Public Health & Social/Behavioral Sciences PDF

How Is Public Health Related to the Social and Behavioral Sciences? The development of social and behavioral sciences in the 19th century is closely connected with the development of public health. These subject areas share a fundamental belief that understanding the organization and motivation behi...

How Is Public Health Related to the Social and Behavioral Sciences? The development of social and behavioral sciences in the 19th century is closely connected with the development of public health. These subject areas share a fundamental belief that understanding the organization and motivation behind social forces, along with a better understanding of the behavior of individuals, can be used to improve the lives of individuals, as well as society as a whole. The 19th-century development of social and behavioral sciences, as well as public health, grew out of the Industrial Revolution in Europe, and later in the United States. It was grounded in efforts to address the social and economic inequalities that developed during this period and provided an intellectual and institutional structure for what was and is now called social justice. Social justice implies a society that provides fair treatment and a fair share of the rewards of society to individuals and groups of individuals. Early public health reformers advocated for social justice and saw public health as an integral aspect of it. The intellectual link between social and behavioral sciences and public health is so basic and so deep that it is often taken for granted. For students with opportunities to learn about both social sciences and public health, it is important to understand the key contributions that social sciences make to public health. It is not an exaggeration to view public health as an application of the social sciences, or in other words, as an applied social science. Table 4.1 summarizes some of the contributions that the social sciences make to public health. TABLE 4.1Examples of Contributions of Social and Behavioral Sciences to Public Health Social science disciplines Examples of disciplinary contributions to public health Psychology Theories of the origins of behavior and risk-taking tendencies and methods for altering individual and social behaviors Sociology Theories of social development, organizational behavior, and systems thinking; social impacts on individual and group behaviors Anthropology Social and cultural influences on individual and population decision-making for health with a global perspective Political science/public policy Approaches to government and policy-making related to public health; structures for policy analysis and the impact of government on public health decision-making Economics Understanding the micro- and macroeconomic impact on public health and healthcare systems Communications Theory and practice of mass and personalized communication and the role of media in communicating health information and health risks Demography Understanding demographic changes in populations globally due to aging, migration, and differences in birth rates, plus their impact on health and society Geography Understanding the impacts of geography on disease and determinants of disease, as well as methods for displaying and tracking the location of disease occurrence How Are Social Systems Related to Health? Social systems can affect individual health through a variety of mechanisms. Berkman and Kawachi2 argue that social systems influence health and health behavior by: Shaping norms: Certain behaviors may become generally accepted among social groups. An attitude of “everyone else is doing it” can have a strong influence on an individual’s decision to partake in the activity. For example, in some communities, perhaps it is rare for anyone to wear a helmet while biking. So an individual who has always used a bicycle helmet in the past may decide to forgo it because nobody else wears one in his new community. Enforcing patterns of social control: Having rules and regulations in place creates structure for society, which can affect health. For instance, having a curfew for teenagers to be off the streets by midnight unless accompanied by an adult may assist in preventing violence. Providing opportunities to engage in healthy behaviors: The opportunities, or lack thereof, in our surroundings can have a strong influence on our health. For instance, having access to a community pool can encourage individuals to learn to swim, thus preventing drowning, while also serving as a form of physical exercise and social cohesion. Encouraging selection of healthy behaviors as a coping strategy: For example, college students often go through stressful periods throughout their academic career, particularly around exam time. Some students may decide to cope with this stress by “blowing off steam.” This can take many forms, from binge drinking to going for a run, each selection having a different effect on health. Having introduced the complex relationship between social systems and individuals, let us now look at three key components of the social system and their relationship to health: socioeconomic status, culture, and religion. How Do Socioeconomic Status, Culture, and Religion Affect Health? Socioeconomic Status Beginning in the 1800s, social scientists developed the concept of socioeconomic status. They also developed elaborate systems to operationalize the definition of “socioeconomic status” and classify individuals. In the United States, the definition has generally included measures that are strongly related to income, including:a Family income Educational level or parents’ educational level and their professional status In developed countries such as the United States, health status, at least as measured by life expectancy, is strongly associated with socioeconomic status and especially with income.3,4 Greater longevity is associated with higher social status, with a gradient of increasing longevity from lowest to highest on the socioeconomic scale. Box 4.1 provides greater detail on this important relationship. Box 4.1 Income and Population Health Health status as measured by life expectancy has been found to improve with a country’s increasing average gross domestic product (GDP) per capita, up to a threshold of about $10,000 per person, which is the current level for the many