PREVENTIVE
MEDICINE
5,
92-105 (1976)
Behavioral
Science
and Prevention
EMIL BERKANOVIC University
of California,
School of Public Health,
Los Angeles,
California
90024
The present paper explores three questions: 1. What can the behavioral sciences contribute to a general understanding of personal health behavior? 2. What techniques from the behavioral sciences can be used to change personal health behavior? 3. What strategies promise to be most useful in applying the principles of the behavioral sciences to prevention? Although there have been a number of models in the behavioral sciences that are applicable to personal health behavior, there is one comprehensive model that has been developed specifically to explain health behavior at the level of individual decision making. The Health Belief Model is described and its implications for preventive health behavior are explored. Although the model identifies several variables that are important determinants of individual health behavior, taken alone, it does not provide a sufficient base for the planning of intervention strategies. Thus, it is important to identify the social networks that influence individual behavior. It is through these networks that specific informational, persuasional, and behavior modifying techniques must function. Finally, it is suggested that controlled field studies are strategically important in testing the efficacy of specific intervention strategies distilled from the behavioral sciences.
The idea that personal life style has consequences for health is as old as mankind. It underlies many of the injunctions of the Old Testament. The golden mean, formulated by Aristotle in an age unencumbered by Cartesian dualism, was intended to achieve both physical and psychological well-being simultaneously (12). Further, one need only read the novels of the time to appreciate that, although the dramatic breakthroughs in prevention in the West during the 18th and 19th centuries focused on changing the environment, the manner in which individuals conducted their daily lives was thought very important for their well-being. Even during the first half of the 20th century, the heyday of the germ theory of disease, the health consequences of personal conduct were not neglected (28). The idea that individual behavior can prevent the occurrence of illness, then, is not new. What is new, at least to the 20th century, is the idea that behavior can be understood through science. Thus, whereas previous ages have regarded individual behavior as the result of the will, many’people in the 20th century have come to view it as the result of natural forces lying both within and without the individual. Further, whereas previous ages felt that moral analysis was the appropriate means for understanding behavior, many people now believe that the same methods, in principle, that led to an understanding of physical and biological phenomena will also lead to an understanding of behavioral phenomena (35). It is the coupling of the belief that behavior can be understood and, hence, controlled through science with the idea that behavior can affect health that gives modern concepts of prevention their special character. Further, with the declining importance of infectious diseases and the corresponding increases in death and disability due to the chronic diseases, prevention has become more urgent, for the
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chronic diseases are seldom cured. Central to modern concepts of prevention is the notion that the personal behaviors of individuals as they conduct their day-today lives must somehow be changed if the health of the citizenry is to be improved. Indeed, there is evidence that such personal behaviors as alcohol consumption, poor eating habits, cigarette smoking, lack of adequate rest, relaxation, and exercise, as well as the failure to recognize potentially dangerous symptoms and act promptly on them, all contribute to an incidence of disease that is much higher than it need be (2, 10). Thus, there is considerable support, both in the form of evidence and in the form of tradition, for the now oft-heard assertion that the next great improvement in the health of industrialized populations will come through changes in personal health-relevant behavior. Further, because of the belief that behavior can be brought under scientific control, there has been considerable enthusiasm for including the behavioral sciences as basic to prevention, in much the same way anatomy and physiology are basic to curative medicine. Clearly, it is assumed by many students of personal health behavior, though by no means all, that the behavioral sciences can be applied to changing the health-relevant behaviors of individuals and, thereby, make a major contribution to the prevention of disease cm.
It is the purpose of the present paper to examine this assumption. Specifically, there are three questions which will be explored: (a) What can the behavioral sciences contribute to a general understanding of personal health behavior? (b) What techniques from the behavioral sciences can be used to change personal health behavior? (c) What strategies promise to be most useful in applying the principles of the behavioral sciences to prevention? In examining these questions, no attempt will be made to review the voluminous literature in the behavioral sciences that pertain to each. Rather, this paper is intended for practitioners in the various health disciplines for whom. the behavioral sciences are useful only to the extent that they produce tools that can be applied to changing health-relevant behavior. Accordingly, that which follows is intended as a broad but coherent overview. Although any attempt to build such an overview will be unsatisfactory from many points of view, it is hoped, nonetheless, that the practitioner will emerge with a realistic, if incomplete, sense of what the behavioral sciences can contribute to, prevention. A MODEL
FOR UNDERSTANDING
PERSONAL
HEALTH BEHAVIOR
Although there are a vast number of models in the behavioral sciences that are applicable to personal health behavior, there is one comprehensive model which has been developed specifically to explain health behavior at the level of individual decision making. The Health Belief Model was initially formulated over 20 years ago in an attempt to explain the use of such preventive services as tuberculosis screening, dental examinations, and the acceptance of polio vaccine (3). Since that time, a large number of studies have been undertaken in which one or more of the causal variables identified in the model have been examined for their effect on a wide range of health behaviors. The Health Belief Model postulates that in the presence of certain cues or
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stimuli to take health action, the likelihood of taking action is dependent on the individual’s beliefs about the seriousness of the health condition to which the action is addressed, his susceptibility to it, the efficacy of the proposed action, and the difficulties he may encounter in attempting to carry out the action. Thus, it is a rational decision model in which a call to action in the form of recognized cues receives a response that seems appropriate to the individual in the light of what he believes to be true about the health condition, the action, the situation, and himself. Further, as the model suggests, these beliefs are linked to the social structural position and experiential background of the individual. As Rosenstock notes, however, although these beliefs are differentially distributed among various subgroups in the population, they have been shown to affect the seeking of preventive health care independently of subgroup membership (34). For example, Kegeles found that, although white women who were relatively young, well educated, and had higher incomes were more likely to hold beliefs appropriate to taking the Papanicolaou Test and to have taken the test, those black women with lower educations and incomes who held the appropriate beliefs were also highly likely to have taken the test (21). Because the model specifies a set of beliefs that is presumed to cause the individual to decide to act, it is subject to the behaviorist’s criticism that beliefs change to conform with changed behavior as often as behavior changes to conform with changed beliefs (1, 13). It is argued, therefore, that change strategies should focus on the behavior itself rather than on the attitudes and beliefs that are merely presumed to affect the behavior in question (1). It is difficult to imagine, however, that free living individuals would voluntarily alter their behavior unless they perceived a reason for doing so. Nonetheless, both appropriate and inappropriate health behavior can be supported by attitudes and beliefs that are irrelevant to the health consequences of such behavior. For example, some men undertake exercise programs for esthetic reasons that are independent of the health consequences of such behavior (16). Thus, there are many reasons that are independent of the Health Belief Model that can induce the individual to try the desired new behavior, and it is quite possible that once the behavior has become established, the beliefs specified in the model will change. Interestingly, Rosenstock, in a recent review of the research applying the Health Belief Model to preventive health behavior, cites only one study in which the model has been applied to personal health behavior that does not involve the seeking of professional services (34). In that study, Heinzelmann and Bagley were able to show that engaging in physical exercise was related to the perceived benefit of reduced risk for heart disease, and that men who had been exercising for some time perceived themselves to be less susceptible to heart disease than they had been prior to the exercise program (18). Thus, although the model has been applied extensively to the prediction of preventive health behavior, the specific behaviors studied have almost exclusively involved the use of such services as examinations for various diseases, or the seeking of vaccines. Clearly, we need to know a great deal more about the ability of the model to predict the personal health-relevant behaviors of everyday life. It may well be that a
