A Framework for Prevention: Changing Health-Damaging To Health-Generating Life Patterns NANCY MILIO, PHD, RN
Abstract: A set of propositions is offered to provide a frame of reference for proposed strategies to improve healthful behavior by placing personal choicemaking in the context of societal option-setting. The health status of populations at a given point in time is seen as a result of customary personal choicemaking. These choices in turn are limited by both the perceived and actual options available to individuals, depending on their personal and their community's resources, from which to make choices. Most people, most of the time will make the easiest choices, i.e., will do the things, develop the patterns or life-styles, which seem to cost them less and/or from which they
will gain more of what they value in tangible and/or intangible terms. The range of options available to them, and the ease with which they may choose certain ones over others, is typically set by organizations, public and private, formal and informal. The more powerful the organization, i.e., the more effective it is in carrying out its policies, the more it affects the options available to other organizations and populations, whether or not these effects are immediately perceived by individuals in their day-by-day choicemaking. Implications for health education strategies are noted. (Am. J. Public Health 66:435-439, 1976)
It is a paradox that health professionals, in their efforts to improve people's health-related practices, seem to expect more of the ordinary consumer than they do of themselves. Almost all patient and consumer health education assumes, explicitly or implicitly, that if people know what is most healthful, they will do it. Perhaps the most obvious test of this assumption is to look at health professionals themselves. If knowing what is health-generating were directly related to doing, then surely we in the health field would be among the most robust in the nation, slim, agile, nonsmoking, temperate eaters of complementary protein, low fat and cholesterol, low-sucrose, and nonrefined carbohydrate foods, avoiders of drugging levels of alcohol and other artificial mood-changers, evenly paced in our daily patterns. This picture is obviously nonexistent. Nor do we expect it to exist. Most will recognize that it is not much more likely for a physician earning $85,000 a year to change his life pattern than for a $6,000 a year hospital aide to do so. However, the potential for lifestyle change, the array of options available to these two individuals, may differ considerably. The point is that most human beings, professional or
nonprofessional, provider or consumer, make the easiest choices available to them most of the time, and not necessarily because of what they know is most healthful. Thus, if it is agreed that health-promoting life patterns are a good thing, then the focus for changing behavior should be on the problem of how to make health-generating choices more easy, and how to make health-damaging choices more difficult.
Dr. Milio is Associate in Nursing, Simmons College, and Director, Alternatives in Health Care, 255 Massachusetts Avenue, No. 1010, Boston, MA 021 15. Address reprint requests to her at the above address. This paper, based on concepts presented by the author in the Sybil Palmer Bellos Memorial Lecture at Yale University School of Nursing, April 9, 1975, was submitted to the Journal on October 8, 1975, revised and accepted for publication January 16, 1976.
AJPH May, 1976, Vol. 66, No. 5
A Time for Change There is increasing national and even international interest in the problems of "primary prevention" of disease, "health education," "life-style changes," etc. This is occurring, in part, because of studies which indicate the historic and contemporary limitations of medical care for improving
the health of populations. Those limits include the narrowing impact that traditional, microbe and infestation-oriented preventive programs can have on the modern profile of chronic and degenerative illness and violent deaths.'"8 A more immediate impetus for serious attention to illness prevention is the uncontrolled rising costs of personal health services. This derives from the capital- and energyintensive nature of the inpatient facilities and technology which dominate health care organization, and is aggravated by inflation in the national economy. As greater shares of health care financing come from governmental sources, more concerted efforts will be made to control costs. One such major effort is to find ways to prevent major disease entities, principally chronic illnesses and accidents. Two recent developments are focused on this issue. One 435
MILIO
is the National Health Education and Promotion Bill which requires health education in delivery systems and sets up mechanisms for nationwide development, testing, and dissemination of methods to promote health-generating behavior. Another important event was the National Conference on Preventive Medicine. Studies cited above, the 1300 pages of Senate health education hearings, and many Conference Task Force papers thoroughly review the "state-of-the-art" of disease prevention, and document the limitations of contemporary health services. These will not be reiterated
here.9' 10 Recommendations from these sources concerning what needs to be done cover a broad spectrum. Some groups recommend educational programs in the elementary schools, in adult education classes, in health services settings using small group techniques; or for the general public, using the media and other advertising and mass communications methods. Others emphasize federal policy changes not directly related to personal health services or to conventional education-information-persuasion methods, such as placing a high tax on cigarettes, the funds to be used in the research and treatment of lung disease. What follows here is a preliminary effort to place in context, as an interrelated set of working hypotheses, the wellfounded but seemingly divergent recommendations of numerous groups actively concerned with the problem of enhancing health-promoting life patterns and/or discouraging health-damaging habits.