successful middle-income developing nations. The United States currently has an average GDP per capita of approximately $50,000. Once this threshold of adequate income is reached, the health status of countries does not always continue to steadily rise as income increases. At these higher levels of GDP per capita, as seen in most developed countries, income disparities are a better predictor of life expectancy than absolute levels of average GDP per capita. Developed countries with lower levels of income disparity, such as Canada, Germany, and the Scandinavian countries, all have longer life expectancies than countries such as the United States, which have greater income disparities. Even in countries with modest levels of income disparities, a socioeconomic gradient of health status exists such that individuals with a higher socioeconomic status tend to have better health outcomes compared to those with a lower socioeconomic status. This gradient can be viewed as a ladder in that moving down the socioeconomic ladder, more ill health and shorter life expectancy are experienced at each rung. Therefore, socioeconomic determinants of health do not solely affect the very poorest or those in the lowest socioeconomic levels, but are rather an issue throughout all income levels. An argument has been made that poorer health leads to lower income and not the other way around. There is little evidence that this phenomenon explains the socioeconomic factors that affect health. Education level is an even stronger predictor of life expectancy than income, and education levels are usually well established before poor health develops. Education level, income level, and professional status are three key components of socioeconomic status as measured in the United States. Therefore, it may be more accurate to say that disparities in socioeconomic status are associated with poorer population health status. A measure that has been adapted to calculate economic inequity across populations is the Gini index, also known as the Gini coefficient. This is a commonly used measure of income distribution, with an index ranging from 0 to 1, with higher values indicating greater inequality. A Gini index of 0 indicates complete income equality (everyone has the same income), and 1 indicates complete inequality in income (one individual receives all the income). Oftentimes, for ease of reporting and drawing comparisons, the index is multiplied by 100 so that the values range from 0 to 100. The Gini index measures the extent of deviation between an economy’s distribution of income among individuals or households and that of perfectly equal distribution. Among developed countries, income inequality is strongly associated with higher rates of mortality. Countries with a wider gap between the poorest of the poor and richest of the rich (a Gini index closer to 1) experience poorer population health outcomes on measures such as infant mortality and life expectancy, compared to countries with a narrow gap between rich and poor (a Gini index closer to 0).5,6 The United States has the highest Gini index of major developed countries. The U.S. Gini index is greater than 41, compared to approximately 35 in the United Kingdom, 33 in Canada, 32 in Germany, and less than 28 in several Scandinavian countries.6 Place matters. Some groups of Americans will die 20 years earlier than others who live just a short distance away because of differences in education, income, race, ethnicity, and where and how they live. One classical study revealed dramatic disparities in life expectancy across U.S. counties overall, and particularly when racial or ethnic differences were also considered. For example, black men in the county with the shortest life expectancy for blacks lived approximately 60 years, while white men in the county with the longest life expectancy for whites could expect to live two decades longer.7,b Socioeconomic factors are associated with an increase in relative risk of death of 1.5 to 2.0 when comparing the lowest and highest socioeconomic groups. This means that those in the lowest group have more than a 50% increase in the death rate compared to the highest group. This relative risk steadily increases as the socioeconomic level decreases. The relationship has a dose-response relationship; that is, there is an increase in longevity with every increase in socioeconomic status. Thus, the impact is not limited to those with the lowest status. A wide range of diseases make up the causes of this increased mortality. The largest contributors to the differences in the death rate are cardiovascular disease; violence; as well as cancer and infectious diseases, including human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and, during the pandemic, COVID-19. The bottom line is wealth equals health.8 We understand many, but not all, of the ways that socioeconomic factors affect health. Greater economic wealth usually implies access to healthier living conditions. Improved sanitation, less crowding, greater access to health care, and safer methods for cooking and eating are all strongly associated with higher economic status in developed, as well as developing, countries. More formal education and the higher social status that results are strongly associated with better health. It may change health outcomes and increase longevity by encouraging behaviors that provide protection against disease and also reduce exposure to behaviors that put individuals at risk of disease. Higher education levels, coupled with the increased resources that greater wealth can provide, may increase access to better medical care and provide greater ability to protect against health hazards. Individuals of lower socioeconomic status are more likely to be exposed to health hazards at work and in the physical environment through toxic exposure in the air they breathe, the water they drink, and the food they eat. Table 4.2 outlines a number of mechanisms by which socioeconomic status can directly and indirectly influence health. TABLE 4.2Examples of Ways That Socioeconomic Status May Affect Health Ways that socioeconomic status may affect health Examples Living conditions Increases in sanitation, reductions in crowding, methods of heating and cooking Overall educational opportunities Education has the strongest association with health behaviors and health outcomes May be due to