informal and formal social networks and norms formed among individuals, groups, and organizations, including cultural and religious practices.

• General socioeconomic, cultural, and environmental conditions: Components of the surroundings external to individuals that comprise living and working conditions, such as education, housing, work environment, and healthcare services. These conditions are shaped by public policy and laws at the local, state, and federal levels.

Influencing Behavior

The complex relationship between social systems and individuals affects health through individual behavior. Berkman and Kawachi argue that social systems influence behavior by 2 :

1. Shaping norms: Certain behaviors may become generally accepted among social groups. An attitude of “everyone else is doing it” can have a strong influence on an individual’s decision to partake in the activity. For example, in some communities, perhaps it is rare for anyone to wear a helmet while biking. So an individual who has always used a bicycle helmet in the past may decide to forego it because nobody else wears one in his new community.

2. Enforcing patterns of social control: Having rules and regulations in place creates structure for society, which can affect health. For instance, having a curfew for teenagers to be off the streets by 9:00 p.m. unless accompanied by an adult may assist in preventing violence.

3. Providing or not providing opportunities to engage in certain behaviors: The opportunities, or lack thereof, in our surroundings can have a strong influence on our health. For instance, having access to a community pool can encourage individuals to learn to swim, thus preventing drowning, while also serving as a form of physical exercise and social cohesion.

4. Reducing or producing stress for which certain behaviors may be an effective coping strategy, at least in the short term: For example, college students often go through stressful periods throughout their academic career, particularly around exam time. Some students may decide to cope with this stress by “blowing off steam.” This can take many forms, from binge drinking to going for a run, each choice having an effect on health.

We have explored the complex relationship between social systems and individuals. Let us now look at three key components of the social system and their relationship to health: socioeconomic status, culture, and religion.

HOW DO SOCIOECONOMIC STATUS, CULTURE, AND RELIGION AFFECT HEALTH?

Socioeconomic Status

Beginning in the 1800s, social scientists developed the concept of socioeconomic status. They also developed elaborate systems to operationalize the definition of “socioeconomic status” and classify individuals. In the United States, the definition has generally included measures that are primarily economic, including:a

• family income

• educational level or parents’ educational level

• professional status or parents’ professional status

In developed countries such as the United States, health status, at least as measured by life expectancy, is strongly associa ted with socioeconomic status. 3 , 4 Greater longevity is associated with higher social status, with a gradient of increasing longevity from lowest to highest on the socioeconomic scale. Box 4-1 provides greater detail on this important relationship.

We understand many, but not all, of the ways that socioeconomic factors affect health. Greater economic wealth usually implies access to healthier living conditions. Improved sanitation, less crowding, greater access to health care, and safer methods for cooking and eating are all strongly associated with higher economic status in developed, as well as developing, countries.

Education is also strongly associated with better health. It may change health outcomes and increase longevity by encouraging behaviors that provide protection against disease and likewise reduce exposure to behaviors that put individuals at risk of disease. Higher education levels, coupled with the increased resources that greater wealth can provide, may increase access to better medical care and provide greater ability to protect against health hazards.

BOX 4-1 Income and Population Health

Health status as measured by life expectancy has been found to improve with increasing average gross domestic product (GDP), up to a threshold of about $10,000 per person, which is the current level for the many successful middle income developing nations. The United States currently has an average GDP above $40,000.

Once this threshold of adequate income is reached, the health status of countries does not continue to steadily rise as income increases. At these higher levels of GDP, as seen in most developed countries, income disparities are a better predictor of life expectancy than absolute levels of average GDP. Developed countries with lower levels of income disparity, such as Japan, Canada, Sweden, and France, have longer life expectancies than countries such as the United States and the United Kingdom, which have greater income disparities.

Even in countries with modest levels of income disparities, a socioeconomic gradient of health status exists such that individuals with a higher socioeconomic status tend to have better health outcomes compared to those with a lower socioeconomic status. This gradient can be viewed as a ladder in that moving down the socioeconomic ladder, more ill health and shorter life expectancy are experienced at each rung. Therefore, socioeconomic determinants of health do not solely affect the very poorest or those in the lowest socioeconomic levels but are rather an issue throughout all income levels.

An argument has been made that poorer health leads to lower income and not the other way around. There is little evidence that this phenomenon explains the socioeconomic factors that affect health. Education level is an even stronger predictor of life expectancy than income, and education levels are usually well established before poor health develops. Education level, income level, and professional status are three key components of socioeconomic status as measured in the United States. Therefore, it may be more accurate to say that disparities in socioeconomic status are associated with poorer population health status.

A measure that has been adapted to calculate economic inequity across populations is the Gini index, also known as the Gini coefficient. This is a commonly used measure of income distribution, with an index ranging from 0 to 1, with higher values indicating greater inequality. A Gini index of 0 indicates complete income equality (everyone has the same income), and 1 indicates complete inequality in income (one individual receives all the income). Oftentimes, for ease of reporting and drawing comparisons, the index is multiplied by 100 so that the values range from 0 to 100. The index measures the extent of deviation between an economy’s distribution of income among individuals or households and that of perfectly equal distribution.

Among developed countries, income inequality is strongly associated with higher rates of mortality. Countries with a wider gap between the poorest of the poor and richest of the rich (a Gini index closer to 1) experience poorer population health outcomes on measures such as infant mortality and life expectancy, compared to countries with a narrow gap between rich and poor (a Gini index closer to 0). 5 , 6

The U.S. Gini index is approximately 45, compared to 34 in the United Kingdom, 32.7 in France, 32.1 in Canada, 27 in Germany, and 23 in Sweden. The United States has the highest Gini index of major developed countries. 6

Place matters. Some Americans will die twenty years earlier than others who live just a short distance away because of differences in education, income, race, ethnicity, and where and how they live. One classical study revealed dramatic disparities in life expectancy across U.S. counties overall, and particularly when racial or ethnic differences were also considered. For example, black men in the county with the shortest life expectancy for blacks lived approximately 60 years, while white men in the county with the longest life expectancy for whites could expect to live two decades longer. 7 , 8 a

_______________

a The association between socioeconomic status and longevity is most strongly associated with an individual’s socioeconomic status as an adult. The socioeconomic status of an individual’s parents has a much weaker association. This suggests that genetic factors have little to do with the association between socioeconomic status and life expectancy. Education has a stronger association with health status than income or professional status. Lower socioeconomic status leads to poor health rather than poor health leading to lower socioeconomic status. Socioeconomic factors are associated with an increase in relative risk of death of 1.5 to 2.0 when comparing the lowest and highest socioeconomic groups. This means that those in the lowest group have more than a 50% increase in the death rate compared to the highest group. This relative risk steadily increases as the socioeconomic level decreases. The relationship has a dose-response relationship; that is, there is an increase in longevity with every increase in socioeconomic status. Thus, the impact is not limited to those with the lowest status. The largest contributors to the differences in the death rate are cardiovascular disease, violence, and, increasingly, AIDS; however, the death rate is impacted in general by a wide range of diseases—most being malignancies and infectious diseases. 9

Individuals of lower socioeconomic status are more likely to be exposed to health hazards at work and in the physical environment through toxic exposure in the air they breathe, in the water they drink, and in the food they eat. Table 4-2 outlines a number of mechanisms by which socioeconomic status can directly and indirectly influence health.