A Set of Propositions 1. The health status ofpopulations is the result of deprivation andlor excess of critical health-sustaining resources. Health-sustaining resources include the seminal ones (e.g., food) or the synergistic ones (e.g., basic education, health services). In any population those subgroups which are deprived of sufficient and safe food, water, shelter, and environment have great vulnerability to acute, infectious disease processes. The poor in Third and Fourth World countries are the most stark examples. The population subgroups which are affluent have disease resulting from too much food (e.g., obesity and hypertension) of the highest cost varieties (e.g., meat, concentrated sucrose, refined carbohydrates, and fats); alcoholic, caffeinated and other drinks, and other dangerous relaxants (e.g., drugs, smoking, passive use of leisure); too rapid transportation and communication-often resulting in accidents and in stressful work overloads dealt with in sedentary posture. Excessive environmental pollution arises from the production-consumption patterns of this affluent way of life. Affluent urban Americans are the best example. Somewhere between the very poor and the affluent are the population subgroups, having a low-income but living in a relatively affluent or "advanced" society. Low-income Americans are not only more vulnerable to acute disease relative to their affluent counterparts, but also sustain more of the chronic degenerative illnesses and accidents which are integral to the affluence of the wider society. The cigarettes, 436
sucrose, cars, pollutants, and tensions are readily available to the poor, while at the same time they are deprived of the level of protection afforded by the quality of food, shelter, and environment which sustain the more affluent. The poor not only succumb more readily to virtually all disease processes, they also possess fewer options for getting the damage repaired or contained through the medical care system. These socioeconomic realities thus form the basis for the typical life-style or behavior patterns which result in the varying illness profiles of different population subgroups.' -16 2. Behavior patterns ofpopulations are a result of habitual selection from limited choices, and these habits of choice are related to: (a) actual and perceived options available; (b) beliefs and expectations developed and refined over time by
socialization, formal learning, and immediate experience. Ordinary, "average," day-to-day behavior stems from daily choices that are relatively set and no longer consciously made. These choices have been limited by what is actually available to groups of people and what they perceive to be available or possible. Their knowledge of the possible and their perceptions are influenced by what they have learned in the past, informally and non-verbally as well as formally, and by what they experience.17 Applied to consumers, this is a point at which new health information and knowledge may influence individual choice-making under certain conditions. 3. Organizational behavior (decisions or policy-choices made by governmentallnongovernmental, nationallnon-national; non-profit/for-profit, formallnon-formal organizations) sets the range of options available to individuals for their personal choice-making. Organizational decisions directly affect the options available to people and/or their awareness of those options and/or the ease with which they may make daily, habitual, selections.'7" 8 For example, federal policy decisions concerning taxation, business subsidies, tax incentives, and import-export restrictions affect whether and how much of such items as cigarettes and palatable soy protein will be available, how widely distributed and advertised, and at what price. These decisions set the array of options available to various economic and geographic populations concerning the ease with which they may or may not choose such items. As another example, combinations of policy choices by such organizations as city government and public and private housing, transportation, and banking firms concerning land use set the range of options available to population subgroups concerning where they may or must live and work, and the means and speed of their transportation (therefore how physically active they may be, how fatiguing or compact their day, how clean their air). Such policies also determine which of the available array of options are the easier. National governmental decisions concerning the political economy in a country such as China stand in marked contrast to those in the U.S.A. The result in China has produced forms of social organization such as rural communes and urban neighborhood and industrial-worker networks which facilitate collective decision-making within organizations. Collective or small-group decision-making can then become a mechanism by which participants can develop new options AJPH May, 1976, Vol. 66, No. 5
FRAMEWORK FOR PREVENTION
for themselves as well as be supported in the reinforcement of the new choices which they make, concerning community and personal health care among other things.'9 -22 4. The choice-making of individuals at a given point in time concerning potentially health-promoting or healthdamaging selections is affected by their effort to maximize valued resources. Choice is therefore related to the type and amount of: (a) their personal resources: their awareness, knowledge, beliefs and skills; those of family, friends, and of other primary (small, face-to-face) groups; available money and time; convenience concerning distance, travel, transportation; the urgency of other priorities; and (b) societal (community and national) resources: the availability of health-sustaining services and resources in terms of cost, distance or location, type, comprehensiveness, program outreach components (e.g., food, housing, income maintenance, environmental protection, health services); alternatives to formal services; penalties or losses incurred, or rewares given, for selection or failure to select given options. All of these resources implicitly or explicitly limit or widen the array of options available to individuals for retaining or altering health-related habitual choices, and determine the ease with which new, possibly more healthful choices may be made. Any change in pattern would involve some effort or cost and some actual and/or perceived gain. An example might be the $85,000 a year physician and the $6,000 a year aide, both of whom have mild hypertension and each of whom would benefit by a more healthful life style. Given that both are made aware of what shifts in behavior would be most likely to have