better appreciation of factors associated with disease and greater ability to control these factors Educational opportunities for women Education for women has an impact on the health of children and families Occupational exposures Lower socioeconomic jobs are traditionally associated with increased exposures to health risks Access to goods and services Ability to access goods, such as protective devices, and high-quality foods and services, including medical and social services to protect and promote health Family size Large family size adversely affects health and is traditionally associated with lower socioeconomic status and lower health status Exposures to high-risk behaviors Social alienation related to poverty may be associated with violence, drugs, and other high-risk behaviors Environmental Lower socioeconomic status is associated with greater exposure to environmental pollution, “natural” disasters, and dangers of the “built environment” These factors, while important, do not explain the entire observed differences in life expectancy among individuals of different socioeconomic status. For instance, the rates of coronary heart disease are considerably higher among those of lower socioeconomic status—even after taking into account cigarette smoking, high blood pressure, cholesterol levels, and blood sugar levels.8 Considerable research is now being directed to better understand these and other effects of socioeconomic status. One theory suggests that social control and social participation may help explain these substantial differences in health. It contends that control over individual and group decision-making is much greater among individuals of higher socioeconomic status. Systemic racism and other forms of discrimination may underly these differences. The theory holds that the ability to control one’s life may be associated with biological changes that affect health and disease.8 Additional research is needed to confirm or reject this idea and/or provide an adequate explanation for these important, yet unexplained, differences in health based upon socioeconomic status. Culture Culture, in a broad sense, helps people make judgments about the world and decisions about behavior. Culture defines what is good or bad, and what is healthy or unhealthy. This may relate to lifestyle patterns, beliefs about risk, and beliefs about body type—for example, a large body type in some cultures symbolizes health and well-being, not overweight, fat, or other negative connotations. Culture directly affects the daily habits of life. Food choice and methods of food preparation and preservation are all affected by culture, as well as socioeconomic status. The Mediterranean diet, which includes olive oil, seafood, vegetables, nuts, and fruits, has been shown to have benefits for the heart even when used in countries far removed from the Mediterranean. There are often clear-cut negative and/or positive impacts on disability related to cultural traditions as diverse as feet binding in China and female genital mutilation in some parts of Africa. Some societies reject strenuous physical activity for those who have the status and wealth to be served by others. Culture is also related to an individual’s response to symptoms and acceptance of interventions. In many cultures, medical care is exclusively for those with symptoms and is not part of prevention. Many traditional cultures have developed sophisticated systems of self-care and self-medication supported by family and traditional healers. These traditions greatly affect how individuals respond to symptoms, how they communicate the symptoms, and the types of medical and public health interventions that they will accept. © Peter Lourenco/Moment/Getty Images Many cultures allow and even encourage the use of traditional approaches alongside Western medical and public health approaches. In some cultures, traditional healers are considered appropriate for health problems whose causes are not thought to be biological, but instead related to spiritual and other phenomena. Recent studies of alternative, or complementary, medicine have provided evidence that specific traditional interventions, such as acupuncture and specific osteopathic and chiropractic manipulation, have measurable benefits. Thus, cultural differences should not be viewed as problems to be addressed, but rather as practices to be understood. Table 4.3 summarizes a number of the ways that culture can affect health. TABLE 4.3Examples of Ways That Culture Can Affect Health Ways that culture may affect health Examples Culture is related to behavior—social practices may put individuals and groups at increased or reduced risk Food preferences—vegetarian, Mediterranean diet Cooking methods History of binding of feet in China Female genital mutilation Role of exercise Culture is related to response to symptoms, such as the level of urgency to recognize symptoms, seek care, and communicate symptoms Cultural differences in seeking care and self-medication Social, family, and work structures provide varying degrees of social support—low degree of social support may be associated with reduced health-related quality of life Culture is related to the types of interventions that are acceptable Variations in degree of acceptance of traditional Western medicine, including reliance on self-help and traditional healers Culture is related to the response to disease and to interventions Cultural differences in follow-up, adherence to treatment, and acceptance of adverse outcome Religion Social factors affecting health include religion, which can be seen as a special component of culture. Religion can have a major impact on health, particularly for specific practices that are encouraged or condemned by a particular religious group. For instance, we now know that male circumcision reduces susceptibility to HIV/AIDS, at least among males. Religious attitudes that condone or condemn the use of condoms, alcohol, and tobacco have direct and indirect impacts on health as well. Some religions prohibit specific medical practices, such as blood transfusions or abortion, or totally reject medical interventions altogether, as is practiced by Christian Scientists. Religious individuals may see medical and public health interventions as complementary to religious practice or may substitute prayer for medical interventions in response to symptoms