These factors, while important, do not explain the entire observed differences in life expectancy among individuals of different socioeconomic status. For instance, the rates of coronary heart disease are considerably higher among those of lower socioeconomic status—even after taking into account cigarette smoking, high blood pressure, cholesterol levels, and blood sugar counts. 9

Considerable research is now being directed to better understand these and other effects of socioeconomic status. One theory suggests that social control and social participation may help explain these substantial differences in health. It contends that control over individual and group decision making is much greater among individuals of higher socioeconomic status. The theory holds that the ability to control one’s life may be associated with biological changes that affect health and disease. 9 Additional research is needed to confirm or reject this idea and/or provide an adequate explanation for these important, yet unexplained, differences in health based upon socioeconomic status.

Culture

Culture, in a broad sense, helps people make judgments about the world and decisions about behavior. Culture defines what is good or bad, and what is healthy or unhealthy. This may relate to lifestyle patterns, beliefs about risk, and beliefs about body type—for example, a large body type in some cultures symbolizes health and well-being, not overweight or other negative conditions.

Culture directly affects the daily habits of life. Food choice and methods of food preparation and preservation are all affected by culture, as well as socioeconomic status. The Mediterranean diet, which includes olive oil, seafood, vegetables, nuts, and fruits, has been shown to have benefits for the heart even when used in countries far removed from the Mediterranean.

There are often clear-cut negative and/or positive impacts on disability related to cultural traditions as diverse as feet binding in China and female genital mutilation in some parts of Africa. Some societies reject strenuous physical activity for those who have the status and wealth to be served by others.

TABLE 4-2 Examples of Ways that Socioeconomic Status May Affect Health

Ways	Examples
Living conditions	Increases in sanitation, reductions in crowding, methods of heating and cooking
Overall educational opportunities	Education has the strongest association with health behaviors and health outcomes May be due to better appreciation of factors associated with disease and greater ability to control these factors
Educational opportunities for women	Education for women has an impact on the health of children and families
Occupational exposures	Lower socioeconomic jobs are traditionally associated with increased exposures to health risks
Access to goods and services	Ability to access goods, such as protective devices, and high-quality foods and services, including medical and social services to protect and promote health
Family size	Large family size affects health and is traditionally associated with lower socioeconomic status and lower health status
Exposures to high-risk behaviors	Social alienation related to poverty may be associated with violence, drugs, and other high-risk behaviors
Environmental	Lower socioeconomic status is associated with greater exposure to environmental pollution, “natural” disasters, and dangers of the “built environment”

TABLE 4-3 Examples of Ways that Culture Can Affect Health

Ways that culture may affect health	Examples
Culture is related to behavior—social practices may put individuals and groups at increased or reduced risk	Food preferences—vegetarian, Mediterranean diet Cooking methods History of binding of feet in China Female genital mutilation Role of exercise
Culture is related to response to symptoms, such as the level of urgency to recognize symptoms, seek care, and communicate symptoms	Cultural differences in seeking care and self-medication Social, family, and work structures provide varying degree of social support—low degree of social support may be associated with reduced health-related quality of life
Culture is related to the types of interventions that are acceptable	Variations in degree of acceptance of traditional Western medicine, including reliance on self-help and traditional healers
Culture is related to the response to disease and to interventions	Cultural differences in follow-up, adherence to treatment, and acceptance of adverse outcome

Culture is also related to an individual’s response to symptoms and acceptance of interventions. In many cultures, medical care is exclusively for those with symptoms and is not part of prevention. Many traditional cultures have developed sophisticated systems of self-care and self-medication supported by family and traditional healers. These traditions greatly affect how individuals respond to symptoms, how they communicate the symptoms, and the types of medical and public health interventions that they will accept.

Many cultures allow and even encourage the use of traditional approaches alongside Western medical and public health approaches. In some cultures, traditional healers are considered appropriate for health problems whose causes are not thought to be biological, but instead related to spiritual and other phenomena. Recent studies of alternative, or complementary, medicine have provided evidence that specific traditional interventions, such as acupuncture and specific osteopathic and chiropractic manipulation, have measurable benefits. Thus, cultural differences should not be viewed as problems to be addressed, but rather as practices to be understood. Table 4-3 summarizes a number of the ways that culture can affect health.

Religion

Social factors affecting health include religion along with culture. Religion can have a major impact on health, particularly for specific practices that are encouraged or condemned by a particular religious group. For instance, we now know that male circumcision reduces susceptibility to HIV/AIDS. Religious attitudes that condone or condemn the use of condoms, alcohol, and tobacco have direct and indirect impacts on health as well.

Some religions prohibit specific healing practices, such as blood transfusions or abortion, or totally reject medical interventions altogether, as is practiced by Christian Scientists. Religious individuals may see medical and public health interventions as complementary to religious practice or may substitute prayer for medical interventions in response to symptoms of disease. Table 4-4 outlines some of the ways that religion may affect health.

We have examined a number of ways that the broad social influences of socioeconomic status, culture, and religion may affect health and the response to disease. Let us now explore additional social factors that determine health.

WHAT ARE SOCIAL DETERMINANTS OF HEALTH?

A subset of all the determinants of health, social determinants of health refer to the conditions in which people are born, grow up, live, learn, work, play, worship, and age, as well as the systems put in place to deal with illnesses that affect health and quality of life. These conditions are shaped by a wider set of forces, including economics, social policies, and politics. 10 , 11

Although there is no universally agreed upon set of social determinants, the following categories highlighted by the World Health Organization encompass many key social determinants that affect health. Each individual has his or her unique combination of influences; however, patterns have been observed and are summarized in the following sections. 12 , 13 Notice that these social determinants should not be viewed in isolation because they often interact with each other.