health-enhancing effects, it is quite apparent that the physician has a potentially greater opportunity to adopt a more health-promoting pattern of daily choices because of his personal resources. The physician may conceivably slow the pace of his life by choosing to live closer to his work in the urban medical center in a quiet townhouse. He may take more frequent vacations as a means to relax and thereby diminish the need for cigarettes, alcoholic drinks, or other drugs. He would have no serious financial problem in obtaining palatable meals within caloric-cholesterol-sodium limits in restaurants or specially prepared for him alone. Medical center fringe benefits would allow him ample sick leave, medical insurance, pension, and other supportive resources. The aide earning $6,000, typically a woman, possibly with adolescent children, has fewer options for making new choices. There is virtually no chance for her to find even a low-paying job in a less hectic environment. Without rapid transit, moving the household to a less congested area is out of the question, even if such housing were available. To work fewer hours is not an option since her husband is sporadically employed at best. Besides, taking too much time off may risk her job security. There is little extra time or money to change the family's customary diet, and food and cigarettes are two of the very few options left for relaxation and pleasure. Neither friends nor family, though willing, have enough resources to share to make a difference. The medical AJPH May, 1976, Vol. 66, No. 5
clinic which diagnosed her condition has no consistent methods to intervene and offer help in her home situation. For either individual, the physician or the aide, the personal and societal resources will not determine whether or not they will alter their life patterns. But those resources will make the likelihood that each one can change-given an initial moderate willingness to do so-either more or less a possibility. This is because of the array of options before them, and because some of those options, health-promoting or health-damaging in their net effects, are easier to choose than others. 5. Social change may be thought of as changes in patterns of behavior resulting from shifts in the choice-making of significant numbers of people within a population. In order then for life-style patterns to alter among individuals in numbers sufficient to affect the incidence of major diseases, new, health-promoting options must be available, and more readily so than health-damaging options, i.e., in such a way as to be less costly in dollar and other costs. People also must be aware of the new options and of what they can gain from selecting them relative to their former choices. 6. Health education, as the process of teaching and learning health-supporting information can have little significantly extensive impact on behavior patterns, that is, on personal choice-making of groups of people, without the easy availability of new, or newly-perceived alternative healthpromoting options for investing personal resources. Typically, what has been regarded as health education has focused on providing consumers with information or knowledge in order to make them aware of the costs and benefits to their health to be derived from particular behaviors. The relative lack of other options from which to choose new behavior patterns has not been dealt with realistically, particularly for outcast groups, such as rural and lower income. It is not enough to make people knowledgeable about healthpromoting choices. The other side of the coin is to provide ready access to health-promoting options.'0023-25 The strategy of making health-promoting options easier is implicit in the small group approach to behavior change, e.g. weight-reduction, cessation of smoking or alcohol consumption. By becoming an integral part of a group which approves of certain choices, individuals can more easily make such choices. Thus by choosing low calorie foods they gain the short term reward of group approval and avoid its disapproval, as well as gaining the longer term reward of weight reduction. The reward is apparently greater than in the typical individual counseling method, making the group approach the more successful.'0 However, the small group approach is limited for several reasons. It is costly to individuals in both time and money, and would be very costly to the delivery system were it applied extensively enough to impact on the behavior of large populations. Its benefits, measured in terms of impact on groups of people, are not very efficient. This approach has successfully reached just over an estimated 2 per cent of all smokers; further, as another common example, up to 4 out of 5 members of weight control groups may drop out. There is also some question as to whether the changes in be437
MILIO
havior that do occur are large enough to be clinically significant.26-28 In one report, a mass media approach was combined with small group techniques for clinically high-risk groups. There was an increase in knowledge and change in attitudes concerning health-relevant choice-making, but relatively little change in actual behavior. Change included a lessening, but not cessation of smoking, and a drop in the number of eggs eaten-a change which also occurred in the non-experimental population apparently related to the economic situation of the communities involved.29 Choice-making regarding physical activity and exercise was unchanged. This non-change is understandable in terms of the earlier discussion about gains and losses of resources. Activity patterns reflect daily concentrations of work, job, leisure, housing location, available transportation, family responsibilities, etc. As such, they are integral to both family and community choice-making. Even a strong desire by an individual to alter and increase his or her physical activity would require a sustained effort if the readily available options in the family-home, job-community favor time-consuming and sedentary or light activities. Under these conditions, a burst of effort at increased exercise is likely to subside and accommodate again to customary, more readily-taken options for less physically exerting activity patterns of household and