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number of non-health related factors enter into individual decision making with respect to smoking, eating, drinking, and exercise behaviors, and that these factors may either reinforce or contradict the decision indicated by the beliefs specified in the model. It seems reasonable to assume, for example, that periodic visits to health care facilities for checkups are far less likely to interfere with deeply held values than is changing daily behaviors that have become highly rewarded habits. On the other hand, any contradiction between the Health Belief Model and other factors that go into the individual’s decision making with respect to his behavior must produce a painful state of ambivalence. The individual, hence, must find a strategy for resolving this ambivalence (13). One such strategy is to discount one side or the other of the conflict. Udry and Morris have suggested that an inherent limit on programs aimed at changing personal health behavior is that they depend on future rewards for present deprivations, and that future rewards are always discounted (38). For example, it is difficult for many teenagers to imagine themselves as old as the bulk of the people who die of heart disease or cancer. Further, they know many people considerably older than they can imagine themselves to be whose everyday behavior is negative from the preventive point of view. It is not surprising that even where they see themselves as vulnerable to a serious disease which a change in their life style could effectively prevent, the remoteness of the disease in time would weigh heavily against deprivations in the present. It is out of considerations such as these that Becker et al. have suggested the need for an additional dimension in the Health Belief Model that refers to motivation or general readiness to undertake action in order to enhance or maintain health (5). Motivation is viewed as a variable state of readiness to act, based on the reward value attributed by the individual to his anticipation of the outcome of his action. The effects of the individual’s beliefs regarding his susceptibility to a disease, the seriousness of it, and the likely benefits of taking action are mediated by how highly he values health. Since any behavior requires the expenditure of time, energy, and resources, all of which are finite, the level of motivation to enhance health will influence the issue of whether there are conflicting values the person wishes to achieve. Thus, Becker et al. were able to show an independent effect for this general motivational component in predicting the keeping of scheduled follow-up visists at a pediatric clinic (4). Although the Health Belief Model has identified several variables that are important determinants of individual health behavior, taken alone it does not provide a sufficient base for the planning of intervention strategies aimed at changing that behavior. Therefore, it is equally important for the practitioner to understand how the beliefs and motives specified in the model are formed and maintained. Clearly, the techniques for changing behavior that are discussed in the subsequent section of this paper cannot be applied in the abstract. Rather, these techniques can be used to influence the behavior of the individual, only to the extent that they are applied through the social structures that impinge on the individual and that constrain his choices. The social networks within which the individual is embedded, and which are
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composed of the persons with whom he has developed significant face-to-face relationships, are crucially important in shaping both his beliefs and his behavior (19). Social networks perform a double role in controlling the life of the individual (29). First, they are the link between the person and the larger world around him. Since families and friendship groups share a number of experiences in common, often coming from similar ethnic, religious, social class, and regional backgrounds, they develop a common perspective through which they interpret the meaning of objects and events. Any attempt to persuade an individual to change some aspect of his life will be interpreted within the framework provided by this perspective. Failure to take these frames of reference into account jeopardizes the attempt to induce change. The second way in which social networks control the life of the individual is through the role of face-to-face relationships in helping the individual understand and define the objects and events that impinge on him. For example, Freidson has shown that many people make use of an extensive “lay referral system” when experiencing symptoms, prior to seeking medical advice (14). Such systems are composed of persons with whom the individual has established and trusting relationships, and it is they who initially interpret the meaning of his symptoms and who ultimately decide whether or not professional advice is required. Thus, any attempt to persuade an isolated individual to change his behavior is apt to be referred to the significant others in his social networks for a collectively agreed upon response. There have been several studies that have explored the impact of social networks on the health behavior of the individual. Suchman, in a study that linked such broad social structural factors as ethnic background and social class to patterns of interaction among family and friendship groups, found that these social networks influenced not only the individual’s orientations toward medicine, but his use of medical services as well (36). McKinley found that certain qualities in the relationship between a working-class woman and her family of origin affected her decision whether or not to seek prenatal care during pregnancy (27). Salloway and Dillon found that persons who were closely bound to their families were less likely to seek medical care when experiencing symptoms than were persons whose primary social network consisted of a more loosely bound friendship group (37). There is some evidence, then, that social structural influences, as they are mediated by social networks, affect both health beliefs and health behavior. Aside from shaping the common experiences out of which social networks come to share similar perspectives, however, certain aspects of social structure may directly affect the individual’s health behavior independently of his beliefs. For example, poor quality environments may not only increase the risk of disease, but they may also make it more difficult for the individual to alter his health-relevant behavior (18). Such factors as crowding, dilapidated housing, fatiguing work assignments, and lack of recreational facilities limit the range of behaviors the individual can choose. Preventive health behavior is largely a matter of life style. Since the social and physical environments in which people must live out their lives limit their possibilities with respect to life style, these environments can directly affect their ability to engage in preventive practices. Indeed, it would
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seem inappropriate to attempt to alter the behavior of individuals living in environments that are hostile to preventive health behaviors without first changing the environment itself. It is clear, then, that the effect of the variables in the Health Belief Model cannot be understood independently of the social structure within which the individual is embedded. In particular, individual decisions occur within the context of the social networks to which the person belongs, and therefore, both the beliefs upon which behavioral decisions are based, and the actions that individuals choose to undertake are shaped by the significant others to whom he refers for advice in understanding the world about him. These networks, in turn, are linked with the individual to such larger social structural factors as ethnic background and social class. Thus, beliefs are largely determined by the social contexts within which they occur, and are unlikely to respond to persuasive appeals presented outside of these contexts. TECHNIQUES
FOR CHANGING
PERSONAL
HEALTH
BEHAVIOR
One approach to changing health behavior that would obviate the Health Belief Model, of course, is to require desired behavior by law. Although many Americans abhor the idea of coercion, it is clear, nonetheless, that our lives are regulated in a number of ways. If it were politically possible to pass and enforce laws aimed at the manufacture and distribution of tobacco, for example, there would be a dramatic decline in cigarette consumption. Similarly, the application of rules requiring desirable preventive practices in occupational and recreational settings could be an effective means of changing the behaviors of large numbers of individuals. Further, even where rules are not formally legislated and enforced, making desirable health behaviors matters for official attention can act as a cueing mechanism and, therefore, function as a strategy for increasing the cues to preventive action that individuals encounter. Where regulatory techniques cannot be used, behavior change depends on persuading individuals that they should alter their behavior and then providing them with the skills they need to carry out their resolve. Approaches to persuasion are equally applicable to changing beliefs as they are to changing motivations. Nonetheless, studies of persuasion indicate that beliefs usually precede motivation in the change process, and that it is important to know the stage the target group or individual is in before attempting a persuasion campaign (32). For example, it appears doubtful that there are many smokers in the United States who do not believe that smoking is bad for their health. Many of them continue to smoke, however, because they are unmotivated to quit. Thus, the value of the future health reward they know is awaiting them if they abandon the cigarette habit is not worth the present value in either pleasure or avoided pain of continuing to smoke. It would be a waste of time to embark on a persuasion campaign aimed at teaching them that smoking can lead to a serious disease to which they are susceptible and which they can avoid by ceasing to smoke. Rather, such people need to be persuaded that the future health reward is of greater value than they currently perceive, that the unpleasant consequences of not smoking do not represent as great a value loss as they think, and that, indeed, there are values that can be
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realized in the present through not smoking that they had not perceived previously. Individuals who become persuaded that they can realize important values through not smoking may be motivated, thereby, to put their knowledge about the negative consequences of smoking into practice. It is also true, however, that many people who are motivated to quit smoking lack the behavioral skills required to realize their motivation. Again, a persuasion campaign aimed at motivating them to want to quit is a waste of time. They need to learn the specific skills that will allow them to bring their smoking behavior under conscious control. The techniques which are discussed below, then, are of two types: those that refer to persuading individuals to change their beliefs and motivation to conform with a desired change of behavior and those that refer to teaching individuals specific behavioral skills. One approach to understanding how persuasion occurs has been by observing the process of diffusion and adoption of innovations and new behaviors in free living population groups (32, 33). There are a number of perspectives from which this process has been observed. For example, the diffusion and acceptance of new information imparted by an active change agent has been studied. The effectiveness of such agents has been found to depend on the extent to which the people they are attempting to persuade regard them as credible, trustworthy, knowledgeable, attractive, and similar to themselves with respect to basic beliefs, values, and experiences of life (26). For example, a birth control program in India that attempted to persuade men to have vasectomies made effective use of local men who had already undergone the operation in persuading others that they should try it (32). These indigenous change agents were perceived to be more trustworthy, credible, knowledgeable, attractive, and similar than the regular members of the project team. Thus, it is less important that the change agent possess any of these qualities objectively than it is that he is perceived to possess them by the people he is attempting to persuade. Because of this, a person who is an effective change agent in one setting may be ineffective in another. It should also be noted that the diffusion of information, beliefs, attitudes, and behaviors in a population follows a predictable pattern that roughly describes an S-shaped curve. At the outset, only a few individuals take up the new belief or practice, while others within their immediate range of social contact observe the consequences of it for the person who has adopted it. Soon, others take it up at an accelerating rate as more and more individuals who hold the belief or engage in the practice influence those who have yet to adopt it. One factor that determines the rate of acceleration of this curve is the intensity of communication within the target population (33). This fact helps explain the superiority of face-to-face contexts over mass media campaigns in eliciting change. Social networks, as mentioned previously, are an important source of restraint with respect to the beliefs and behaviors that an individual finds acceptable. Such groups develop and enforce norms of behavior among their constituent members (15, 19). Where these norms conflict with behaviors advocated by a change agent, it is unlikely that individuals will risk violating the established relationships and expectations by modifying their behavior in the manner desired by the change agent (32, 33). This, in turn, suggests that the group, rather than the individual, is