TABLE 4-4 Examples of Ways that Religion May Affect Health

Ways that religion affects health	Examples
Religion may affect social practices that put individuals at increased or reduced risk	Sexual: circumcision, use of contraceptives Food: avoidance of seafood, pork, beef Alcohol use: part of religion versus prohibited Tobacco use: actively discouraged by Mormons and Seventh-Day Adventists as part of their religion
Religion may affect the response to symptoms	Christian Scientists reject medical care as a response to symptoms
Religion may affect the types of interventions that are acceptable	Prohibition against blood transfusions Attitudes toward stem cell research Attitudes toward abortion End-of-life treatments
Religion may affect the response to disease and to interventions	Role of prayer as an intervention to alter outcome

10 Key Categories of Social Determinants of Health

Social Status

Societies place value on certain characteristics such that a hierarchical social structure is formed. In the United States, value tends to be placed on income, education, and occupation, which collectively form socioeconomic status. Social status interacts and influences many of the other social determinants of health.

Social Support or Alienation

Being part of a social network has benefits to health, including emotional effects associated with feelings of inclusion and tangible benefits, such as having someone to go jogging with or having someone to provide a ride to the doctor’s office. Social exclusion can occur due to racism, discrimination, and other forms of marginalization, limiting the opportunities for education, leisure activities, and other community services, either directly through discriminatory practices or as a consequence of cumulative exposure to discrimination resulting in fear, anger, distrust, or stress so that individuals do not seek out such opportunities.

Food

An inadequate or insecure food source remains an issue for disadvantaged populations in the United States and around the world. However, excess calorie intake and the lack of a nutritious diet is a rapidly growing problem. Not only is education important in being aware of what constitutes a good diet, but having access to affordable, healthy food is also a central component of leading a healthy lifestyle. A food desert is a term used to describe geographic areas that lack grocery stores and other establishments in which low-income individuals are able to purchase nutritious food due to high prices or inaccessibility. Although these areas may have food available, the options easily accessible via public transportation and price to low-income families often include unhealthy food such as that offered at convenience stores and fast food establishments.

Housing

Having affordable, stable housing influences health in a number of ways. Homelessness can lead to malnutrition, lack of medical care, drug use, and violence. Therefore, those with a home tend to have better overall health compared to those without; however, hazards can also be present in the home, including lack of clean water and sanitation, asthma triggers such as mold and dust, lead paint, cockroaches, inadequate sanitation, and unsafe structural conditions.

Education

Even within the same overall socioeconomic status, those with more education tend to experience better health compared to those with less education. Efforts to address health should, therefore, include making quality education at all levels widely accessible to populations. In the United States, increasing the high school graduation rate is now a leading indicator of Healthy People 2020, a collaborative initiative of the United States Department of Health and Human Services which guides the national prevention agenda.

Work

Several aspects of work can affect health. Overall, being employed tends to be better for health compared to being unemployed. This is partially attributed to the connection between socioeconomic status and health. Having an income assists a person’s ability to secure resources that may protect and promote health, such as safe housing, food, and education. Being employed can also assist in accessing health services if the employer provides health insurance to its employees. Type of employment can also affect health. Some jobs are more hazardous to health than others. Health effects associated with work are not restricted to physical health because work can also affect mental health. Job satisfaction and stress in the workplace contribute to health. Those who are unemployed also face psychological consequences due to the anxiety and stress that can be associated with lack of job security and inability to adequately provide for their families.

Stress

Stress is a social and psychological response with biological consequences. A variety of circumstances can create anxiety and worry, whether it is an intense work setting or the threat of losing one’s home. Sustained periods of stress can negatively affect physical health due to the body’s fight or flight response, which increases the heart rate and cortisol levels. Over time, stress can lead to such conditions as cardiovascular disease and depression.

Transportation

A component of environmental health, transportation also affects health in a number of ways. By driving less and walking/cycling more and using mass transit, people increase their physical activity levels. It is becoming even more important to find ways to integrate physical activity into our lives as lifestyles in the United States grow increasingly sedentary and obesity is on the rise. Opting for walking, cycling, and mass transit also increases social contact, which can serve as a protective health factor. Relying less on cars also reduces air and noise pollution, contributing to environmental health as well. Therefore, city planning can have an impact on health.

Place

Where you live affects your health. For example, those living in rural areas have fewer healthcare services available nearby, whereas those living in urban areas are exposed to increased air pollution from factories and vehicles. The built environment also affects health in that it influences whether there are safe places to be physically active, including walking and biking trails and green spaces, as well as easy access to nutritious food.

Access to Health Services

Having access to preventive health services and medical care contributes to overall health. Access to such services is often limited by health insurance. On a broader scale, having an appropriate number and type of healthcare professionals is instrumental to maintaining the health of individuals and populations.

HOW DO SOCIAL DETERMINANTS AFFECT HEALTH?

Social determinants of health contribute to a wide variety of illnesses and diseases rooted in lifestyle, environmental, and social factors. Recent increased attention on social determinants of health has been driven by their connection with health disparities. A health disparity is a type of difference in health that is closely linked with social or economic disadvantage. Health disparities negatively affect groups of people who have systematically experienced greater social or economic obstacles to health. These obstacles stem from characteristics historically linked to discrimination or exclusion, such as race or ethnicity, religion, socioeconomic status, gender, disability, mental health, sexual orientation, and geographic location. b

Disparities occur in a wide range of health conditions, including communicable and noncommunicable diseases and environmental health and safety. Table 4-5 provides a few examples of conditions in which disparities occur within the U.S. population.

It is important to note that social determinants affect not only physical health, but mental health as well. Mental health is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with challenges. 14 Mental illness refers to all diagnosable mental disorders, which are health conditions characterized by alterations in thinking, mood, and/or behavior associated with distress and/or impaired functioning. Examples of mental disorders are depression, anxiety, bipolar disorder, schizophrenia, and dementia. Mental disorders are the leading cause of disability in the United States, with approximately 1 in 17 U.S. adults exhibiting a debilitating mental illness in any given year. 14 The suicide rate increased by over 10% among the U.S. population between 1999 and 2008, and it varies by race and ethnicity, with the highest rate observed among the white non-Hispanic population in the United States. 15

TABLE 4-5 Disparities in Health, United States

Noncommunicable Disease

Coronary heart disease: Black men and women are much more likely to die of heart disease and stroke compared to white men and women.