community.30 The small group approach seems somewhat more efficient when applied to patients, especially those who are seriously ill.9 31 This again is understandable. III people have relatively more to gain by making choices which will diminish their symptoms and restore their ability to live more painlessly and with less effort. As awareness of the limitations of traditional health education grows, a contemporary concept is developing which includes, along with information and motivation, changemaking in the living environment, conceivably to the broadening of healthful options for personal choice-making.32 There is also evidence of more comprehensive and planned approaches to health education, with increasing emphasis on cost-effectiveness and the evaluation of results, including the measurement of changes in behavior and health status. 9' 33-37
Summary These hypotheses provide a framework in which health status of populations at a given point in time is viewed as the outcome of customary personal choice-making. These choices in turn are limited by the actual and perceived options available to individuals, which reflect their personal and their community's resources. Most people, most of the
time will make the easiest choices, that is, will develop the patterns of behavior or life-styles which seem to cost them less and/or from which they will gain more of what they value in tangible and/or intangible terms. The range of options available to populations, and the ease with which they may choose certain ones over others, is typically set by organizations, public and private, non-profit 438
and for-profit, formal and informal. This is done through the organizations' capacity to determine policy choices which affect the allocation and distribution of various kinds of amounts of goods and services and their price, direct or indirect, to the user. The more powerful the organization, that is, the more effective it is in carrying out its policies, the more it affects the options available to other organizations and populations, whether or not these effects are immediately perceived by individuals in their day-by-day choice-making. Implicit in this view of organizational decision-making and individual choice-making as they affect health-relevant patterns is the notion of a pyramid of decisions. The decisions taken at the "higher", more powerful organizational levels, set the range of options available at lower levels. This may be seen in the ways in which both federal government or multinational and large scale corporation policies concerning food, energy, transportation, or antipollution enforcement ultimately affect not only the policy-choices of public and private bodies at state and local levels, but also the individual in his and her daily choices about diet, residence, exercise and pace of life. ' 8
Implications Given this framework, strategies for encouraging health-promoting choices may also be put in perspective. Their minimal aim, for example, might be to broaden the range of options available to people and to make healthpromoting choices easier and/or to diminish health-damaging options by making them more difficult to choose. For the most widespread impact, the focus might be on national-level policy-making which would in turn change the range of options for the largest number of people, i.e., the national population. Selected populations, those most vulnerable to ill health because of the limited healthful options available to them, might also receive special attention. This frame of reference can also help assess or project the relative effectiveness of various efforts at behavior change. For example, a local effort at conveying more knowledge about healthful diets is not likely to result in changes of eating patterns unless it is accompanied by a combination of healthful, low cost, readily available foods-changes which require effort beyond the individual or small group methods, and extend to the community public and private organizational structure. The question may be raised that this perspective suggests a manipulation of behavior, a constraint on freedom. Quite the contrary, since as this discussion shows, current policy and allocative decisions clearly constrain personal choice-making, even if not so perceived by many people. This framework rather suggests strategies which will enhance the freedom to choose, making it readily possible for individuals and groups who now have difficult options to create healthful lifestyles. Those who wish to pursue healthdamaging patterns would still be able to do so. These are working hypotheses, not yet sufficiently refined to be fully testable. Hopefully, passage of an adequate AJPH May, 1976, Vol. 66, No. 5
FRAMEWORK FOR PREVENTION
National Health Education and Promotion Act will make possible the development and testing of such models in order to help health professionals and consumers focus effectively on the prevention of disease rather than on its repair or containment.
19.
20.
REFERENCES 1. Freymann, J., Medicine's great schism: prevention vs. cure: an historical interpretation". Med. Care, 13:525-36, 1975. 2. Powles, J., On the limitations of modem medicine. Science, Medicine and Society, 1:1-30, 1973. 3. McKeown, T., et al, An interpretation of the modem rise of population in Europe. Population Studies, 26:345-83, 1972. 4. Illich, I., Medical Nemesis, London: Calder & Boyars, 1975. 5. Carlson, R., The End of Medicine, New York: Wiley, 1975. 6. Screening for Disease (series) Lancet. Oct. 5 through Dec. 14, 1974. 7. Cochrane, A. L., Effectiveness and Efficiency, London: Nuffield Provincial Hosp. Trust, 1972. 8. Minister of National Health and Welfare, A New Perspective on the Health of Canadians: A Working Document, Ottawa: Govt. of Canada, 1974. 9. U.S. Senate, Hearings on National Health Promotion and Education 1975, Subcomm. on Health, May 7-8, 1975, Wash., D.C. Senate-passed S. 1467 10. Task Force Reports for the National Conference on Preventive Medicine, inclusions in Hearings, op. cit. 11. National Center for Health Statistics. Vital and Health Statistics Series from the ongoing Health Interview Survey, the Health Examination Survey, Health and Nutrition Survey, National High Blood Pressure Survey, Rockville, MD: HEW, Health Resources Administration, 1973. 12. Milio, N., et al., Simiplified Primary Care Data Guide (in preparation). 13. Milio, N., The Care of Health in Communities: Access for Outcasts, New York: Macmillan, 1975. 14. Puffer, R., and Serrano, V., Patterns of Mortality in Childhood, D.C.: Pan Am. Health Org., 1973. 15. Hinkle, L., Ecological observations of the relation of physical illness, mental illness, and the social environment, Psychosom. Med. 23:289-97, 1961. 16. Cairns, J., The cancer problem, Scient. Am. Nov., 1975. 17. Moss, G., Illness, Immunity, and Social Interaction: The Dynamics of Biosocial Resonation, New York: Wiley, 1973, Chapter 3. 18. Waldron, I., and Eyer, J., Socioeconomic causes of the recent
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21. 22. 23. 24.
25. 26. 27.
28. 29. 30. 31. 32. 33. 34.
35.