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the appropriate target for change. Further, new groups can be formed in order to carry out change objectives. These groups will succeed to the extent that the individuals come to identify with them and, therefore, to accept the new norms as appropriate guides for their behavior (9). It has been found, for example, that individuals who make public commitments to the goals of an ad hoc group are more likely to make the changes required by those goals than are individuals who do not publicly commit themselves (23). The effectiveness of interpersonal influence is rooted in the fact that ideas are transmitted from person to person through social networks that have established mechanisms for arriving at shared beliefs, attitudes, and behavioral norms (19). It has also been found that such mechanisms develop rather quickly in newly formed groups (15). The extent to which these mechanisms can control the behavior of the individual outside of the group is contingent on the reward value that the group comes to play in the person’s life. This helps explain the frequently observed fact that many individuals who cease smoking or lose weight during a period of participation in an ad hoc group backslide shortly after the group is dissolved. Social networks are also influenced by more remote forces through the mechanism of the opinion leader. The opinion leader is essentially the early adopter. The opinion leader is more likely to attend to the mass media and to pass along the beliefs and motives he has acquired through the media to those with whom he is in face-to-face contact (33). Thus, the opinion leader is usually the best informed person in his group and acts as a broker between the group and the world around it. In addition to group processes and the characteristics of the change agent, characteristics of the message itself can affect persuasion. For example, it is usually better to present both sides of an issue so that the audience is prepared for counterpersuasion attempts (26). Similarly, it is usually best to draw the explicit conclusion implied by the message, since there will be less opportunity for misunderstanding (39). The impact of fear appeals is complex. In general, fear arousal is effective only when it is immediately followed with a recommendation for action that the person can believe is effective protection against the feared object (22). This point has relevance for the Health Belief Model. It may be that increasing belief in the seriousness of an ailment without also increasing belief in the benefits of taking action will produce little change of behavior. Persuasion campaigns of both face-to-face and the mass media types are most effective in changing behavior when they are accompanied by specific opportunities for practicing the desired behavior change. Indeed, it has been found that the media are not very effective in inducing behavior change, although a welldesigned media campaign can alter beliefs, and, to some extent, motivation (8, 39). Changing behavior, however, requires that the person possess the skills necessary to engage in the new behavior. Up to this point, techniques of persuasion have been discussed. The second class of techniques to be reviewed are those that facilitate the learning of specific behavioral skills. Most techniques of behavior change are based in social learning theory. It is assumed that behavior is cued by stimuli that the person encounters in his day-to-
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day life and reinforced by the rewards the person receives or expects to receive as a result of the behavior (1). For example, turning on a television set at night acts as a cue for many people to eat “snack” foods. Aside from the inherent pleasures of eating, this behavior is probably rewarded both by the relaxation implied by devoting one’s time to viewing television, and by the entertainment value of the program. Further, for many people, television viewing is an activity involving other people and this in itself is rewarding. Thus, social learning theory assumes that behavior persists to the extent that it is reinforced, and that the bulk of the reinforcers humans respond to are social in character. In order to change behavior, therefore, the individual must first recognize the cues that elicit the old behavior and dissociate the behavior from the cues. Second, the person must reinforce the change that accompanies this dissociation. Since cues are discrete, it is important for the person to understand the nature of the temptations to revert to the old behavior that he is apt to encounter. For example, some former smokers who have experienced little desire to smoke for an extended period of time report a sudden rise in desire for a cigarette upon entering a situation they had not been in since quitting. It is also important that the individual develop the capacity to reinforce his new behavior. Reinforcers are of several types. Positive reinforcement consists of rewarding the new behavior and aversive reinforcement consists of punishing the old behavior. In general, the latter has been found to be less effective in inducing change than the former (39). Reinforcement may be symbolic as well as material (1). It may also be selfgenerated (2). Thus self-concept and the esteem that attends it can be a powerful mechanism for the control of behavior. Reinforcement may also be vicarious, in that the individual can acquire or discard behaviors by observing the consequences of these behaviors for others (2). Obviously, extinguishing old behaviors and learning new ones require work. Unmotivated individuals are unlikely to make the effort entailed by such changes even when they believe there is a reason to change. Because most reinforcers are social in nature, however, the same principles of group processes and interpersonal influences apply to skills for learning behavior change as apply to persuasion. For this reason, the group itself may be the appropriate target for the change agent rather than the individual in isolation from the group. Indeed, without involving the group, the change agent has little control over the reinforcers that occur in the person’s day-to-day life. Even the creation of an ad-hoc group with norms that reinforce the new behavior can pose a powerful alternative for individuals whose social networks are unsupportive of the new behavior. This principle underlies such health related groups as Weight Watchers, Smoke Watchers, and Alcoholics Anonymous, as well as religious and political conversion processes. There are also a number of techniques that facilitate the identification of cues and reinforcers. First, the specific goals and outcomes of the change effort are identified in detail. Record keeping can be used to map the circumstances under which the behavior to be changed occurs. Based on these records, a detailed analysis of the behavior can be made and used to develop a sequence of steps and their reinforcers that will lead to the ultimate changes desired. Both modeling and guided participation can be used to teach the specific skills required at each step (1).
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In sum, both techniques of persuasion and techniques of behavior change are required to change personal health behavior. As was noted previously, the Health Belief Model has specified the relationships among beliefs, motives, and behavior. Techniques have been reviewed in this section that are applicable to each of these. It is essential, however, for the change agent to know which techniques are appropriate to the specific situation at hand. STRATEGIES
FOR APPLYING THE BEHAVIOR PREVENTION
SCIENCES
TO
There are several sources of data underlying the techniques for inducing change discussed in the previous section. Three sources that have been used in the design of intervention programs are market research, experimental social psychology, and studies in the field. Although market research is a major source of information about behavior change, a great deal of this research is kept confidential. Frequently the results of market research are only seen in the form of advertising lore (11). Nonetheless, the media are saturated with applications of market research, and it is possible to detect some underlying strategies for behavior change that may be useful in media campaigns aimed at improving health behavior. For example, the amount of change sought through any particular advertising campaign is quite small. This is in keeping with the principle that interpersonal influence is frequently required in order to translate motivation into action (8, 15, 32). This suggests that preventive health programs making use of the media should consist of multiple appeals aimed at specific subgroups, and that each appeal should seek very simple and easily undertaken changes in behavior. The difficulty with applying market research to preventive programs, however, is twofold. First, since a great deal of the data are unavailable, no evaluation of their adequacy can be made. Second, these data apply only to the use of the media in inducing buying behavior. The extent to which these principles of mediated salesmanship can be directly applied to other kinds of behavior change remains to be demonstrated. Probably the largest source of information about changing behavior comes from the experimental social psychology laboratory. The scientific basis of the information derived from laboratory experiments is, obviously, considerably greater than market research. Indeed, it is likely that the effects of most of the variables studied in market research have been tested in the social psychology laboratory. Certainly the techniques for change discussed in this paper, as well as the variables in the Health Belief Model, are rooted in this experimental work. There is, however, a problem in attempting to apply these results in preventive health programs. Although these experiments are quite useful in establishing causal relationships that are independent of extraneous events, the laboratory is a highly artificial setting. Thus, there is no guarantee that the effects observed in an experiment will be operative in complex settings where “other things” are not equal (6). Nonetheless, these experiments are a valuable source of information about the determinants of change. The third source of information useful in designing intervention programs are studies conducted in the field. Clearly this type of research is one means of further testing the findings of the experimental social psychology laboratory under less
