BEHAVIORAL DETERMINANTS

It is almost universally accepted that each case of disease arises as the result of a chain of events. The origin can usually be traced back to underlying "determinants" such as economic, social, or environmental conditions; war; or famine. At the other end of the chain is the individual case: the malnourished child, the case of cholera, or the accident victim. Somewhere among the intermediate links in the causal chain lie human behaviors, commonly termed "health behaviors" to illustrate their relevance to disease. The metaphor of a chain does not do justice to the complexity, however, for there are mutually reinforcing relationships among each of these causal stages that can be very hard to alter. Behavior, for example, is influenced by social environment and culture, but also contributes to sustaining that culture. Likewise, behavior influences the risk of disease, but is in turn influenced by disease or the fear of disease. For example, the death of a friend from heart disease may stimulate a person to have his or her blood pressure checked, and to join an exercise program.

Nonetheless, behaviors directly influence the risk of disease and are among the few modifiable risk factors that exist for some diseases. Tobacco smoking, drug use, lack of physical exercise, excess alcohol consumption, inappropriate nutrition, failure to use safety equipment including automobile seat belts, and failure to follow preventive guidelines are all associated with elevated risk of disease or death. The relationship is sufficiently convincing that the question is not one of whether public health programs should seek to modify behavior, but how.

Health behaviors rarely occur in isolation, but cluster in patterns that in combination influence a person's risk of disease. Thus the "sedentary lifestyle" of some people in industrial societies connotes a loose pattern of mutually influencing behaviors such as taking little exercise, eating foods of poor nutritional value, consuming calorific drinks, and perhaps also smoking cigarettes. While these factors do not determine disease in an inevitable sense, they place the person at elevated risk of obesity, high blood pressure, and subsequently of cardiovascular disease. Other unhealthful behavioral patterns include the connections among smoking, undernutrition, and drug taking, and those among alcohol consumption, aggression, and violence. Each of these patterns is reinforced by membership in a social milieu that brings similar people together, as well as by individual personality traits. Each pattern also tends to correspond to personal values and beliefs, which form the connection between behavior and culture. While all human behavior is learned, it quickly becomes habitual and less accessible to modification.

Because of the importance and yet the difficulty of modifying behavior, great attention has been paid to conceptual approaches to understanding health behavior. Theories include the Health Belief Model (Becker, 1980), the Theory of Reasoned Action (Ajzen, 1980), and many others, most of which focus on the forces that maintain behavior and how these may be changed. Several models propose stages of changing health behaviors, generally beginning with a period of precontemplation in which the person is not interested in change; interventions such as a smoking-cessation program would be premature and wasted (Prochaska, 1983). In the contemplation stage, preparatory cognitive changes are occurring and interventions can support the person's decision making process. The actual behavior is not altered until the stage of initiating change, and during this fragile phase there may be frequent relapses. There follows a long-term phase of maintenance of the change, during which the new behavior must be reinforced until it is finally incorporated into the person's normal behavior pattern. Such theories underscore the long-term nature of the process of altering health behaviors, and of the need to make a detailed behavioral diagnosis for each person and to tailor interventions to match his or her current stage of readiness to change.

Ian McDowell

(see also: Behavioral Change; Customs; Illness and Sick-Role Behavior; Lay Concepts of Health and Illness; Medical Sociology; Multifactorial Diseases; Self-Care Behavior; Smoking Behavior; Smoking Cessation )

Bibliography

Ajzen, I., and Fishbein, M. (1980). Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall.

Becker, M. H., and Maiman, L. A. (1980). "Strategies for Enhancing Compliance." Journal of Community Health 6:113–135.

Prochaska, J. O., and DiClimente, C. C. (1983). "Stages and Processes of Self-Change of Smoking: Toward an Integrative Model of Change." Journal of Consulting and Clinical Psychology 51:390–395.