of disease. Table 4.4 outlines some of the ways that religion may affect health. TABLE 4.4Examples of Ways That Religion May Affect Health Ways that religion may affect health Examples Religion may affect social practices that put individuals at increased or reduced risk Sexual: circumcision, use of contraceptives Food: avoidance of seafood, pork, beef Alcohol use: part of religion versus prohibited Tobacco use: actively discouraged by Mormons and Seventh-Day Adventists as part of their religion Religion may affect the response to symptoms Christian Scientists reject medical care as a response to symptoms Religion may affect the types of interventions that are acceptable Prohibition against blood transfusions Attitudes toward stem cell research Attitudes toward abortion End-of-life treatments Religion may affect the response to disease and to interventions Role of prayer as an intervention to alter outcome on its own versus to support medical care a A more formal social hierarchy has traditionally existed in Europe. European social scientists utilized the concept of social class when categorizing individuals by socioeconomic status. In Europe, economics alone was not thought to be adequate to explain socioeconomic status or categorize individuals. b The association between socioeconomic status and longevity is most strongly associated with an individual’s socioeconomic status as an adult. The socioeconomic status of an individual’s parents has a much weaker association. This suggests that genetic factors have little to do with the association between socioeconomic status and life expectancy. An individual’s level of education has a stronger association with health status than income or professional status. These facts have led to the conclusion that lower socioeconomic status leads to poor health rather than poor health leading to lower socioeconomic status. Can Individual Health Behavior Be Changed? Accomplishing the goals of Healthy People 2030 will require changes in behavior at the individual level. Much of the preventable disease and disability today in the United States and other developed countries is related to the behavior of individuals. From cigarette smoking to obesity, from intentional to unintentional injuries, from sexual behavior to drug abuse, health issues can be traced to the behavior of individuals. Consider all the behaviors related to health. Some are intentional health behaviors, while others are not necessarily motivated by health concerns. Getting a mammogram could be an example of an intentional health behavior because it is a behavior most likely undertaken for health benefits—in this case, screening for breast cancer. However, driving the speed limit may be a behavior that has an effect on health but is undertaken not because the individual is concerned about the health benefits of doing so (avoiding injury from a motor vehicle crash), but because he or she wants to avoid getting a ticket. Therefore, in order to have an impact on health, a wide range of behavioral motivations and factors needs to be addressed. At times, we hear discouraging messages that behavior cannot be changed. However, if we take a relatively long-term view, we find that there are many examples of behavioral change that have occurred for the better. For instance: Cigarette smoking in the United States among men has been reduced from approximately 50% in the 1960s to approximately 15% today. Infants today generally are placed on their backs for sleeping and napping and not on their stomachs, as was the usual practice in the 1980s and earlier. Back-to-Sleep campaigns are believed to have reduced sudden infant death syndrome (SIDS) by nearly 50% in the United States. Seat belt use in the United States has increased from less than 25% in the 1970s to over 80% currently. Drunk driving in the United States has been dramatically reduced, with a resulting decline in alcohol-related automobile fatalities. Mammography use increased by approximately 50% during the 1990s and early 21st century and has been credited with beginning to reduce the previously rising mortality rates from breast cancer. The COVID-19 pandemic demonstrated how quickly behavior such as social distancing, mask use, and vaccination can be changed among some individuals and how resistant to change it can be among others. The potential to change behavior can lead to poorer health as well. The following changes for the worse have also occurred in the United States in recent years: Over the last three decades, Americans have increased their caloric intake and reduced their average amount of exercise, resulting in more than doubling the obesity rate to nearly 35% of all adults. Between the 1960s and the 1990s, teenage girls and young adult women increased their cigarette smoking, subjecting their unborn children to additional hazards of low birthweight. Fortunately this trend has been reversed in recent years. Texting and driving has increased dramatically in recent years, though national educational campaigns and new technologies have begun to reverse this trend. Opioid use, including increasingly powerful and dangerous opioids, have increased dramatically in the United States during the last decade, leading to an unprecedented opioid epidemic. Behavioral change is possible for the better and for the worse. Some behaviors, however, are easier to change than others. Let’s take a look at why this is. Why Are Some Individual Health Behaviors Easier to Change Than Others? Some behaviors are relatively easy to change, while others are extremely difficult. Being able to recognize the difference is an important place to start when trying to alter behavior. It is relatively easy to change a behavior when the behavior can be substituted for a similar one and results in a potentially large payoff. In these situations, knowledge often goes a long way. For instance, the substitution of acetaminophen (Tylenol) for aspirin to prevent Reye’s syndrome was relatively easy. Similarly, the Back-to-Sleep campaign was quite successful in reducing the rate of death from SIDS. In both of these cases, an acceptable and convenient substitute was available, making the needed behavioral change much easier to accomplish. Along with knowledge, incentives—such as reduced cost, increased availability, or improvements in ease of use—can encourage rapid acceptance and motivate