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artificial circumstances. Although such studies ‘seldom permit the random assignment of subjects to various treatment groups, there are a number of quasiexperimental designs currently available that permit the researcher to control for a large number of potential sources of invalidity (7). Unfortunately, the number of such studies in which quasi-experimental controls have been applied is small, especially in the field of preventive health behavior. Nonetheless, the well controlled field study would appear to be an extremely important strategy for testing intervention programs of all sorts. Certainly we need evidence of the probable effects of such programs prior to committing major resources to massive program implementation (3 1). Although such evidence is best obtained experimentally, the quasi-experimental field study can provide a great deal of valid information regarding the operating characteristics and specific outcomes of programs (30). One recent field study employing a true experimental design partially tested the Health Belief Model (21). Urban, black, ghetto women were randomly assigned to treatment and control groups and each was given a pretest to determine her perceived vulnerability to cervical cancer and her perception of the efficacy of early detection and treatment in improving, prognosis. Each member of the treatment group was visited by an indigenous health worker who read a booklet to her emphasizing her vulnerability to cervical cancer and stressing the efficacy of early detection. Each member of the control group was visited by an indigenous health worker who read a booklet to her describing iron deficiency. In addition, both groups were given information about cervical cytology, the location of the clinic, and they were urged to make an appointment at the end of the visit. The post-test results showed that, although there were no differences between the two groups in the percentage of women whose beliefs changed after the interventions, those in the treatment group whose beliefs changed in the appropriate direction were more likely to report for cervical screening than were those in the control group whose beliefs had similarly changed. Kegeles interprets this finding as suggesting that the message about cervical cancer given to the women in the treatment group, although no more effective in changing beliefs than the information about cervical screening given to both groups, had a persuasive impact in increasing the motivation to take action in the light of these beliefs and in the presence of a strong cue in the form of the health worker seeking to make an appointment at the screening clinic. In any event, this experiment provides evidence that an intervention strategy designed in accord with the Health Belief Model, making use of change agents who are similar to the targets for change in face-to-face contexts, can affect behavior. A second field study applying behavioral science techniques to prevention is the Stanford Heart Study (currently in progress) (25). This quasi-experimental study was conducted in three small towns with a number of similar characteristics. In each community, 600 men and women between the ages of 35 and 60 were screened for risk of heart disease. Two communities were considered experimental, and the third served as a control. The experimental communities were saturated with a media campaign about risk factors and changes individuals could make to reduce risk. In addition, in one of these communities, the 100 persons found at highest risk were invited to participate in an intensive instruction pro-
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gram designed to teach and reinforce the specific behavioral skills required for changing smoking habits, dietary patterns, weight, and physical activity levels. Techniques for persuading these 100 individuals consisted of a highly credible source, a physician, delivering a fear-inducing messagein a face-to-face encounter with the person, and then immediately offering the person a specific activity, participation in the instructional groups, that would reduce the likelihood of the feared event occurring. Nearly all of the persons contacted participated in the entire program. The program itself was based on the principles of behavior modification and group process. Preliminary results indicate reductions in all risk behaviors in both experimental towns, with somewhat higher levels of risk reduction among those who participated in the intensive groups. This study indicates that a number of the techniques for changing behavior described in the previous section can be effectively applied in the field to promote preventive health behavior. Specifically, it provides evidence that ad-hoc face-to-face groups can be formed in communities similar to the ones studied, that people in the community can be motivated through established techniques of interpersonal influence, and that deeply rooted behaviors can be more effectively changed by this means than by means of an extensive media campaign alone. Interestingly, although the highly successful attempt to persuade the 100 persons at highest risk to participate in the instructional groups was not explicitly guided by the Health Belief Model, it could be interpreted as having fulfilled the conditions of the model rather closely. Thus, the results of the screening probably provided a strong cue to action, while the fear appeal probably increased the perception of vulnerability. Further, the fear-reducing activity may have increased the perceived benefits of taking action, and both the fear and the immediate offer of help probably served to increase motivation. These two projects demonstrate the advantages of well-controlled field studies in testing intervention strategies. Each addresses a serious health problem in a complex community where these problems naturally occur. Each applies behavioral science techniques that have some prior empirical support to the solution of each problem in these natural settings. Further, each tests intervention strategies based on these behavioral science techniques under controlled conditions that permit sorting of the effects of various techniques on the various components of each problem. It would appear that the well-controlled field study is a strategically important source of evidence needed for the design and implementation of intervention programs aimed at applying the behavioral sciences to improving personal health behavior. Indeed, Riecken and Boruch, in an excellent introduction to the uses and techniques of social experimentation, list six contributions that well-controlled field studies can make to the design of intervention programs (30). Such studies can test hypotheses, they can be used to develop the elements of intervention programs, they can be used in comprehensive program development, they provide data for choosing among program designs, they permit valid estimates of critical parameters, and they are a means of evaluating claims made about programs. Typically, judgments about each of these are made by the planners and administrators of intervention programs with very little data. Hence, programs are
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frequently designed and implemented without any evidence that they are effective in meeting the needs for which they are intended (31). The potential for wasted resources is apparent. From the point of view of improving the personal health behavior of the general public, it is apparent that health education efforts have been less successful than we might have hoped. The well-controlled field study applying the principles of behavioral science would seem to offer the best hope for improving our ability to design effective programs aimed at inducing change in personal health behavior. REFERENCES 1. Bandura, A. “Principles of Behavior Modification.” Holt, Rinehart & Winston, New York, 1%9. 2. Belloc, N. B. and Breslow, L. Relationship of physical health status and health practices. Prev. Med. 1, 409421 (1972). 3. Becker, M. H. The health belief model and personal health behavior. Health Ed. Monogr. 2, 326-327 (1974). 4. Becker, M. H., Drachman, R. H., and Kirscht J. P., Motivations and predictors of health behavior. Health Serv. Rep. 87, 852-862 (1972). 5. Becker, M. H., Drachman, R. H. and Kirscht, J. P. A new approach to explaining sick role behavior in low income populations. Amer. J. Pub. Health 64, 205-216 (1974). 6. Brunswik, E. “Perception and the Representative Design of Psychological Experiments.” University of California Press, Berkeley, 1965. 7. Campbell, D. T., and Stanley, J. C. “Experimental and Quasi-Experimental Designs for Research.” Rand McNally, Chicago, 1963. 8. Cartwright, D. Some principles of mass persuasion. Hum. Rel. 2, 253-267, (1949). 9. Crosbie, P. V., Petroni, F. A. and Stitt, B. G. The dynamics of ‘corrective groups’, J. Health Sot. Behav. 13, 294-302 (1972). 10. Dawber, T. R., and Kannel, W. B. Current status of coronary prevention, Prev. Med. 1,499-512 (1972). Il. Dichter, E. “Handbook of consumer motivations.” McGraw-Hill, New York, 1964. 12. Dubos, R. “The Mirage of Health,” Mentor, New York, 1958. 13. Festinger, L. “A Theory of Cognitive Dissonance.” Stanford University Press, Palo Alto, 1957. 14. Friedson, E. Client control and medical practice. Amer. J. Sot. 65,374-382 (1960). 15. Hare, A. P. Interpersonal relations in the small group, in “Handbook of Modem Sociology” (R. E. L. Faris, Ed.), p. 217. Rand McNally, Chicago, 1964. 16. Harris, D. V. Physical activity history and attitudes of middle-aged men. Med. Sci. Sports, 2,203 (1970). 17. Heinzelmann, F., and Bagley, R. W. Response to physical activity programs and their effects on health behavior. Pub. Health Rep. 85, 905-911 (1970). 18. Henderson, J. B. Applying behavioral science to cardiovascular risk, in “Behavioral Science and Preventive Medicine,” (R. Kane and C. Hughes, Eds.). Fogerty International Center, NIH, PHS, DHEW, in press. 19. Homans, G. C., “The Human Group.” Harcourt, Brace, and World, New York, 1950. 20. Kane, R., and C. Hughes (Eds.), “Behavioral Science and Preventive Medicine.” Fogerty International Center, NIH, PHS, DHEW, in press. 21. Kegeles, S. S. A field experimental attempt to change beliefs and behavior of women in an urban ghetto. J. Health Sot. Behav. 10, 115-124 (1969). 22. Leventhal, H. Findings and theory in the study of fear communications, in “Advances in Experimental Social Psychology,” (L. Berkowitz, Ed.), Vol. 5. Academic Press, New York, 1970. 23. Lewin, K. Group decision and social change, in “Readings in Social Psychology,” (N. Maccoby, T. Newcomb, and E. Hartley, Eds.), pp. 197-211. Holt, Rinehart & Winston, New York, 1958. 24. Liska, A. E. Emergent issues in the attitude-behavior consistency controversy, Amer. socio/. Rev. 39, 261-272 (1974). 25. Maccoby, N., and Farquhar, J. W. Communication for health: UnseJJing heart disease. J. Comm. 25, 114-126 (1975).
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26. McGuire, W. J. The nature of attitudes and attitude change, in “Handbook of Social Psychology,” (G. Lindzey, and E. Aronson, Eds.), Vol. 3. Addison-Wesley, Reading, 1968. 27. McKinlay, J. B. Some aspects of lower working class utilization behavior. Unpublished doctoral dissertation, Aberdeen University, 1970. 28. Means, R. “The History of Health Education in America.” Lea and Febiger, New York, 1%2. 29. Mitchell, J. C. The concept of social networks, in “Social Networks in Urban Situations,” (J. C. Mitchell, Ed.). Manchester University Press, Manchester, 1%9. 30. Riecken, H. W., and Boruch, R. F. “Social Experimentation.” Academic Press, New York 1974. 3 1. Rivlin, A. N. “Systematic Thinking for Social Action.” Brookings Institute, Washington, 1971. 32. Rogers, E. M. “Communication Strategies for Family Planning.” Free Press, Glencoe, 1973. 33. Rogers, E. M., and Shoemaker, F. F. “The Communication of Innovation.” Free Press, Glencoe, 1971. 34. Rosenstock, I. M. The health belief model and preventive health behavior, in, He&h Ed. Monogr. (M. H. Becker, Ed.). 2, 354-386 (1974). 35. Rudner, R. S. “Philosophy of Social,Science,” Prentice-Hall, Englewood Cliffs, N. J., 1966. 36. Suchman, E. A. Sociomedical variations among ethnic groups. Amer. J. Sot. 70,3 19-331 (1964). 37. Sahoway, J. C., and Dillion, P. B. A comparison of family networks and friend networks in health care utilization. J. Camp. Fam. Studies 4, 131-142 (1973). 38. Udry, J. R., and Morris, N. M. A spoonful of sugar helps the medicine go down. Amer. 1. Public. Health
61, 776-785 (1975).