Colorectal cancer screening: Disparities in colorectal cancer screening rates exist based on education level and income. As education increases, screening for colorectal cancer also increases. The same pattern exists for income level: as income increases, screening rates increase.

Environmental Health and Safety

Air pollution: Local sources of air pollution, often in urban areas, can impact the health of people who live or work near these sources. Everyone in these areas, regardless of socioeconomic status, can experience the negative health effects of air pollution; however, because racial/ethnic minority groups are more likely to live in the most polluted sections of urban areas, they continue to experience a disproportionately larger impact.

Motor vehicle crashes: Men of all races/ethnicities are two to three times more likely to die in motor vehicle crashes than are women, and death rates are twice as high among American Indians/Alaska Natives.

Communicable Disease

HIV: Racial/ethnic minorities, with the exception of Asians/Pacific Islanders, experience disproportionately higher rates of new human immunodeficiency virus diagnoses than whites, as do men who have sex with men (MSM). In addition, rates are increasing among black and American Indian/Alaska Native males, as well as MSM, while rates hold steady or are decreasing in other groups.

Influenza vaccination: Whites aged 65 years and older consistently have higher rates of influenza vaccine coverage compared to all other races/ethnicities in this age group, with non-Hispanic blacks experiencing the lowest rates of flu vaccine coverage.

Data from the Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report – United States, 2011. Morbidity and Mortality Weekly Report. Supplement / Vol. 60. January 14, 2011.

Mental health is not only essential to successful function in and contribution to society but it can also impact physical health. For example, depression may prohibit an individual’s desire and motivation to exercise and seek out nutritious food, contributing to chronic conditions such as cardiovascular disease and diabetes. Therefore, understanding the factors, both internal and external to the individual, contributing to emotional, psychological, and social well-being is critical in addressing population health. National objectives, as part of Healthy People 2020, have been set to improve mental health status and expand mental health screening and treatment services.

CAN HEALTH BEHAVIOR BE CHANGED?

Much of the preventable disease and disability today in the United States and other developed countries is related to the behavior of individuals. From cigarette smoking to obesity, from intentional to unintentional injuries, from sexual behavior to drug abuse, health issues can be traced to the behavior of individuals.

Consider all the behaviors related to health. Some are intentional health behaviors, while others are not necessarily motivated by health concerns. Getting a mammogram could be an example of an intentional health behavior because it is a behavior most likely undertaken for health benefits—in this case, screening for breast cancer. However, driving the speed limit may be a behavior that has an effect on health but is undertaken not because the individual is concerned about the health benefits of doing so (avoiding injury from a motor vehicle crash) but because he or she wants to avoid getting a ticket. Therefore, in order to have an impact on health, a wide range of behavioral motivations and factors needs to be addressed.

At times, we hear discouraging messages that behavior cannot be changed. However, if we take a relatively long-term view, we find that there are many examples of behavioral change that have occurred for the better. For instance:

• Cigarette smoking in the United States among males has been reduced from approximately 50% in the 1960s to approximately 20% today.

• Infants today generally are placed on their backs for sleeping and napping and not on their stomachs, as was the usual practice in the 1980s and earlier. Back-to-Sleep campaigns are believed to have reduced sudden infant death syndrome (SIDS) by nearly 50% in the United States.

• Seat belt use in the United States has increased from less than 25% in the 1970s to over 80% currently.

• Drunk driving in the United States has been dramatically reduced, with a resulting decline in automobile-related fatalities.

• Mammography use increased by approximately 50% during the 1990s and has been credited with beginning to reduce the previously rising mortality rates from breast cancer.

The potential to change behavior can make health worse as well. The following changes for the worse have also occurred in the United States in recent years:

• Over the last three decades, Americans have increased their caloric intake and reduced their average amount of exercise, resulting in more than doubling the obesity rate to over 33% of all adults.

• Between the 1960s and the 1990s, teenage girls and young adult women increased their cigarette smoking, subjecting their unborn children to additional hazards of low birthweight.

Thus, behavioral change is possible for the better and for the worse. Some behaviors, however, are easier to change than others. Let’s take a look at why this is.

WHY ARE SOME INDIVIDUAL HEALTH BEHAVIORS EASIER TO CHANGE THAN OTHERS?

Some behaviors are relatively easy to change, while others are extremely difficult. Being able to recognize the difference is an important place to start when trying to alter behavior. It is relatively easy when one behavior can be substituted for a similar one and results in a potentially large payoff. In these situations, knowledge often goes a long way. For instance, the substitution of acetaminophen (Tylenol) for aspirin to prevent Reye’s Syndrome was relatively easy. Similarly, the Back-to-Sleep campaign was quite successful in reducing the rate of death from SIDS. In both of these cases, an acceptable and convenient substitute was available, making the needed behavioral change much easier to accomplish.

Along with knowledge, incentives—such as reduced cost, increased availability, or improvements in ease of use—can encourage rapid acceptance and motivate behavioral change. For instance, easier-to-install child restraint systems have increased their use. Greater insurance coverage and widespread availability of modern mammography equipment has led to an increase in the number of mammograms performed.

The most difficult behaviors to change are those that have a physiological component, such as obesity, or an addictive element, such as cigarette smoking. Individual interventions aimed at smoking cessation or long-term weight control generally succeed less than 30% of the time—even among motivated individuals. Even intensive interventions with highly motivated individuals cannot be expected to be successful more than 50% of the time, as was illustrated by the Multiple Risk Factor Intervention Trial (MRFIT), which attempted intensive interventions to reduce risk factors for cardiovascular disease.

In addition, physical, social, and economic barriers can stand in the way of behavior change, even if individuals themselves are motivated. If health care is not accessible, or if survival needs require individuals to engage in risks they might not take otherwise, change in behavior may be impeded.

Successful behavioral change requires that we understand as much as we can about how behavior can be changed and what we can do to help.

HOW CAN INDIVIDUAL BEHAVIOR BE CHANGED?