behavioral change. For instance, easier-to-install child restraint systems have increased their use. Greater insurance coverage and widespread availability of modern mammography equipment has led to an increase in the number of mammograms performed. The most difficult behaviors to change are those that have a physiological component, such as obesity, or an addictive element, such as cigarette smoking. Individual interventions aimed at smoking cessation or long-term weight control generally succeed less than 30% of the time—even among motivated individuals. Even intensive interventions with highly motivated individuals cannot be expected to be successful more than 50% of the time, as was illustrated by the Multiple Risk Factor Intervention Trial (MRFIT), which attempted intensive interventions to reduce risk factors for cardiovascular disease. In addition, physical, social, and economic barriers can stand in the way of behavior change, even if individuals themselves are motivated. If health care is not accessible, or if survival needs require individuals to engage in risks they might not take otherwise, change in behavior may be difficult. Successful behavioral change requires that we understand as much as we can about how behavior can be changed and what we can do to help. How Can Individual Behavior Be Changed? There is a wide variety of useful theories of how individual behaviors develop and change. These theories help guide our understanding about how to intervene to effectively change individual behavior. One such theory, which had gained widespread use in clinical medicine and public health, is called the Stages of Change Model. The underlying assumption of this model is that people go through a set of incremental stages when changing behavior rather than making significant changes all at once.9,c The first stage, called precontemplation, implies that an individual has not yet considered changing his or her behavior. At this stage, efforts to encourage change are not likely to be successful. However, efforts to educate and offer help in the future may lay the groundwork for later success. The second phase, known as contemplation, implies that an individual is actively thinking about the benefits and barriers to change. At this stage, information focused on short- and immediate-term gains, as well as long-term benefits, can be especially useful. In addition, the contemplation stage lends itself to developing a baseline—that is, establishing the current severity or extent of the problem in order to measure future progress. The third phase is called preparation. During this phase, the individual is developing a plan of action. At this point, the individual may be especially receptive to setting goals, considering a range of strategies, and developing a timetable. Help in recognizing and preparing for unanticipated barriers can be especially useful to the individual during this phase. The fourth phase is the action phase, when the change in behavior takes place. This is the time to bring together all possible outside support to reinforce and reward the new behavior and help with problems or setbacks that occur. The fifth—and hopefully final—phase is the maintenance phase, in which the new behavior becomes a permanent part of an individual’s lifestyle. The maintenance phase requires education on how to anticipate the long-term nature of behavioral change, especially how to resist the inevitable temptations to resume the old behavior. Using cigarette smoking as illustration again, Table 4.5 summarizes the stages of behavioral change and the specific actions that can be helpful at each of the stages. TABLE 4.5Stages of Change Model and Cigarette Smoking Stages of change Actions Example: cigarette smoking Precontemplation Prognosticate Individual not considering change Assessing readiness for change—timing is key Determine individual’s readiness to quit If not ready, indicate receptivity to help in the future Look for receptive timing, such as during acute respiratory symptoms Social factors, such as workplace and indoor restriction on smoking and taxation, increase likelihood of entering precontemplation phase Contemplation Motivate change Individual thinks actively about the health risk and action required to reduce that risk Issue of change is on the individual’s agenda but no action is planned Provide information focused on short and intermediate gains from behavioral change, as well as long-term benefits Doubtful, dire, and distant impacts are less effective Reinforce increase in exercise level, reduction in cough, financial savings, serving as example to children, protection of fetus, etc. Continue to inform of longer-term effects on health Establish baseline to assess severity of the problem; focus attention on the problem and provide basis for comparison Develop log of timing, frequency, and quantity of smoking, as well as associated events Preparation Plan change Prepare for action, including developing a plan and setting a timetable Set specific measurable and obtainable goals with deadlines Quit date or possible tapering if heavy smoker Two or more well-chosen simultaneous interventions may maximize effectiveness Family support, peer support, individual planning, medication, etc., may reinforce and multiply impacts Recognize habitual nature of existing behavior and remove associated activities Remove cigarettes, ashtrays, and other associated smoking equipment Remove personal and environmental impacts of past smoking, such as teeth cleaning and cleaning of draperies Anticipate temptations, such as associations with food, drink, and social occasions Action Reinforce change Observable changes in behavior with potential for relapse Provide/suggest tangible rewards Provide rewards, such as alternative use of money, focus on personal hygiene or personal environment Positive feedback and encouragement of new behavior Anticipate adverse effects and frustrations Focus on measurable progress toward new behavior Provide receptive environment, but avoid focus on excuses Take short-term, one-day-at-a-time approach Recognize potential for symptoms to worsen at first before improvement occurs Anticipate potential for weight gain and encourage exercise and other behaviors to reduce potential for weight gain Utilize group/peer support Family and peer reinforcement critical during action phase Maintenance Maintain