39. Zimbardo, P. and Ebbesen, E. B. “Influencing Wesley, Reading, Pa., 1970.
Attitudes and Changing Behavior.”
Addison-
MEDICINE
5,
92-105 (1976)
Behavioral
Science
and Prevention
EMIL BERKANOVIC University
of California,
School of Public Health,
Los Angeles,
California
90024
The present paper explores three questions: 1. What can the behavioral sciences contribute to a general understanding of personal health behavior? 2. What techniques from the behavioral sciences can be used to change personal health behavior? 3. What strategies promise to be most useful in applying the principles of the behavioral sciences to prevention? Although there have been a number of models in the behavioral sciences that are applicable to personal health behavior, there is one comprehensive model that has been developed specifically to explain health behavior at the level of individual decision making. The Health Belief Model is described and its implications for preventive health behavior are explored. Although the model identifies several variables that are important determinants of individual health behavior, taken alone, it does not provide a sufficient base for the planning of intervention strategies. Thus, it is important to identify the social networks that influence individual behavior. It is through these networks that specific informational, persuasional, and behavior modifying techniques must function. Finally, it is suggested that controlled field studies are strategically important in testing the efficacy of specific intervention strategies distilled from the behavioral sciences.
The idea that personal life style has consequences for health is as old as mankind. It underlies many of the injunctions of the Old Testament. The golden mean, formulated by Aristotle in an age unencumbered by Cartesian dualism, was intended to achieve both physical and psychological well-being simultaneously (12). Further, one need only read the novels of the time to appreciate that, although the dramatic breakthroughs in prevention in the West during the 18th and 19th centuries focused on changing the environment, the manner in which individuals conducted their daily lives was thought very important for their well-being. Even during the first half of the 20th century, the heyday of the germ theory of disease, the health consequences of personal conduct were not neglected (28). The idea that individual behavior can prevent the occurrence of illness, then, is not new. What is new, at least to the 20th century, is the idea that behavior can be understood through science. Thus, whereas previous ages have regarded individual behavior as the result of the will, many’people in the 20th century have come to view it as the result of natural forces lying both within and without the individual. Further, whereas previous ages felt that moral analysis was the appropriate means for understanding behavior, many people now believe that the same methods, in principle, that led to an understanding of physical and biological phenomena will also lead to an understanding of behavioral phenomena (35). It is the coupling of the belief that behavior can be understood and, hence, controlled through science with the idea that behavior can affect health that gives modern concepts of prevention their special character. Further, with the declining importance of infectious diseases and the corresponding increases in death and disability due to the chronic diseases, prevention has become more urgent, for the
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chronic diseases are seldom cured. Central to modern concepts of prevention is the notion that the personal behaviors of individuals as they conduct their day-today lives must somehow be changed if the health of the citizenry is to be improved. Indeed, there is evidence that such personal behaviors as alcohol consumption, poor eating habits, cigarette smoking, lack of adequate rest, relaxation, and exercise, as well as the failure to recognize potentially dangerous symptoms and act promptly on them, all contribute to an incidence of disease that is much higher than it need be (2, 10). Thus, there is considerable support, both in the form of evidence and in the form of tradition, for the now oft-heard assertion that the next great improvement in the health of industrialized populations will come through changes in personal health-relevant behavior. Further, because of the belief that behavior can be brought under scientific control, there has been considerable enthusiasm for including the behavioral sciences as basic to prevention, in much the same way anatomy and physiology are basic to curative medicine. Clearly, it is assumed by many students of personal health behavior, though by no means all, that the behavioral sciences can be applied to changing the health-relevant behaviors of individuals and, thereby, make a major contribution to the prevention of disease cm.
It is the purpose of the present paper to examine this assumption. Specifically, there are three questions which will be explored: (a) What can the behavioral sciences contribute to a general understanding of personal health behavior? (b) What techniques from the behavioral sciences can be used to change personal health behavior? (c) What strategies promise to be most useful in applying the principles of the behavioral sciences to prevention? In examining these questions, no attempt will be made to review the voluminous literature in the behavioral sciences that pertain to each. Rather, this paper is intended for practitioners in the various health disciplines for whom. the behavioral sciences are useful only to the extent that they produce tools that can be applied to changing health-relevant behavior. Accordingly, that which follows is intended as a broad but coherent overview. Although any attempt to build such an overview will be unsatisfactory from many points of view, it is hoped, nonetheless, that the practitioner will emerge with a realistic, if incomplete, sense of what the behavioral sciences can contribute to, prevention. A MODEL
FOR UNDERSTANDING
PERSONAL
HEALTH BEHAVIOR
Although there are a vast number of models in the behavioral sciences that are applicable to personal health behavior, there is one comprehensive model which has been developed specifically to explain health behavior at the level of individual decision making. The Health Belief Model was initially formulated over 20 years ago in an attempt to explain the use of such preventive services as tuberculosis screening, dental examinations, and the acceptance of polio vaccine (3). Since that time, a large number of studies have been undertaken in which one or more of the causal variables identified in the model have been examined for their effect on a wide range of health behaviors. The Health Belief Model postulates that in the presence of certain cues or
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stimuli to take health action, the likelihood of taking action is dependent on the individual’s beliefs about the seriousness of the health condition to which the action is addressed, his susceptibility to it, the efficacy of the proposed action, and the difficulties he may encounter in attempting to carry out the action. Thus, it is a rational decision model in which a call to action in the form of recognized cues receives a response that seems appropriate to the individual in the light of what he believes to be true about the health condition, the action, the situation, and himself. Further, as the model suggests, these beliefs are linked to the social structural position and experiential background of the individual. As Rosenstock notes, however, although these beliefs are differentially distributed among various subgroups in the population, they have been shown to affect the seeking of preventive health care independently of subgroup membership (34). For example, Kegeles found that, although white women who were relatively young, well educated, and had higher incomes were more likely to hold beliefs appropriate to taking the Papanicolaou Test and to have taken the test, those black women with lower educations and incomes who held the appropriate beliefs were also highly likely to have taken the test (21). Because the model specifies a set of beliefs that is presumed to cause the individual to decide to act, it is subject to the behaviorist’s criticism that beliefs change to conform with changed behavior as often as behavior changes to conform with changed beliefs (1, 13). It is argued, therefore, that change strategies should focus on the behavior itself rather than on the attitudes and beliefs that are merely presumed to affect the behavior in question (1). It is difficult to imagine, however, that free living individuals would voluntarily alter their behavior unless they perceived a reason for doing so. Nonetheless, both appropriate and inappropriate health behavior can be supported by attitudes and beliefs that are irrelevant to the health consequences of such behavior. For example, some men undertake exercise programs for esthetic reasons that are independent of the health consequences of such behavior (16). Thus, there are many reasons that are independent of the Health Belief Model that can induce the individual to try the desired new behavior, and it is quite possible that once the behavior has become established, the beliefs specified in the model will change. Interestingly, Rosenstock, in a recent review of the research applying the Health Belief Model to preventive health behavior, cites only one study in which the model has been applied to personal health behavior that does not involve the seeking of professional services (34). In that study, Heinzelmann and Bagley were able to show that engaging in physical exercise was related to the perceived benefit of reduced risk for heart disease, and that men who had been exercising for some time perceived themselves to be less susceptible to heart disease than they had been prior to the exercise program (18). Thus, although the model has been applied extensively to the prediction of preventive health behavior, the specific behaviors studied have almost exclusively involved the use of such services as examinations for various diseases, or the seeking of vaccines. Clearly, we need to know a great deal more about the ability of the model to predict the personal health-relevant behaviors of everyday life. It may well be that a