36. 37.
rise in death rates for 15-24 year-olds, Soc. Sc. and Med. 9:38396, 1975. Milio, N., Organization and Power: The Israeli Kibbutz and Chinese Commune. A Comparative Study in Social Organization (unpub. manuscript), Yale University Departments of Sociology and Far Eastern Studies, May, 1969. Milio, N., Co-mingling rings: can organizations become self-renewing? Intention: A J. of Alternative Institutions, June, 1971. Terrill, R., The 800,000: The Real China, Boston: AtlanticLittle-Brown Books, 1972. Newell, K., Ed. Health by the People, Geneva: WHO, 1975. Stycos, J. M., The Clinic and Information Flow, Ithaca, N.Y.: Cornell Univ., 1974. Coburn, D., and Pope, C., Socioeconomic status and preventive health behavior, J. Health and Social Behavior, 15:67-78, 1974. Steele, J., and McBroom, W., Conceptual and empirical dimensions of health behavior, J. Health and Social Behavior, 13:38292, 1972. Farquhar, J., Interdisciplinary approaches to heart disease prevention inclusion, Hearings, op. cit. Green, L., Diffusion and adoption of innovations related to cardiovascular risk behavior in the public, report included in Hearings, op. cit. Pomerlau, O., et al., Role of behavior modification in preventive medicine, N. Eng. J. Med. 292:1277-82, 1975. Maccoby, N., Achieving behavior change via mass media and interpersonal communication, in Hearings, op. cit. Institute for Communications Research, Annual Report 197374, Calif.: Stanford Univ., Oct., 1974. Rosenberg, S., A Case for Patient Education, Hospital Formulary Management, 6:1-4, 1971. Toward a National Policy of Health Promotion and Consumer Health Education, Task Force Report IV National Conference on Preventive Medicine, June 9-11, 1975, Wash., D.C. Simmons, J., Ed. Making Health Education Work, AJPH (suppl.) 65: Oct., 1975. APHA Committee on Educational Tasks in Chronic Illness, A Model for Planning Patient Education, Wash., D.C.: NIH, Oct., 1970. Kucha, D., Guidelines for Implementing An Ambulatory Consumer Health Information System: A Handbook for Health Education, Texas: U.S. Army-Baylor University Graduate Research Series, 1973. Young, M., Review of research and studies related to health education practice, Health Education Monographs series in vols. 23-28, 1967-69. Green, L., and Figa-Talamanca, I., Suggested designs for evaluation of patient education programs, Health Education Monographs, 2:54-71, 1974.
439
Abstract: A set of propositions is offered to provide a frame of reference for proposed strategies to improve healthful behavior by placing personal choicemaking in the context of societal option-setting. The health status of populations at a given point in time is seen as a result of customary personal choicemaking. These choices in turn are limited by both the perceived and actual options available to individuals, depending on their personal and their community's resources, from which to make choices. Most people, most of the time will make the easiest choices, i.e., will do the things, develop the patterns or life-styles, which seem to cost them less and/or from which they
will gain more of what they value in tangible and/or intangible terms. The range of options available to them, and the ease with which they may choose certain ones over others, is typically set by organizations, public and private, formal and informal. The more powerful the organization, i.e., the more effective it is in carrying out its policies, the more it affects the options available to other organizations and populations, whether or not these effects are immediately perceived by individuals in their day-by-day choicemaking. Implications for health education strategies are noted. (Am. J. Public Health 66:435-439, 1976)
It is a paradox that health professionals, in their efforts to improve people's health-related practices, seem to expect more of the ordinary consumer than they do of themselves. Almost all patient and consumer health education assumes, explicitly or implicitly, that if people know what is most healthful, they will do it. Perhaps the most obvious test of this assumption is to look at health professionals themselves. If knowing what is health-generating were directly related to doing, then surely we in the health field would be among the most robust in the nation, slim, agile, nonsmoking, temperate eaters of complementary protein, low fat and cholesterol, low-sucrose, and nonrefined carbohydrate foods, avoiders of drugging levels of alcohol and other artificial mood-changers, evenly paced in our daily patterns. This picture is obviously nonexistent. Nor do we expect it to exist. Most will recognize that it is not much more likely for a physician earning $85,000 a year to change his life pattern than for a $6,000 a year hospital aide to do so. However, the potential for lifestyle change, the array of options available to these two individuals, may differ considerably. The point is that most human beings, professional or
nonprofessional, provider or consumer, make the easiest choices available to them most of the time, and not necessarily because of what they know is most healthful. Thus, if it is agreed that health-promoting life patterns are a good thing, then the focus for changing behavior should be on the problem of how to make health-generating choices more easy, and how to make health-damaging choices more difficult.
Dr. Milio is Associate in Nursing, Simmons College, and Director, Alternatives in Health Care, 255 Massachusetts Avenue, No. 1010, Boston, MA 021 15. Address reprint requests to her at the above address. This paper, based on concepts presented by the author in the Sybil Palmer Bellos Memorial Lecture at Yale University School of Nursing, April 9, 1975, was submitted to the Journal on October 8, 1975, revised and accepted for publication January 16, 1976.