change New behavior needs to be consolidated as part of permanent lifestyle change Practice/reinforce methods for maintaining new behavior Avoid old associations and prepare/practice response when encountering old circumstances Recognize long-term nature of behavioral change and need for supportive peers and social reinforcementNegative social attitudes toward smoking among peers and society along with social restrictions, such as limiting public indoor smoking, and social actions, such as taxation, help prevent smoking and reinforce maintenance of cessation How Can Group and Population Interventions Complement Individual Interventions? Behavioral change is often regarded as a solely individual process with interventions focused on individuals one at a time. However, it is important to recognize that individual behavior develops and changes in response to group and population influences. Therefore, when looking at the stages of change, we need to also examine the impact of interventions aimed at groups and populations. Group and population interventions often reinforce individual interventions. It is possible to use group and population interventions at each stage of the stages of behavioral change model. Table 4.6 illustrates ways that group and population interventions can reinforce individually directed intervention. TABLE 4.6Stages of Change—Individual, Group, and Population/Social Interventions to Change Cigarette Smoking Behavior Description Combining individual interventions with group and population interventions has been shown to be the most successful approach to smoking cessation. None of the specific approaches works as well without the use of multiple other interventions. Cigarette taxation, restrictions on smoking, and negative public attitudes toward smoking make it easier for smokers to move from precontemplation to contemplation to action. These population interventions also encourage continued cessation through the long and often difficult maintenance. What Are Other Widely Used Theories of Behavioral Change? A wide range of other theories has been developed to explain human behavior and changes in human behavior. Intrapersonal theories and models focus on characteristics of the individual, including knowledge, attitudes, beliefs, motivation, self-concept, past experiences, and skills. The Health Belief Model, a widely used intrapersonal theory, contends that individuals will change behavior if (1) they believe the condition has serious consequences; (2) they believe taking action would benefit them, with the benefits outweighing the harms; and (3) they are exposed to factors that prompt action; and (4) they believe in their ability to successfully perform the action. Interpersonal theories and models incorporate the influences of other people on an individual’s behavior. These other people can include family members, peers, coworkers, healthcare providers, etc., and they can influence behavior by sharing their advice, feelings, and opinions, and through the support and assistance they provide. The Theory of Planned Behavior, a widely used interpersonal theory, proposes that behavioral intention is influenced by an individual’s attitude toward performing a behavior, their beliefs about whether people important to them approve or disapprove of the behavior, and their beliefs about their control over performing the behavior. Theories and models on the population, or community level, explore factors within social systems, offering strategies that can be used to alter these factors to address health issues within a population. The Diffusion of Innovation theory is one widely used population-focused theory. The theory proposes that the diffusion and adoption, or rejection, of an innovation is affected by perceived attributes of the innovation, including (1) relative advantage (Is the innovation better than what it will replace?), (2) compatibility (Does the innovation fit with the values and needs of the intended audience?), (3) complexity (Is the innovation easy to understand and use?), (4) trialability (Can the innovation be tried before making a decision to adopt?), and (5) observability (Are the results of the innovation observable and easily measurable?). The Diffusion of Innovation theory has contributed the concept of different types of adopters, including early adopters (those who seek to experiment with innovative ideas), early majority adopters (often opinion leaders whose social status frequently influences others to adopt the behavior), and late adopters (or laggards—those who need support and encouragement to make adoption as easy as possible).10 What Are Some Effective Principles for Influencing Individual Behaviors? An emerging field known as behavioral economics seeks to utilize new understandings about human behavior to change the behavior of clinicians and patients. These understandings include: Losses loom larger than gains—Incentive systems for behavioral changes are more effective when individuals view the incentive as a way to avoid a potential loss, not just obtain a potential gain. For instance, instead of offering a positive incentive payment (e.g., $10) after each of 10 sessions attended, it may be more effective to offer one large payment (e.g., $100) at the end of the program, with each session missed being viewed as a loss. Just-in-time reminders work well—Desirable behavior is often reinforced by reminders that are seen just before the time of the desirable behavior. These types of reminders have been successfully used to remind clinicians to wash their hands and potential elevator users to walk a flight or two of stairs. Default choices are usually retained—When people need to take action to change the default choice, they usually accept the default. This principle has been shown to affect clinicians’ choice of generic versus name brand drugs and patients’ choices of health insurance and even end-of-life care. Creating new habits is key to behavioral change—Apps that provide reminders to take medication, exercise, or do other routine behavior may be useful for developing and reinforcing new behaviors. New understanding from the behavioral sciences is likely to continue to improve our ability to change behavior in ways that improve outcomes.11 What Are Some Effective Principles for Influencing Individual Behaviors? An emerging field known as behavioral economics