The behavior of individuals is often the final common pathway through which disease, disability, and death can be prevented. The fact that individual behavior has a clearly observable connection with these factors does not necessarily imply that the best or only way to address the behavior of individuals is to focus exclusively on individuals. The forces at work to mold individual behaviors are sometimes referred to as downstream factors, mainstream factors, and upstream factors. Downstream factors are those that directly involve an individual and can potentially be altered by individual interventions, such as an addiction to nicotine. Mainstream factors are those that result from the relationship of an individual with a larger group or population, such as peer pressure to smoke or the level of taxation on cigarettes. These factors require attention at the group or population level. Finally, upstream factors are often grounded in social structures and policies, such as government-sponsored programs that encourage tobacco production. These require us to look beyond traditional health care and public health interventions to the broader social and economic forces that affect health.

Thus, changes in behavior often require more than individual motivation and determination to change. They require encouragement and support from groups ranging from friends and families to work and peer groups. Behavioral change may also require social policies and expectations that reinforce individual efforts.

HOW CAN HEALTH BEHAVIOR BE EXPLAINED AND PREDICTED?

When addressing issues affecting the health of populations, behaviors contributing to these issues must be explored and understood. But what tools do we have to understand these behaviors? A theory is a set of interrelated concepts that presents a systematic view of relationships among variables in order to explain and predict events and situations. Similarly, a model is a combination of ideas and concepts taken from multiple theories and applied to specific problems in particular settings. Theories and models are tools commonly used by health researchers and health practitioners to gain insight into why people behave in healthy or unhealthy ways and to guide the development and evaluation of interventions aimed at changing behavior to improve health.

Because theories present a systematic way to understand events or situations, linking various factors and elements together, they provide a useful framework to study health problems, develop appropriate interventions, and evaluate the impact of the interventions. Theory serves as a road map for research and practice, exploring the “why,” “what,” and “how” of health issues and their solutions. In accordance with evidence-based public health principles, interventions developed based on theory and supported by evidence using these theories are more likely to succeed than those that were not.

Let us take a look at a few examples of theories and their application to health behavior.

WHAT ARE SOME KEY THEORIES AND MODELS USED TO ADDRESS HEALTH BEHAVIOR?

Many theories and models are used in health behavior research and practice. A few key theories and models will be highlighted here. Theories and models are categorized according to three levels of influence:

• Intrapersonal: Focusing on characteristics of the individual, including knowledge, attitudes, beliefs, motivation, self-concept, past experiences, and skills

• Interpersonal: Focusing on relationships between people, acknowledging that other people influence behavior by sharing their thoughts, advice, feelings, emotional support, and other assistance

• Population and community: Focusing on factors within social structures, such as norms, rules, regulations, policies, and laws

Intrapersonal Level

Health promotion and health education efforts set out to raise awareness of health issues among individuals; therefore, a number of intrapersonal theories and models exist, focusing on factors within the individual that influence behavior, such as knowledge, attitudes, beliefs, and skills.

One of the original theories of health behavior that remains among the most widely recognized today is the Health Belief Model. The model, developed in the 1950s by a group of U.S. Public Health Service social psychologists, originated out of a desire to understand why so few people were taking advantage of a free mobile x-ray unit to screen for tuberculosis (TB). 16 The social psychologists theorized that people’s readiness to act was influenced by their beliefs about whether or not they were susceptible to TB and their perceptions of the benefits of screening for the disease.

The Health Belief Model is an intrapersonal theory, as it focuses on individuals’ characteristics, including their perceptions and thought processes prior to taking health-related action. The premise of the model is that personal beliefs influence health behavior. The model proposes that people will be more likely to take action if they believe they are susceptible to the condition; they believe the condition has serious consequences; they believe taking action would benefit them, with the benefits outweighing the harms; and they are exposed to factors that prompt action and believe in their ability to successfully perform the action. Table 4-6 summarizes the model’s constructs and their application to osteoporosis.

Another widely used intrapersonal model is the Transtheoretical Model, also referred to as the Stages of Change Model. The underlying assumption of this model is that people go through a set of incremental stages when changing behavior rather than making significant changes all at once. 17 c

TABLE 4-6 Health Belief Model and Osteoporosis

Construct	Description	Example: osteoporosis
Perceived susceptibility	An individual’s opinion of getting a condition	“Osteoporosis only happens to old women, not me.”
Perceived severity	An individual’s opinion of how serious a condition is and its consequences	“Osteoporosis is not a big deal.”
Perceived benefits	An individual’s belief in the advised action to reduce risk and/or severity of condition	“Screening for osteoporosis will catch it early so I can continue to live an active lifestyle.”
Perceived barriers	An individual’s belief of the costs (tangible and psychological) of the advised action	“Screening for osteoporosis takes too much time.”
Modifying variables	Individual characteristics that influence personal perceptions	“Women in my culture are viewed as strong; therefore, we do not concern ourselves with osteoporosis.”
Cues to action	Strategies/events that encourage one’s “readiness” to act	“My sister was recently diagnosed with osteoporosis, so I should get screened.”
Self-efficacy	Belief in one’s ability to take action	“If I am diagnosed with osteoporosis, I know I can manage it.”

Data from National Cancer Institute. U.S. Department of Health and Human Services. Theory at a Glance: A Guide for Health Promotion Practice. 2nd edition. Available at: http://www.cancer.gov/cancertopics/cancerlibrary/theory.pdf . Accessed August 5, 2013.

The first stage, called precontemplation, implies that an individual has not yet considered changing his or her behavior. At this stage, efforts to encourage change are not likely to be successful. However, efforts to educate and offer help in the future may lay the groundwork for later success.

The second phase, known as contemplation, implies that an individual is actively thinking about the benefits and barriers to change. At this stage, information focused on short- and immediate-term gains, as well as long-term benefits, can be especially useful. In addition, the contemplation stage lends itself to developing a baseline—that is, establishing the current severity or extent of the problem in order to measure future progress.

The third phase is called preparation. During this phase, the individual is developing a plan of action. At this point, the individual may be especially receptive to setting goals, considering a range of strategies, and developing a timetable. Help in recognizing and preparing for unanticipated barriers can be especially useful to the individual during this phase.

The fourth phase is the action phase, when the change in behavior takes place. This is the time to bring together all possible outside support to reinforce and reward the new behavior and help with problems or setbacks that occur.

The fifth—and hopefully final—phase is the maintenance phase, in which the new behavior becomes a permanent part of an individual’s lifestyle. The maintenance phase requires education on how to anticipate the long-term nature of behavioral change, especially how to resist the inevitable temptations to resume the old behavior. Using cigarette smoking as illustration again, Table 4-7 summarizes the stages of behavioral change and the specific actions that can be helpful at each of the stages.