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number of non-health related factors enter into individual decision making with respect to smoking, eating, drinking, and exercise behaviors, and that these factors may either reinforce or contradict the decision indicated by the beliefs specified in the model. It seems reasonable to assume, for example, that periodic visits to health care facilities for checkups are far less likely to interfere with deeply held values than is changing daily behaviors that have become highly rewarded habits. On the other hand, any contradiction between the Health Belief Model and other factors that go into the individual’s decision making with respect to his behavior must produce a painful state of ambivalence. The individual, hence, must find a strategy for resolving this ambivalence (13). One such strategy is to discount one side or the other of the conflict. Udry and Morris have suggested that an inherent limit on programs aimed at changing personal health behavior is that they depend on future rewards for present deprivations, and that future rewards are always discounted (38). For example, it is difficult for many teenagers to imagine themselves as old as the bulk of the people who die of heart disease or cancer. Further, they know many people considerably older than they can imagine themselves to be whose everyday behavior is negative from the preventive point of view. It is not surprising that even where they see themselves as vulnerable to a serious disease which a change in their life style could effectively prevent, the remoteness of the disease in time would weigh heavily against deprivations in the present. It is out of considerations such as these that Becker et al. have suggested the need for an additional dimension in the Health Belief Model that refers to motivation or general readiness to undertake action in order to enhance or maintain health (5). Motivation is viewed as a variable state of readiness to act, based on the reward value attributed by the individual to his anticipation of the outcome of his action. The effects of the individual’s beliefs regarding his susceptibility to a disease, the seriousness of it, and the likely benefits of taking action are mediated by how highly he values health. Since any behavior requires the expenditure of time, energy, and resources, all of which are finite, the level of motivation to enhance health will influence the issue of whether there are conflicting values the person wishes to achieve. Thus, Becker et al. were able to show an independent effect for this general motivational component in predicting the keeping of scheduled follow-up visists at a pediatric clinic (4). Although the Health Belief Model has identified several variables that are important determinants of individual health behavior, taken alone it does not provide a sufficient base for the planning of intervention strategies aimed at changing that behavior. Therefore, it is equally important for the practitioner to understand how the beliefs and motives specified in the model are formed and maintained. Clearly, the techniques for changing behavior that are discussed in the subsequent section of this paper cannot be applied in the abstract. Rather, these techniques can be used to influence the behavior of the individual, only to the extent that they are applied through the social structures that impinge on the individual and that constrain his choices. The social networks within which the individual is embedded, and which are
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composed of the persons with whom he has developed significant face-to-face relationships, are crucially important in shaping both his beliefs and his behavior (19). Social networks perform a double role in controlling the life of the individual (29). First, they are the link between the person and the larger world around him. Since families and friendship groups share a number of experiences in common, often coming from similar ethnic, religious, social class, and regional backgrounds, they develop a common perspective through which they interpret the meaning of objects and events. Any attempt to persuade an individual to change some aspect of his life will be interpreted within the framework provided by this perspective. Failure to take these frames of reference into account jeopardizes the attempt to induce change. The second way in which social networks control the life of the individual is through the role of face-to-face relationships in helping the individual understand and define the objects and events that impinge on him. For example, Freidson has shown that many people make use of an extensive “lay referral system” when experiencing symptoms, prior to seeking medical advice (14). Such systems are composed of persons with whom the individual has established and trusting relationships, and it is they who initially interpret the meaning of his symptoms and who ultimately decide whether or not professional advice is required. Thus, any attempt to persuade an isolated individual to change his behavior is apt to be referred to the significant others in his social networks for a collectively agreed upon response. There have been several studies that have explored the impact of social networks on the health behavior of the individual. Suchman, in a study that linked such broad social structural factors as ethnic background and social class to patterns of interaction among family and friendship groups, found that these social networks influenced not only the individual’s orientations toward medicine, but his use of medical services as well (36). McKinley found that certain qualities in the relationship between a working-class woman and her family of origin affected her decision whether or not to seek prenatal care during pregnancy (27). Salloway and Dillon found that persons who were closely bound to their families were less likely to seek medical care when experiencing symptoms than were persons whose primary social network consisted of a more loosely bound friendship group (37). There is some evidence, then, that social structural influences, as they are mediated by social networks, affect both health beliefs and health behavior. Aside from shaping the common experiences out of which social networks come to share similar perspectives, however, certain aspects of social structure may directly affect the individual’s health behavior independently of his beliefs. For example, poor quality environments may not only increase the risk of disease, but they may also make it more difficult for the individual to alter his health-relevant behavior (18). Such factors as crowding, dilapidated housing, fatiguing work assignments, and lack of recreational facilities limit the range of behaviors the individual can choose. Preventive health behavior is largely a matter of life style. Since the social and physical environments in which people must live out their lives limit their possibilities with respect to life style, these environments can directly affect their ability to engage in preventive practices. Indeed, it would
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seem inappropriate to attempt to alter the behavior of individuals living in environments that are hostile to preventive health behaviors without first changing the environment itself. It is clear, then, that the effect of the variables in the Health Belief Model cannot be understood independently of the social structure within which the individual is embedded. In particular, individual decisions occur within the context of the social networks to which the person belongs, and therefore, both the beliefs upon which behavioral decisions are based, and the actions that individuals choose to undertake are shaped by the significant others to whom he refers for advice in understanding the world about him. These networks, in turn, are linked with the individual to such larger social structural factors as ethnic background and social class. Thus, beliefs are largely determined by the social contexts within which they occur, and are unlikely to respond to persuasive appeals presented outside of these contexts. TECHNIQUES
FOR CHANGING
PERSONAL
HEALTH
BEHAVIOR
One approach to changing health behavior that would obviate the Health Belief Model, of course, is to require desired behavior by law. Although many Americans abhor the idea of coercion, it is clear, nonetheless, that our lives are regulated in a number of ways. If it were politically possible to pass and enforce laws aimed at the manufacture and distribution of tobacco, for example, there would be a dramatic decline in cigarette consumption. Similarly, the application of rules requiring desirable preventive practices in occupational and recreational settings could be an effective means of changing the behaviors of large numbers of individuals. Further, even where rules are not formally legislated and enforced, making desirable health behaviors matters for official attention can act as a cueing mechanism and, therefore, function as a strategy for increasing the cues to preventive action that individuals encounter. Where regulatory techniques cannot be used, behavior change depends on persuading individuals that they should alter their behavior and then providing them with the skills they need to carry out their resolve. Approaches to persuasion are equally applicable to changing beliefs as they are to changing motivations. Nonetheless, studies of persuasion indicate that beliefs usually precede motivation in the change process, and that it is important to know the stage the target group or individual is in before attempting a persuasion campaign (32). For example, it appears doubtful that there are many smokers in the United States who do not believe that smoking is bad for their health. Many of them continue to smoke, however, because they are unmotivated to quit. Thus, the value of the future health reward they know is awaiting them if they abandon the cigarette habit is not worth the present value in either pleasure or avoided pain of continuing to smoke. It would be a waste of time to embark on a persuasion campaign aimed at teaching them that smoking can lead to a serious disease to which they are susceptible and which they can avoid by ceasing to smoke. Rather, such people need to be persuaded that the future health reward is of greater value than they currently perceive, that the unpleasant consequences of not smoking do not represent as great a value loss as they think, and that, indeed, there are values that can be
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realized in the present through not smoking that they had not perceived previously. Individuals who become persuaded that they can realize important values through not smoking may be motivated, thereby, to put their knowledge about the negative consequences of smoking into practice. It is also true, however, that many people who are motivated to quit smoking lack the behavioral skills required to realize their motivation. Again, a persuasion campaign aimed at motivating them to want to quit is a waste of time. They need to learn the specific skills that will allow them to bring their smoking behavior under conscious control. The techniques which are discussed below, then, are of two types: those that refer to persuading individuals to change their beliefs and motivation to conform with a desired change of behavior and those that refer to teaching individuals specific behavioral skills. One approach to understanding how persuasion occurs has been by observing the process of diffusion and adoption of innovations and new behaviors in free living population groups (32, 33). There are a number of perspectives from which this process has been observed. For example, the diffusion and acceptance of new information imparted by an active change agent has been studied. The effectiveness of such agents has been found to depend on the extent to which the people they are attempting to persuade regard them as credible, trustworthy, knowledgeable, attractive, and similar to themselves with respect to basic beliefs, values, and experiences of life (26). For example, a birth control program in India that attempted to persuade men to have vasectomies made effective use of local men who had already undergone the operation in persuading others that they should try it (32). These indigenous change agents were perceived to be more trustworthy, credible, knowledgeable, attractive, and similar than the regular members of the project team. Thus, it is less important that the change agent possess any of these qualities objectively than it is that he is perceived to possess them by the people he is attempting to persuade. Because of this, a person who is an effective change agent in one setting may be ineffective in another. It should also be noted that the diffusion of information, beliefs, attitudes, and behaviors in a population follows a predictable pattern that roughly describes an S-shaped curve. At the outset, only a few individuals take up the new belief or practice, while others within their immediate range of social contact observe the consequences of it for the person who has adopted it. Soon, others take it up at an accelerating rate as more and more individuals who hold the belief or engage in the practice influence those who have yet to adopt it. One factor that determines the rate of acceleration of this curve is the intensity of communication within the target population (33). This fact helps explain the superiority of face-to-face contexts over mass media campaigns in eliciting change. Social networks, as mentioned previously, are an important source of restraint with respect to the beliefs and behaviors that an individual finds acceptable. Such groups develop and enforce norms of behavior among their constituent members (15, 19). Where these norms conflict with behaviors advocated by a change agent, it is unlikely that individuals will risk violating the established relationships and expectations by modifying their behavior in the manner desired by the change agent (32, 33). This, in turn, suggests that the group, rather than the individual, is