seeks to utilize new understandings about human behavior to change the behavior of clinicians and patients. These understandings include: Losses loom larger than gains—Incentive systems for behavioral changes are more effective when individuals view the incentive as a way to avoid a potential loss, not just obtain a potential gain. For instance, instead of offering a positive incentive payment (e.g., $10) after each of 10 sessions attended, it may be more effective to offer one large payment (e.g., $100) at the end of the program, with each session missed being viewed as a loss. Just-in-time reminders work well—Desirable behavior is often reinforced by reminders that are seen just before the time of the desirable behavior. These types of reminders have been successfully used to remind clinicians to wash their hands and potential elevator users to walk a flight or two of stairs. Default choices are usually retained—When people need to take action to change the default choice, they usually accept the default. This principle has been shown to affect clinicians’ choice of generic versus name brand drugs and patients’ choices of health insurance and even end-of-life care. Creating new habits is key to behavioral change—Apps that provide reminders to take medication, exercise, or do other routine behavior may be useful for developing and reinforcing new behaviors. New understanding from the behavioral sciences is likely to continue to improve our ability to change behavior in ways that improve outcomes.11 How Can Marketing Principles Be Used to Change Behavior? In recent years, public health has begun to apply marketing approaches to try to better understand and change the health behaviors of groups of people—especially those who are at high risk for the health impacts of their behavior, such as cigarette smokers. Social marketing, a use and extension of traditional product marketing, has become a key component of a public health approach to behavioral change.12 Social marketing campaigns were first successfully used in the developing world for promoting a range of products and behaviors, including family planning and pediatric rehydration therapy. In recent years, social marketing efforts have been widely and increasingly successfully used in developed countries, including such efforts as: The truth® campaign—Developed by the American Legacy Foundation, it aimed to redirect the perception of smoking being seen as a teenage rebellion to the decision to not smoke being a rebellion against the alleged behavior-controlling tobacco industry. The National Youth Anti-Drug campaign—It used social marketing efforts directed at young people, including the “Parents. The Anti-Drug” campaign. The VERB™ campaign—It focused on 9- to 13-year-olds, or “tweens,” with a goal of making exercise fun and “cool” for everyone, not just competitive athletes. Social marketing incorporates the “4 P’s,” which are widely used to structure traditional marketing efforts: Product: identifying the behavior or innovation that is being marketed Price: identifying the benefits, the barriers, and the financial costs Place: identifying the target audiences and how to reach them Promotion: organizing a campaign or program to reach the target audience(s) Social marketing, like product marketing, often relies on what marketers call branding. Branding includes words and symbols that help the target audience identify with the service; however, it goes deeper than just words and symbols. It can be seen as a method of implementing the fourth “P,” or promotion. It also builds upon the first three “P’s”: Branding requires a clear understanding of the product or the behavior to be changed (product). Successful branding puts forth strategies for reducing the financial and psychological costs (price). Branding identifies the audience and segments of the audience and asks how each segment can be reached (place). Branding is the public face of social marketing, but it also needs to be integrated into the core of the marketing plan.d Social marketing efforts in developing and developed countries have demonstrated that it is possible to change key health behaviors of well-defined groups of people, including adolescents, who are often regarded as the hardest to reach. An example of the use of social marketing to reach young people, the VERB™ campaign, is examined in Box 4.2.13 Box 4.2 VERB™ Campaign The VERB™ social marketing campaign was funded through the Centers for Disease Control and Prevention (CDC), which worked with advertising agencies to reach tweens and make exercise “cool.” After a series of focus groups and other efforts to define and understand the market, it was concluded that the message should not be one of improving health, but rather of having fun with friends, exploring new activities with a sense of adventure, and being free to experiment without being judged on performance. Marketing efforts also identified barriers, including time constraints and the attraction of other activities, from social occasions to television to computers. In addition, barriers included lack of access to facilities, as well as negative images of competition, embarrassment, and the inability to become an elite athlete. The VERB™ campaign implied action and used the tagline “It’s what you do.” Initial messages used animated figures of children covered with verbs being physically active. Later, messages turned these animated verb–covered kids into real kids actively playing. Widely used logos were developed and promoted as part of the branding effort. The VERB™ campaign partnered with television channels that successfully reached tweens, sponsored outreach events, and distributed promotional materials. During the 4 years of the VERB™ campaign, tweens developed widespread recognition of the program and rated it highly in terms of “saying something important to me” and “makes me want to get more active,” with maximum levels of recognition of 64% and 68%, respectively. Data from Wong F, Huhman M, Asbury L, Mueller RB, et al. VERB™—A social marketing campaign to increase physical activity among youth. Preventing Chronic Disease. 