AJPH May, 1976, Vol. 66, No. 5
A Time for Change There is increasing national and even international interest in the problems of "primary prevention" of disease, "health education," "life-style changes," etc. This is occurring, in part, because of studies which indicate the historic and contemporary limitations of medical care for improving
the health of populations. Those limits include the narrowing impact that traditional, microbe and infestation-oriented preventive programs can have on the modern profile of chronic and degenerative illness and violent deaths.'"8 A more immediate impetus for serious attention to illness prevention is the uncontrolled rising costs of personal health services. This derives from the capital- and energyintensive nature of the inpatient facilities and technology which dominate health care organization, and is aggravated by inflation in the national economy. As greater shares of health care financing come from governmental sources, more concerted efforts will be made to control costs. One such major effort is to find ways to prevent major disease entities, principally chronic illnesses and accidents. Two recent developments are focused on this issue. One 435
MILIO
is the National Health Education and Promotion Bill which requires health education in delivery systems and sets up mechanisms for nationwide development, testing, and dissemination of methods to promote health-generating behavior. Another important event was the National Conference on Preventive Medicine. Studies cited above, the 1300 pages of Senate health education hearings, and many Conference Task Force papers thoroughly review the "state-of-the-art" of disease prevention, and document the limitations of contemporary health services. These will not be reiterated
here.9' 10 Recommendations from these sources concerning what needs to be done cover a broad spectrum. Some groups recommend educational programs in the elementary schools, in adult education classes, in health services settings using small group techniques; or for the general public, using the media and other advertising and mass communications methods. Others emphasize federal policy changes not directly related to personal health services or to conventional education-information-persuasion methods, such as placing a high tax on cigarettes, the funds to be used in the research and treatment of lung disease. What follows here is a preliminary effort to place in context, as an interrelated set of working hypotheses, the wellfounded but seemingly divergent recommendations of numerous groups actively concerned with the problem of enhancing health-promoting life patterns and/or discouraging health-damaging habits.
A Set of Propositions 1. The health status ofpopulations is the result of deprivation andlor excess of critical health-sustaining resources. Health-sustaining resources include the seminal ones (e.g., food) or the synergistic ones (e.g., basic education, health services). In any population those subgroups which are deprived of sufficient and safe food, water, shelter, and environment have great vulnerability to acute, infectious disease processes. The poor in Third and Fourth World countries are the most stark examples. The population subgroups which are affluent have disease resulting from too much food (e.g., obesity and hypertension) of the highest cost varieties (e.g., meat, concentrated sucrose, refined carbohydrates, and fats); alcoholic, caffeinated and other drinks, and other dangerous relaxants (e.g., drugs, smoking, passive use of leisure); too rapid transportation and communication-often resulting in accidents and in stressful work overloads dealt with in sedentary posture. Excessive environmental pollution arises from the production-consumption patterns of this affluent way of life. Affluent urban Americans are the best example. Somewhere between the very poor and the affluent are the population subgroups, having a low-income but living in a relatively affluent or "advanced" society. Low-income Americans are not only more vulnerable to acute disease relative to their affluent counterparts, but also sustain more of the chronic degenerative illnesses and accidents which are integral to the affluence of the wider society. The cigarettes, 436
sucrose, cars, pollutants, and tensions are readily available to the poor, while at the same time they are deprived of the level of protection afforded by the quality of food, shelter, and environment which sustain the more affluent. The poor not only succumb more readily to virtually all disease processes, they also possess fewer options for getting the damage repaired or contained through the medical care system. These socioeconomic realities thus form the basis for the typical life-style or behavior patterns which result in the varying illness profiles of different population subgroups.' -16 2. Behavior patterns ofpopulations are a result of habitual selection from limited choices, and these habits of choice are related to: (a) actual and perceived options available; (b) beliefs and expectations developed and refined over time by
socialization, formal learning, and immediate experience. Ordinary, "average," day-to-day behavior stems from daily choices that are relatively set and no longer consciously made. These choices have been limited by what is actually available to groups of people and what they perceive to be available or possible. Their knowledge of the possible and their perceptions are influenced by what they have learned in the past, informally and non-verbally as well as formally, and by what they experience.17 Applied to consumers, this is a point at which new health information and knowledge may influence individual choice-making under certain conditions. 3. Organizational behavior (decisions or policy-choices made by governmentallnongovernmental, nationallnon-national; non-profit/for-profit, formallnon-formal organizations) sets the range of options available to individuals for their personal choice-making. Organizational decisions directly affect the options available to people and/or their awareness of those options and/or the ease with which they may make daily, habitual, selections.'7" 8 For example, federal policy decisions concerning taxation, business subsidies, tax incentives, and import-export restrictions affect whether and how much of such items as cigarettes and palatable soy protein will be available, how widely distributed and advertised, and at what price. These decisions set the array of options available to various economic and geographic populations concerning the ease with which they may or may not choose such items. As another example, combinations of policy choices by such organizations as city government and public and private housing, transportation, and banking firms concerning land use set the range of options available to population subgroups concerning where they may or must live and work, and the means and speed of their transportation (therefore how physically active they may be, how fatiguing or compact their day, how clean their air). Such policies also determine which of the available array of options are the easier. National governmental decisions concerning the political economy in a country such as China stand in marked contrast to those in the U.S.A. The result in China has produced forms of social organization such as rural communes and urban neighborhood and industrial-worker networks which facilitate collective decision-making within organizations. Collective or small-group decision-making can then become a mechanism by which participants can develop new options AJPH May, 1976, Vol. 66, No. 5