A third widely used intrapersonal theory is the Theory of Planned Behavior. This theory is based on the idea that intention is the main predictor of behavior. The theory proposes that behavioral intention is influenced by an individual’s attitude toward performing a behavior, his or her beliefs about whether people important to him or her approve or disapprove of the behavior, and his or her beliefs about their control over performing the behavior. According to the theory, intention determines whether someone will engage in a behavior; therefore, interventions based on the Theory of Planned Behavior set out to affect individuals’ intention to perform a behavior. 18 Figure 4-1 illustrates the theory’s constructs in relation to getting a flu vaccine.

Interpersonal Level

Interpersonal theories and models take into consideration the influences of other people on an individual’s behavior. These other people can include family members, peers, coworkers, healthcare providers, etc., and they can influence behavior by sharing their advice, feelings, and opinions and through the support and assistance they provide.

TABLE 4-7 Stages of Change Model and Cigarette Smoking

Stages of change	Actions	Example: cigarette smoking
*Precontemplation*	*Prognosticate*
Individual not considering change	Assessing readiness for change—timing is key	Determine individual’s readiness to quit. If not ready, indicate receptivity to help in the future. Look for receptive timing, such as during acute respiratory symptoms Social factors, such as workplace and indoor restriction on smoking and taxation, increase likelihood of entering precontemplation phase
*Contemplation*	*Motivate change*
Individual thinks actively about the health risk and action required to reduce that risk Issue of change is on the individual’s agenda but no action is planned	Provide information focused on short and intermediate gains from behavioral change, as well as long-term benefits Doubtful, dire, and distant impacts are less effective	Reinforce increase in exercise level, reduction in cough, financial savings, serving as example to children, protection of fetus, etc. Continue to inform of longer term effects on health
	Establish baseline to assess severity of the problem; focus attention on the problem and provide basis for comparison	Develop log of timing, frequency, and quantity of smoking, as well as associated events
*Preparation*	*Plan change*
Prepare for action, including developing a plan and setting a timetable	Set specific measurable and obtainable goals with deadlines	Quit date or possible tapering if heavy smoker
	Two or more well-chosen simultaneous interventions may maximize effectiveness	Family support, peer support, individual planning, medication, etc., may reinforce and multiply impacts
	Recognize habitual nature of existing behavior and remove associated activities	Remove cigarettes, ashtrays, and other associated smoking equipment Remove personal and environmental impacts of past smoking, such as teeth cleaning and cleaning of drapery Anticipate temptations, such as associations with food, drink, and social occasions
*Action*	*Reinforce change*
Observable changes in behavior with potential for relapse	Provide/suggest tangible rewards	Provide rewards, such as alternative use of money, focus on personal hygiene or personal environment
	Positive feedback and encouragement of new behavior Anticipate adverse effects and frustrations	Focus on measurable progress toward new behavior Provide receptive environment, but avoid focus on excuses Take short-term, one-day-at-a-time approach Recognize potential for symptoms to worsen at first before improvement occurs Anticipate potential for weight gain and encourage exercise and other behaviors to reduce potential for weight gain
	Utilize group/peer support	Family and peer reinforcement critical during action phase
*Maintenance*	*Maintain change*
New behavior needs to be consolidated as part of permanent lifestyle change	Practice/reinforce methods for maintaining new behavior	Avoid old associations and prepare/practice response when encountering old circumstances
	Recognize long-term nature of behavioral change and need for supportive peers and social reinforcement	Negative social attitudes toward smoking among peers and society along with social restrictions, such as limiting public indoor smoking, and social actions, such as taxation, help prevent smoking and reinforce maintenance of cessation

Data from Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983;51:390–395.

FIGURE 4-1 Theory of Planned Behavior and Flu Vaccine

Data from Azjen I and Drive BL. Prediction of leisure participation from behavioral, normative, and control beliefs: an application of the theory of planned behavior. Leisure Science 13:185-204, 1991.

One of the most commonly used interpersonal theories is the Social Cognitive Theory. The Social Ccognitive Theory, originally known as the Social Learning Theory, focuses on the interaction between individuals and their social systems. According to the theory, changing behavior requires an understanding of:

• Individual characteristics, such as knowledge, skills, and beliefs

• Influences in the social and physical environment, such as peer influence, level of family support, characteristics of the neighborhood, and work and school environments that help or hinder opportunities for health

• Interaction among all these factors

A key concept of the theory is reciprocal determinism, the dynamic interplay among personal factors, the environment, and behavior. The theory proposes that changing one of these factors will change them all. 19 Figure 4-2 illustrates the concept of reciprocal determinism.

Social Cognitive Theory can be applied to a wide variety of public health issues that encompass the complex interactions between individual characteristics, influences in the social system, and individual behavior. Addiction to drugs, alcohol, and tobacco are such public health issues. Illicit drug use, the use and abuse of illegal drugs, has been on the rise in the United States, with 2011 estimates indicating nearly 9% of the U.S. population had used an illicit drug or abused a psychotherapeutic medication in the past month. 20 Over 50% of adults in the United States aged 18 years and older are current regular drinkers, consuming at least 12 drinks in the past year. 21 Tobacco use in the United States is on the decline, falling from 26% to 22% of the population aged 12 years and older between 2002 and 2011. 20 Table 4-8 illustrates application of the Social Cognitive Theory to drug addiction.

FIGURE 4-2 Reciprocal Determinism

Data from Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall, 1986.

Population and Community Level

Theories and models on the population, or community, level explore factors within social systems, offering strategies that can be used to alter these factors to address health issues within the population. Theories and models on the community level are typically viewed as change theories guiding strategies that change aspects within the social systems, such as norms, rules, regulations, policies, and laws. This contrasts with theories and models on the intrapersonal and interpersonal levels, which are viewed as explanatory theories because they primarily identify and describe reasons for a problem.

A commonly used community-level theory is the Diffusion of Innovation. This theory focuses on how a new idea, product, or social practice (an innovation) is disseminated and adopted in a population. The theoretical constructs include the innovation itself, the time it takes to adopt the innovation, the communication channels used to transmit the innovation, and the social system in which diffusion of the innovation takes place. 22

The theory proposes that the diffusion and adoption, or rejection, of an innovation is affected by perceived attributes of the innovation, including relative advantage (Is the innovation better than what it will replace?), compatibility (Does the innovation fit with the values and needs of the intended audience?), complexity (Is the innovation easy to understand and use?), trialability (Can the innovation be tried before making a decision to adopt?), and observability (Are the results of the innovation observable and easily measureable?).