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the appropriate target for change. Further, new groups can be formed in order to carry out change objectives. These groups will succeed to the extent that the individuals come to identify with them and, therefore, to accept the new norms as appropriate guides for their behavior (9). It has been found, for example, that individuals who make public commitments to the goals of an ad hoc group are more likely to make the changes required by those goals than are individuals who do not publicly commit themselves (23). The effectiveness of interpersonal influence is rooted in the fact that ideas are transmitted from person to person through social networks that have established mechanisms for arriving at shared beliefs, attitudes, and behavioral norms (19). It has also been found that such mechanisms develop rather quickly in newly formed groups (15). The extent to which these mechanisms can control the behavior of the individual outside of the group is contingent on the reward value that the group comes to play in the person’s life. This helps explain the frequently observed fact that many individuals who cease smoking or lose weight during a period of participation in an ad hoc group backslide shortly after the group is dissolved. Social networks are also influenced by more remote forces through the mechanism of the opinion leader. The opinion leader is essentially the early adopter. The opinion leader is more likely to attend to the mass media and to pass along the beliefs and motives he has acquired through the media to those with whom he is in face-to-face contact (33). Thus, the opinion leader is usually the best informed person in his group and acts as a broker between the group and the world around it. In addition to group processes and the characteristics of the change agent, characteristics of the message itself can affect persuasion. For example, it is usually better to present both sides of an issue so that the audience is prepared for counterpersuasion attempts (26). Similarly, it is usually best to draw the explicit conclusion implied by the message, since there will be less opportunity for misunderstanding (39). The impact of fear appeals is complex. In general, fear arousal is effective only when it is immediately followed with a recommendation for action that the person can believe is effective protection against the feared object (22). This point has relevance for the Health Belief Model. It may be that increasing belief in the seriousness of an ailment without also increasing belief in the benefits of taking action will produce little change of behavior. Persuasion campaigns of both face-to-face and the mass media types are most effective in changing behavior when they are accompanied by specific opportunities for practicing the desired behavior change. Indeed, it has been found that the media are not very effective in inducing behavior change, although a welldesigned media campaign can alter beliefs, and, to some extent, motivation (8, 39). Changing behavior, however, requires that the person possess the skills necessary to engage in the new behavior. Up to this point, techniques of persuasion have been discussed. The second class of techniques to be reviewed are those that facilitate the learning of specific behavioral skills. Most techniques of behavior change are based in social learning theory. It is assumed that behavior is cued by stimuli that the person encounters in his day-to-
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day life and reinforced by the rewards the person receives or expects to receive as a result of the behavior (1). For example, turning on a television set at night acts as a cue for many people to eat “snack” foods. Aside from the inherent pleasures of eating, this behavior is probably rewarded both by the relaxation implied by devoting one’s time to viewing television, and by the entertainment value of the program. Further, for many people, television viewing is an activity involving other people and this in itself is rewarding. Thus, social learning theory assumes that behavior persists to the extent that it is reinforced, and that the bulk of the reinforcers humans respond to are social in character. In order to change behavior, therefore, the individual must first recognize the cues that elicit the old behavior and dissociate the behavior from the cues. Second, the person must reinforce the change that accompanies this dissociation. Since cues are discrete, it is important for the person to understand the nature of the temptations to revert to the old behavior that he is apt to encounter. For example, some former smokers who have experienced little desire to smoke for an extended period of time report a sudden rise in desire for a cigarette upon entering a situation they had not been in since quitting. It is also important that the individual develop the capacity to reinforce his new behavior. Reinforcers are of several types. Positive reinforcement consists of rewarding the new behavior and aversive reinforcement consists of punishing the old behavior. In general, the latter has been found to be less effective in inducing change than the former (39). Reinforcement may be symbolic as well as material (1). It may also be selfgenerated (2). Thus self-concept and the esteem that attends it can be a powerful mechanism for the control of behavior. Reinforcement may also be vicarious, in that the individual can acquire or discard behaviors by observing the consequences of these behaviors for others (2). Obviously, extinguishing old behaviors and learning new ones require work. Unmotivated individuals are unlikely to make the effort entailed by such changes even when they believe there is a reason to change. Because most reinforcers are social in nature, however, the same principles of group processes and interpersonal influences apply to skills for learning behavior change as apply to persuasion. For this reason, the group itself may be the appropriate target for the change agent rather than the individual in isolation from the group. Indeed, without involving the group, the change agent has little control over the reinforcers that occur in the person’s day-to-day life. Even the creation of an ad-hoc group with norms that reinforce the new behavior can pose a powerful alternative for individuals whose social networks are unsupportive of the new behavior. This principle underlies such health related groups as Weight Watchers, Smoke Watchers, and Alcoholics Anonymous, as well as religious and political conversion processes. There are also a number of techniques that facilitate the identification of cues and reinforcers. First, the specific goals and outcomes of the change effort are identified in detail. Record keeping can be used to map the circumstances under which the behavior to be changed occurs. Based on these records, a detailed analysis of the behavior can be made and used to develop a sequence of steps and their reinforcers that will lead to the ultimate changes desired. Both modeling and guided participation can be used to teach the specific skills required at each step (1).
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In sum, both techniques of persuasion and techniques of behavior change are required to change personal health behavior. As was noted previously, the Health Belief Model has specified the relationships among beliefs, motives, and behavior. Techniques have been reviewed in this section that are applicable to each of these. It is essential, however, for the change agent to know which techniques are appropriate to the specific situation at hand. STRATEGIES
FOR APPLYING THE BEHAVIOR PREVENTION
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There are several sources of data underlying the techniques for inducing change discussed in the previous section. Three sources that have been used in the design of intervention programs are market research, experimental social psychology, and studies in the field. Although market research is a major source of information about behavior change, a great deal of this research is kept confidential. Frequently the results of market research are only seen in the form of advertising lore (11). Nonetheless, the media are saturated with applications of market research, and it is possible to detect some underlying strategies for behavior change that may be useful in media campaigns aimed at improving health behavior. For example, the amount of change sought through any particular advertising campaign is quite small. This is in keeping with the principle that interpersonal influence is frequently required in order to translate motivation into action (8, 15, 32). This suggests that preventive health programs making use of the media should consist of multiple appeals aimed at specific subgroups, and that each appeal should seek very simple and easily undertaken changes in behavior. The difficulty with applying market research to preventive programs, however, is twofold. First, since a great deal of the data are unavailable, no evaluation of their adequacy can be made. Second, these data apply only to the use of the media in inducing buying behavior. The extent to which these principles of mediated salesmanship can be directly applied to other kinds of behavior change remains to be demonstrated. Probably the largest source of information about changing behavior comes from the experimental social psychology laboratory. The scientific basis of the information derived from laboratory experiments is, obviously, considerably greater than market research. Indeed, it is likely that the effects of most of the variables studied in market research have been tested in the social psychology laboratory. Certainly the techniques for change discussed in this paper, as well as the variables in the Health Belief Model, are rooted in this experimental work. There is, however, a problem in attempting to apply these results in preventive health programs. Although these experiments are quite useful in establishing causal relationships that are independent of extraneous events, the laboratory is a highly artificial setting. Thus, there is no guarantee that the effects observed in an experiment will be operative in complex settings where “other things” are not equal (6). Nonetheless, these experiments are a valuable source of information about the determinants of change. The third source of information useful in designing intervention programs are studies conducted in the field. Clearly this type of research is one means of further testing the findings of the experimental social psychology laboratory under less