FRAMEWORK FOR PREVENTION
for themselves as well as be supported in the reinforcement of the new choices which they make, concerning community and personal health care among other things.'9 -22 4. The choice-making of individuals at a given point in time concerning potentially health-promoting or healthdamaging selections is affected by their effort to maximize valued resources. Choice is therefore related to the type and amount of: (a) their personal resources: their awareness, knowledge, beliefs and skills; those of family, friends, and of other primary (small, face-to-face) groups; available money and time; convenience concerning distance, travel, transportation; the urgency of other priorities; and (b) societal (community and national) resources: the availability of health-sustaining services and resources in terms of cost, distance or location, type, comprehensiveness, program outreach components (e.g., food, housing, income maintenance, environmental protection, health services); alternatives to formal services; penalties or losses incurred, or rewares given, for selection or failure to select given options. All of these resources implicitly or explicitly limit or widen the array of options available to individuals for retaining or altering health-related habitual choices, and determine the ease with which new, possibly more healthful choices may be made. Any change in pattern would involve some effort or cost and some actual and/or perceived gain. An example might be the $85,000 a year physician and the $6,000 a year aide, both of whom have mild hypertension and each of whom would benefit by a more healthful life style. Given that both are made aware of what shifts in behavior would be most likely to have health-enhancing effects, it is quite apparent that the physician has a potentially greater opportunity to adopt a more health-promoting pattern of daily choices because of his personal resources. The physician may conceivably slow the pace of his life by choosing to live closer to his work in the urban medical center in a quiet townhouse. He may take more frequent vacations as a means to relax and thereby diminish the need for cigarettes, alcoholic drinks, or other drugs. He would have no serious financial problem in obtaining palatable meals within caloric-cholesterol-sodium limits in restaurants or specially prepared for him alone. Medical center fringe benefits would allow him ample sick leave, medical insurance, pension, and other supportive resources. The aide earning $6,000, typically a woman, possibly with adolescent children, has fewer options for making new choices. There is virtually no chance for her to find even a low-paying job in a less hectic environment. Without rapid transit, moving the household to a less congested area is out of the question, even if such housing were available. To work fewer hours is not an option since her husband is sporadically employed at best. Besides, taking too much time off may risk her job security. There is little extra time or money to change the family's customary diet, and food and cigarettes are two of the very few options left for relaxation and pleasure. Neither friends nor family, though willing, have enough resources to share to make a difference. The medical AJPH May, 1976, Vol. 66, No. 5
clinic which diagnosed her condition has no consistent methods to intervene and offer help in her home situation. For either individual, the physician or the aide, the personal and societal resources will not determine whether or not they will alter their life patterns. But those resources will make the likelihood that each one can change-given an initial moderate willingness to do so-either more or less a possibility. This is because of the array of options before them, and because some of those options, health-promoting or health-damaging in their net effects, are easier to choose than others. 5. Social change may be thought of as changes in patterns of behavior resulting from shifts in the choice-making of significant numbers of people within a population. In order then for life-style patterns to alter among individuals in numbers sufficient to affect the incidence of major diseases, new, health-promoting options must be available, and more readily so than health-damaging options, i.e., in such a way as to be less costly in dollar and other costs. People also must be aware of the new options and of what they can gain from selecting them relative to their former choices. 6. Health education, as the process of teaching and learning health-supporting information can have little significantly extensive impact on behavior patterns, that is, on personal choice-making of groups of people, without the easy availability of new, or newly-perceived alternative healthpromoting options for investing personal resources. Typically, what has been regarded as health education has focused on providing consumers with information or knowledge in order to make them aware of the costs and benefits to their health to be derived from particular behaviors. The relative lack of other options from which to choose new behavior patterns has not been dealt with realistically, particularly for outcast groups, such as rural and lower income. It is not enough to make people knowledgeable about healthpromoting choices. The other side of the coin is to provide ready access to health-promoting options.'0023-25 The strategy of making health-promoting options easier is implicit in the small group approach to behavior change, e.g. weight-reduction, cessation of smoking or alcohol consumption. By becoming an integral part of a group which approves of certain choices, individuals can more easily make such choices. Thus by choosing low calorie foods they gain the short term reward of group approval and avoid its disapproval, as well as gaining the longer term reward of weight reduction. The reward is apparently greater than in the typical individual counseling method, making the group approach the more successful.'0 However, the small group approach is limited for several reasons. It is costly to individuals in both time and money, and would be very costly to the delivery system were it applied extensively enough to impact on the behavior of large populations. Its benefits, measured in terms of impact on groups of people, are not very efficient. This approach has successfully reached just over an estimated 2 per cent of all smokers; further, as another common example, up to 4 out of 5 members of weight control groups may drop out. There is also some question as to whether the changes in be437