The diffusion of innovation theory has contributed the concept of different types of adopters, including early adopters (those who seek to experiment with innovative ideas), early majority adopters (often opinion leaders whose social status frequently influences others to adopt the behavior), and late adopters (or laggards—those who need support and encouragement to make adoption as easy as possible).

A different approach is often needed to engage each of these groups. For instance, marketing efforts may initially target early adopters with an approach encouraging innovation and creativity. This may be followed by an approach to opinion leaders who can help the innovation or behavior change become mainstream. A different approach emphasizing ease of use and widespread acceptance may be most helpful for encouraging late adopters. Table 4-9 illustrates the innovation-decision process regarding the adoption of the new idea to sneeze into one’s elbow as a public health measure.

TABLE 4-8 Social Cognitive Theory and Drug Addiction

Construct	Description	Example: drug addiction
Self-efficacy	Belief in one’s ability to take action	“I am able to stop taking drugs.”
Observational learning (modeling)	Learning by watching others	“My best friend has been drug-free for three years.”
Expectations	The likely outcome of a particular behavior	“If I quit taking drugs, I will be able to hold a job and earn income.”
Expectancies	The value placed on the outcome of the behavior	“Being able to work and have an income is very important to me.”
Emotional arousal	Emotional reaction to a situation	“When I take drugs, I feel like I am out of control and that is very frightening.”
Behavioral capability	Knowledge and skills needed to engage in a behavior	“I know I need to seek professional assistance to quit my drug addiction and I know where and how to get that assistance.”
Reinforcement	Rewards or punishments for performing a behavior	“When I take drugs, people do not want to hang out with me. But when I am not taking drugs, I am surrounded by my friends and family.”
Locus of control	One’s belief regarding one’s personal power over events	“Only I can get myself drug-free.”

Data from Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall, 1986.

TABLE 4-9 Innovation-Decision Process: Diffusion of Innovation of Sneezing into Elbow

Stage	Description	Example
Knowledge	Before people can adopt an innovation, they must know it exists. Communication channels, such as media, friends, family members, and physicians, are influential in this stage.	Knowing sneezing into elbow exists as a public health measure
Persuasion	In the persuasion stage, people develop an opinion about the innovation. That opinion may be positive or negative. The perceived characteristics of the innovation are particularly influential in the persuasion stage.	Considering whether to begin sneezing into elbow Relative advantage: “Sneezing into your elbow is a lot better than sneezing into your hand.” Compatibility: “Sneezing into my elbow is consistent with my desire to prevent the spread of disease.” Complexity: “Sneezing into your elbow is easy to do.” Trialability: “I can give sneezing into my elbow a try.” Observability: “I have seen others sneeze into their elbows.”
Decision	During the decision stage, people decide to either adopt or reject an innovation.	Deciding to sneeze into elbow
Implementation	During the implementation stage, an innovation is tried.	Sneezing into elbow
Confirmation	During the confirmation stage, support is sought for the decision, so that there is either continued adoption, continued rejection, later adoption, or discontinuance of the innovation.	Continue to sneeze into elbow as a common practice that becomes a habit after continued use

Data from Rogers, E.M. (2003). Diffusion of Innovations. New York: Free Press.

HOW CAN THEORIES BE APPLIED IN PRACTICE?

Choosing a Theory/Model

Choosing which theory or model to use requires an understanding of the public health issue and population being addressed, but there is no set formula for which theory or model is most appropriate in every situation. Components from multiple theories and models may be used when addressing particular situations and populations. Even though there are no right and wrong theories and models to use in given situations, some guidance is helpful in selecting the theoretical framework. Hayden offers the following guidance in choosing a theory:23

1. Identify the health issue or problem and the population affected.

2. Gather information about the issue, population, or both.

3. Identify possible reasons or causes for the problem.

4. Identify the level of interaction (intrapersonal, interpersonal, or community) under which the reasons or causes most logically fit.

5. Identify the theory or theories that best match the level and the reasons or causes.

Planning Frameworks

Theory is useful in identifying points at which to intervene in an effort to protect and promote the health of populations. These points will vary depending on the issue and the population. For instance, assume that theory-guided research on colon cancer screening suggests that women are unlikely to get screened because they do not think they are susceptible to the disease, while men are unlikely to get screened because they are not encouraged or reminded to do so. Interventions aimed at addressing colon cancer screening would, therefore, vary for women and men. Perhaps an intervention for women would focus on raising awareness of colon cancer among women, whereas an intervention for men may focus on the role of physicians and significant others to encourage them to make an appointment.

A variety of approaches can be undertaken to apply theory to practice. Two useful approaches, social marketing and the PRECEDE-PROCEED framework, will be described.

In recent years, public health has begun to apply marketing approaches to try to better understand and change the health behaviors of groups of people—especially those who are at high risk for the health impacts of their behavior, such as cigarette smokers. Social marketing, a use and extension of traditional product marketing, has become a key component of a public health approach to behavioral change. 24 Social marketing campaigns were first successfully used in the developing world for promoting a range of products and behaviors, including family planning and pediatric rehydration therapy. In recent years, social marketing efforts have been widely and successfully used in developed countries, including such efforts as:

• The truth® campaign—Developed by the American Legacy Foundation, it aims to redirect the perception of smoking being seen as a teenage rebellion to the decision to not smoke being a rebellion against the alleged behavior-controlling tobacco industry.

The National Youth Anti-Drug campaign—It uses social marketing efforts directed at young people, including the “Parents. The Anti-Drug.” campaign.

• The VERB™ campaign—It focused on 9- to 13-year-olds, or “tweens,” with a goal of making exercise fun and “cool” for everyone, not just competitive athletes.

Social marketing incorporates the “4 Ps,” which are widely used to structure traditional marketing efforts. These are:

• Product: Identifying the behavior or innovation that is being marketed

• Price: Identifying the benefits, the barriers, and the financial costs

• Place: Identifying the target audiences and how to reach them

• Promotion: Organizing a campaign or program to reach the target audience(s)

Social marketing, like product marketing, often relies on what marketers call branding. Branding includes words and symbols that help the target audience identify with the service; however, it goes deeper than just words and symbols. It can be seen as a method of implementing the fourth “P,” or promotion. It also builds upon the first three “Ps”:

• Branding requires a clear understanding of the product or the behavior to be changed (product).

• Successful branding puts forth strategies for reducing the financial and psychological costs (price).