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artificial circumstances. Although such studies ‘seldom permit the random assignment of subjects to various treatment groups, there are a number of quasiexperimental designs currently available that permit the researcher to control for a large number of potential sources of invalidity (7). Unfortunately, the number of such studies in which quasi-experimental controls have been applied is small, especially in the field of preventive health behavior. Nonetheless, the well controlled field study would appear to be an extremely important strategy for testing intervention programs of all sorts. Certainly we need evidence of the probable effects of such programs prior to committing major resources to massive program implementation (3 1). Although such evidence is best obtained experimentally, the quasi-experimental field study can provide a great deal of valid information regarding the operating characteristics and specific outcomes of programs (30). One recent field study employing a true experimental design partially tested the Health Belief Model (21). Urban, black, ghetto women were randomly assigned to treatment and control groups and each was given a pretest to determine her perceived vulnerability to cervical cancer and her perception of the efficacy of early detection and treatment in improving, prognosis. Each member of the treatment group was visited by an indigenous health worker who read a booklet to her emphasizing her vulnerability to cervical cancer and stressing the efficacy of early detection. Each member of the control group was visited by an indigenous health worker who read a booklet to her describing iron deficiency. In addition, both groups were given information about cervical cytology, the location of the clinic, and they were urged to make an appointment at the end of the visit. The post-test results showed that, although there were no differences between the two groups in the percentage of women whose beliefs changed after the interventions, those in the treatment group whose beliefs changed in the appropriate direction were more likely to report for cervical screening than were those in the control group whose beliefs had similarly changed. Kegeles interprets this finding as suggesting that the message about cervical cancer given to the women in the treatment group, although no more effective in changing beliefs than the information about cervical screening given to both groups, had a persuasive impact in increasing the motivation to take action in the light of these beliefs and in the presence of a strong cue in the form of the health worker seeking to make an appointment at the screening clinic. In any event, this experiment provides evidence that an intervention strategy designed in accord with the Health Belief Model, making use of change agents who are similar to the targets for change in face-to-face contexts, can affect behavior. A second field study applying behavioral science techniques to prevention is the Stanford Heart Study (currently in progress) (25). This quasi-experimental study was conducted in three small towns with a number of similar characteristics. In each community, 600 men and women between the ages of 35 and 60 were screened for risk of heart disease. Two communities were considered experimental, and the third served as a control. The experimental communities were saturated with a media campaign about risk factors and changes individuals could make to reduce risk. In addition, in one of these communities, the 100 persons found at highest risk were invited to participate in an intensive instruction pro-
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gram designed to teach and reinforce the specific behavioral skills required for changing smoking habits, dietary patterns, weight, and physical activity levels. Techniques for persuading these 100 individuals consisted of a highly credible source, a physician, delivering a fear-inducing messagein a face-to-face encounter with the person, and then immediately offering the person a specific activity, participation in the instructional groups, that would reduce the likelihood of the feared event occurring. Nearly all of the persons contacted participated in the entire program. The program itself was based on the principles of behavior modification and group process. Preliminary results indicate reductions in all risk behaviors in both experimental towns, with somewhat higher levels of risk reduction among those who participated in the intensive groups. This study indicates that a number of the techniques for changing behavior described in the previous section can be effectively applied in the field to promote preventive health behavior. Specifically, it provides evidence that ad-hoc face-to-face groups can be formed in communities similar to the ones studied, that people in the community can be motivated through established techniques of interpersonal influence, and that deeply rooted behaviors can be more effectively changed by this means than by means of an extensive media campaign alone. Interestingly, although the highly successful attempt to persuade the 100 persons at highest risk to participate in the instructional groups was not explicitly guided by the Health Belief Model, it could be interpreted as having fulfilled the conditions of the model rather closely. Thus, the results of the screening probably provided a strong cue to action, while the fear appeal probably increased the perception of vulnerability. Further, the fear-reducing activity may have increased the perceived benefits of taking action, and both the fear and the immediate offer of help probably served to increase motivation. These two projects demonstrate the advantages of well-controlled field studies in testing intervention strategies. Each addresses a serious health problem in a complex community where these problems naturally occur. Each applies behavioral science techniques that have some prior empirical support to the solution of each problem in these natural settings. Further, each tests intervention strategies based on these behavioral science techniques under controlled conditions that permit sorting of the effects of various techniques on the various components of each problem. It would appear that the well-controlled field study is a strategically important source of evidence needed for the design and implementation of intervention programs aimed at applying the behavioral sciences to improving personal health behavior. Indeed, Riecken and Boruch, in an excellent introduction to the uses and techniques of social experimentation, list six contributions that well-controlled field studies can make to the design of intervention programs (30). Such studies can test hypotheses, they can be used to develop the elements of intervention programs, they can be used in comprehensive program development, they provide data for choosing among program designs, they permit valid estimates of critical parameters, and they are a means of evaluating claims made about programs. Typically, judgments about each of these are made by the planners and administrators of intervention programs with very little data. Hence, programs are
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frequently designed and implemented without any evidence that they are effective in meeting the needs for which they are intended (31). The potential for wasted resources is apparent. From the point of view of improving the personal health behavior of the general public, it is apparent that health education efforts have been less successful than we might have hoped. The well-controlled field study applying the principles of behavioral science would seem to offer the best hope for improving our ability to design effective programs aimed at inducing change in personal health behavior. REFERENCES 1. Bandura, A. “Principles of Behavior Modification.” Holt, Rinehart & Winston, New York, 1%9. 2. Belloc, N. B. and Breslow, L. Relationship of physical health status and health practices. Prev. Med. 1, 409421 (1972). 3. Becker, M. H. The health belief model and personal health behavior. Health Ed. Monogr. 2, 326-327 (1974). 4. Becker, M. H., Drachman, R. H., and Kirscht J. P., Motivations and predictors of health behavior. Health Serv. Rep. 87, 852-862 (1972). 5. Becker, M. H., Drachman, R. H. and Kirscht, J. P. A new approach to explaining sick role behavior in low income populations. Amer. J. Pub. Health 64, 205-216 (1974). 6. Brunswik, E. “Perception and the Representative Design of Psychological Experiments.” University of California Press, Berkeley, 1965. 7. Campbell, D. T., and Stanley, J. C. “Experimental and Quasi-Experimental Designs for Research.” Rand McNally, Chicago, 1963. 8. Cartwright, D. Some principles of mass persuasion. Hum. Rel. 2, 253-267, (1949). 9. Crosbie, P. V., Petroni, F. A. and Stitt, B. G. The dynamics of ‘corrective groups’, J. Health Sot. Behav. 13, 294-302 (1972). 10. Dawber, T. R., and Kannel, W. B. Current status of coronary prevention, Prev. Med. 1,499-512 (1972). Il. Dichter, E. “Handbook of consumer motivations.” McGraw-Hill, New York, 1964. 12. Dubos, R. “The Mirage of Health,” Mentor, New York, 1958. 13. Festinger, L. “A Theory of Cognitive Dissonance.” Stanford University Press, Palo Alto, 1957. 14. Friedson, E. Client control and medical practice. Amer. J. Sot. 65,374-382 (1960). 15. Hare, A. P. Interpersonal relations in the small group, in “Handbook of Modem Sociology” (R. E. L. Faris, Ed.), p. 217. Rand McNally, Chicago, 1964. 16. Harris, D. V. Physical activity history and attitudes of middle-aged men. Med. Sci. Sports, 2,203 (1970). 17. Heinzelmann, F., and Bagley, R. W. Response to physical activity programs and their effects on health behavior. Pub. Health Rep. 85, 905-911 (1970). 18. Henderson, J. B. Applying behavioral science to cardiovascular risk, in “Behavioral Science and Preventive Medicine,” (R. Kane and C. Hughes, Eds.). Fogerty International Center, NIH, PHS, DHEW, in press. 19. Homans, G. C., “The Human Group.” Harcourt, Brace, and World, New York, 1950. 20. Kane, R., and C. Hughes (Eds.), “Behavioral Science and Preventive Medicine.” Fogerty International Center, NIH, PHS, DHEW, in press. 21. Kegeles, S. S. A field experimental attempt to change beliefs and behavior of women in an urban ghetto. J. Health Sot. Behav. 10, 115-124 (1969). 22. Leventhal, H. Findings and theory in the study of fear communications, in “Advances in Experimental Social Psychology,” (L. Berkowitz, Ed.), Vol. 5. Academic Press, New York, 1970. 23. Lewin, K. Group decision and social change, in “Readings in Social Psychology,” (N. Maccoby, T. Newcomb, and E. Hartley, Eds.), pp. 197-211. Holt, Rinehart & Winston, New York, 1958. 24. Liska, A. E. Emergent issues in the attitude-behavior consistency controversy, Amer. socio/. Rev. 39, 261-272 (1974). 25. Maccoby, N., and Farquhar, J. W. Communication for health: UnseJJing heart disease. J. Comm. 25, 114-126 (1975).
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