MILIO
havior that do occur are large enough to be clinically significant.26-28 In one report, a mass media approach was combined with small group techniques for clinically high-risk groups. There was an increase in knowledge and change in attitudes concerning health-relevant choice-making, but relatively little change in actual behavior. Change included a lessening, but not cessation of smoking, and a drop in the number of eggs eaten-a change which also occurred in the non-experimental population apparently related to the economic situation of the communities involved.29 Choice-making regarding physical activity and exercise was unchanged. This non-change is understandable in terms of the earlier discussion about gains and losses of resources. Activity patterns reflect daily concentrations of work, job, leisure, housing location, available transportation, family responsibilities, etc. As such, they are integral to both family and community choice-making. Even a strong desire by an individual to alter and increase his or her physical activity would require a sustained effort if the readily available options in the family-home, job-community favor time-consuming and sedentary or light activities. Under these conditions, a burst of effort at increased exercise is likely to subside and accommodate again to customary, more readily-taken options for less physically exerting activity patterns of household and
community.30 The small group approach seems somewhat more efficient when applied to patients, especially those who are seriously ill.9 31 This again is understandable. III people have relatively more to gain by making choices which will diminish their symptoms and restore their ability to live more painlessly and with less effort. As awareness of the limitations of traditional health education grows, a contemporary concept is developing which includes, along with information and motivation, changemaking in the living environment, conceivably to the broadening of healthful options for personal choice-making.32 There is also evidence of more comprehensive and planned approaches to health education, with increasing emphasis on cost-effectiveness and the evaluation of results, including the measurement of changes in behavior and health status. 9' 33-37
Summary These hypotheses provide a framework in which health status of populations at a given point in time is viewed as the outcome of customary personal choice-making. These choices in turn are limited by the actual and perceived options available to individuals, which reflect their personal and their community's resources. Most people, most of the
time will make the easiest choices, that is, will develop the patterns of behavior or life-styles which seem to cost them less and/or from which they will gain more of what they value in tangible and/or intangible terms. The range of options available to populations, and the ease with which they may choose certain ones over others, is typically set by organizations, public and private, non-profit 438
and for-profit, formal and informal. This is done through the organizations' capacity to determine policy choices which affect the allocation and distribution of various kinds of amounts of goods and services and their price, direct or indirect, to the user. The more powerful the organization, that is, the more effective it is in carrying out its policies, the more it affects the options available to other organizations and populations, whether or not these effects are immediately perceived by individuals in their day-by-day choice-making. Implicit in this view of organizational decision-making and individual choice-making as they affect health-relevant patterns is the notion of a pyramid of decisions. The decisions taken at the "higher", more powerful organizational levels, set the range of options available at lower levels. This may be seen in the ways in which both federal government or multinational and large scale corporation policies concerning food, energy, transportation, or antipollution enforcement ultimately affect not only the policy-choices of public and private bodies at state and local levels, but also the individual in his and her daily choices about diet, residence, exercise and pace of life. ' 8
Implications Given this framework, strategies for encouraging health-promoting choices may also be put in perspective. Their minimal aim, for example, might be to broaden the range of options available to people and to make healthpromoting choices easier and/or to diminish health-damaging options by making them more difficult to choose. For the most widespread impact, the focus might be on national-level policy-making which would in turn change the range of options for the largest number of people, i.e., the national population. Selected populations, those most vulnerable to ill health because of the limited healthful options available to them, might also receive special attention. This frame of reference can also help assess or project the relative effectiveness of various efforts at behavior change. For example, a local effort at conveying more knowledge about healthful diets is not likely to result in changes of eating patterns unless it is accompanied by a combination of healthful, low cost, readily available foods-changes which require effort beyond the individual or small group methods, and extend to the community public and private organizational structure. The question may be raised that this perspective suggests a manipulation of behavior, a constraint on freedom. Quite the contrary, since as this discussion shows, current policy and allocative decisions clearly constrain personal choice-making, even if not so perceived by many people. This framework rather suggests strategies which will enhance the freedom to choose, making it readily possible for individuals and groups who now have difficult options to create healthful lifestyles. Those who wish to pursue healthdamaging patterns would still be able to do so. These are working hypotheses, not yet sufficiently refined to be fully testable. Hopefully, passage of an adequate AJPH May, 1976, Vol. 66, No. 5
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National Health Education and Promotion Act will make possible the development and testing of such models in order to help health professionals and consumers focus effectively on the prevention of disease rather than on its repair or containment.
19.
20.
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