• Branding identifies the audience and segments of the audience and asks how each segment can be reached (place).

BOX 4-2 VERB™ Campaign

The VERB™ social marketing campaign was funded through the Centers for Disease Control and Prevention (CDC), which worked with advertising agencies to reach tweens and make exercise “cool.” After a series of focus groups and other efforts to define and understand the market, it was concluded that the message should not be one of improving health, but rather of having fun with friends, exploring new activities with a sense of adventure, and being free to experiment without being judged on performance.

Marketing efforts also identified barriers, including time constraints and the attraction of other activities, from social occasions to television to computers. In addition, barriers included lack of access to facilities, as well as negative images of competition, embarrassment, and the inability to become an elite athlete.

The VERB™ campaign implied action and used the tagline “It’s what you do.” Initial messages used animated figures of children covered with verbs being physically active. Later, messages turned these animated verb–covered kids into real kids actively playing. Widely used logos were developed and promoted as part of the branding effort. The VERB™ campaign partnered with television channels that successfully reach tweens, sponsored outreach events, and distributed promotional materials.

During the four years of the VERB™ campaign, tweens developed widespread recognition of the program and rated it highly in terms of “saying something important to me” and “makes me want to get more active,” with maximum levels of recognition of 64% and 68%, respectively. Despite the documented success of VERB™, it was discontinued because of cuts in the federal budget.

_______________

Data from Wong F, Huhman M, Asbury L, Mueller RB, McCarthy S, Londe P, et al. VERB™—A social marketing campaign to increase physical activity among youth. Prev Chronic Disease. 2004;3(1):1–7.

Thus, branding is the public face of social marketing, but it also needs to be integrated into the core of the marketing plan. d

Social marketing efforts in developing and developed countries have demonstrated that it is possible to change key health behaviors of well-defined groups of people, including adolescents, who are often regarded as the hardest to reach. An example of the use of social marketing to reach young people, the VERB™ campaign, is examined in Box 4-2. 25

The PRECEDE-PROCEED planning framework provides a structure to design and evaluate health education and health promotion programs through a diagnostic planning process followed by an implementation and evaluation process. There are nine steps of the framework, divided into two phases: PRECEDE and PROCEED. 26 e

Table 4-10 illustrates the nine steps of the PRECEDE-PROCEED framework. Theory is applied in each step of the PRECEDE-PROCEED framework, guiding researchers and practitioners in their decisions.

The diagnostic phase of PRECEDE consists of collecting data and information to understand societal needs (step 1: social assessment), prioritizing community needs (step 2: epidemiological assessment), identifying factors contributing to the health issue (step 3: behavioral and environmental assessment), identifying factors that must be in place to initiate and sustain behavioral change (step 4: educational and ecological assessment) and identifying policies, resources and other circumstances that may assist or hinder efforts (step 5: administrative and policy assessment).

TABLE 4-10 PRECEDE-PROCEED Framework and Application

Step	Description	Example: gun violence
*Diagnostic phase: PRECEDE*
1: Social assessment	Assess people’s perceptions of their own needs and quality of life through data collection activities such as surveys, interviews, focus groups, and observation.	Gun violence emerged as a major concern among community members through focus groups that were conducted to explore health and safety concerns in the community.
2. Epidemiological assessment	Determine which health problems are most important for which groups in a community, often by analyzing data from vital statistics, state and/or national surveys, etc. This step should assist in identifying subpopulations at high risk and provide data to set measurable objectives for the program.	Data from death certificates and crime reports reveals that the majority of deaths among males aged 24 years and younger in the community are due to gunshot wounds.
3. Behavioral and environmental assessment	Identify factors, internal and external to the individual, that contribute to the health issue of interest. Literature searches and theory application provide guidance during this step.	A literature search provides insight into factors contributing to gun violence among males aged 24 years and younger. Gang-related behavior is found to be frequent in populations with similar socioeconomic status as that of the target population.
4. Educational and organizational assessment	Preceding and reinforcing factors that initiate and sustain behavior change are identified, such as an individual’s knowledge, skills and attitudes, social support, peer influence, and availability of services.	Interventions aimed at males 16 years and younger are found to be most successful. Young males with older male role models are more likely to view gangs as negative and more likely to participate in sports and community service.
5. Administrative and policy assessment	Identify policies, resources, and circumstances that may help or hinder implementation of the intervention.	Communication system recently established between school system and law enforcement to report truancy and criminal behavior among student population. May assist in identifying subgroups to target intervention.
*Implementation and evaluation phase: PROCEED*
6. Implementation	The intervention is implemented.	After-school program implemented that incorporates educational, service-oriented, and physical activity components, led by males from the community. The program is tailored for males 12–16 years of age.
7. Process evaluation	Process evaluation assesses the extent to which the intervention was implemented as planned.	Evaluate how program activities were delivered.
8. Impact evaluation	Impact evaluation assesses the change in the factors identified in steps 3 and 4.	Evaluate gang associations among participants in the after-school programming.
9. Outcome evaluation	Outcome evaluation assesses the effect of the intervention on the health issue of interest.	Evaluate deaths due to gun violence in the community before and after intervention.

Data from Green LW, Kreuter MW (1999). Health Promotion Planning: An Educational and Ecological Approach (3rd edition). McGraw-Hill.

The implementation and evaluation phase of PROCEED begins with implementation of the strategies developed based on the findings from the PRECEDE phase in step 6. Knowing what works and what does not work is important across all public health interventions; therefore, evaluation is a critical component embedded within this planning model. In step 7, evaluation of the intervention components takes place to determine if the program is functioning the way it was intended, reaching the target population, etc. Step 8 evaluates the impact the intervention has on the factors being targeted. In step 9, outcomes of the intervention are evaluated to determine whether the intervention has affected the overall public health issue it set out to address.

As we have seen, understanding and applying social and behavioral theories are central to population health. Expect to see new theories emerge and existing theories be modified as we gain greater understanding of social and individual behaviors. Social and behavioral sciences play an important role in population health. Analyzing the factors that influence health behavior assists in developing targeted interventions to promote healthy behavior and reduce health disparities. Health behavior theories and models are important tools used to explain and predict health behavior, providing useful road maps for the development of health promotion strategies. Additional planning frameworks, such as social marketing and PRECEDE-PROCEED, are also employed throughout the development, implementation, dissemination, and evaluation processes, contributing to sound health behavior interventions aimed at preserving, promoting, and protecting the health of populations.