2004;3(1):1–7. The COVID-19 pandemic brought to national and international attention the importance of behavioral change, from social distancing, to use of masks, to acceptance of vaccines. A large number of approaches have been attempted to gain acceptance of vaccines. Let us take a look at what has been learned about the options for effectively addressing what has been called vaccine hesitancy. We will use the four “how” options for implementation—that is, education, motivation, obligation, and innovation. How Can Marketing Principles Be Used to Change Behavior? In recent years, public health has begun to apply marketing approaches to try to better understand and change the health behaviors of groups of people—especially those who are at high risk for the health impacts of their behavior, such as cigarette smokers. Social marketing, a use and extension of traditional product marketing, has become a key component of a public health approach to behavioral change.12 Social marketing campaigns were first successfully used in the developing world for promoting a range of products and behaviors, including family planning and pediatric rehydration therapy. In recent years, social marketing efforts have been widely and increasingly successfully used in developed countries, including such efforts as: The truth® campaign—Developed by the American Legacy Foundation, it aimed to redirect the perception of smoking being seen as a teenage rebellion to the decision to not smoke being a rebellion against the alleged behavior-controlling tobacco industry. The National Youth Anti-Drug campaign—It used social marketing efforts directed at young people, including the “Parents. The Anti-Drug” campaign. The VERB™ campaign—It focused on 9- to 13-year-olds, or “tweens,” with a goal of making exercise fun and “cool” for everyone, not just competitive athletes. Social marketing incorporates the “4 P’s,” which are widely used to structure traditional marketing efforts: Product: identifying the behavior or innovation that is being marketed Price: identifying the benefits, the barriers, and the financial costs Place: identifying the target audiences and how to reach them Promotion: organizing a campaign or program to reach the target audience(s) Social marketing, like product marketing, often relies on what marketers call branding. Branding includes words and symbols that help the target audience identify with the service; however, it goes deeper than just words and symbols. It can be seen as a method of implementing the fourth “P,” or promotion. It also builds upon the first three “P’s”: Branding requires a clear understanding of the product or the behavior to be changed (product). Successful branding puts forth strategies for reducing the financial and psychological costs (price). Branding identifies the audience and segments of the audience and asks how each segment can be reached (place). Branding is the public face of social marketing, but it also needs to be integrated into the core of the marketing plan.d Social marketing efforts in developing and developed countries have demonstrated that it is possible to change key health behaviors of well-defined groups of people, including adolescents, who are often regarded as the hardest to reach. An example of the use of social marketing to reach young people, the VERB™ campaign, is examined in Box 4.2.13 Box 4.2 VERB™ Campaign The VERB™ social marketing campaign was funded through the Centers for Disease Control and Prevention (CDC), which worked with advertising agencies to reach tweens and make exercise “cool.” After a series of focus groups and other efforts to define and understand the market, it was concluded that the message should not be one of improving health, but rather of having fun with friends, exploring new activities with a sense of adventure, and being free to experiment without being judged on performance. Marketing efforts also identified barriers, including time constraints and the attraction of other activities, from social occasions to television to computers. In addition, barriers included lack of access to facilities, as well as negative images of competition, embarrassment, and the inability to become an elite athlete. The VERB™ campaign implied action and used the tagline “It’s what you do.” Initial messages used animated figures of children covered with verbs being physically active. Later, messages turned these animated verb–covered kids into real kids actively playing. Widely used logos were developed and promoted as part of the branding effort. The VERB™ campaign partnered with television channels that successfully reached tweens, sponsored outreach events, and distributed promotional materials. During the 4 years of the VERB™ campaign, tweens developed widespread recognition of the program and rated it highly in terms of “saying something important to me” and “makes me want to get more active,” with maximum levels of recognition of 64% and 68%, respectively. Data from Wong F, Huhman M, Asbury L, Mueller RB, et al. VERB™—A social marketing campaign to increase physical activity among youth. Preventing Chronic Disease. 2004;3(1):1–7. The COVID-19 pandemic brought to national and international attention the importance of behavioral change, from social distancing, to use of masks, to acceptance of vaccines. A large number of approaches have been attempted to gain acceptance of vaccines. Let us take a look at what has been learned about the options for effectively addressing what has been called vaccine hesitancy. We will use the four “how” options for implementation—that is, education, motivation, obligation, and innovation. What Can Be Done to Achieve Vaccine Acceptance When Education Alone Is Not Effective? When education is not effective on its own, we need to consider the use of additional options for implementation. However, it is important to remember that education remains an important implementation method even when it is not successful on its own. Education can facilitate the successful implementation of the other options. Motivation: Incentives for vaccination have been built into most COVID-19 vaccination programs. Vaccines have generally been provided without cost to the individual receiving the vaccine. A range of financial incentives have been tried. Some employers have increased insurance rates for those who are unvaccinated. Lotteries for those who become vaccinated with financial payments for winners have been tried with little success. Direct payments for vaccination have also been tried, but large payments may be needed to effectively change behavior. To address the issue of known side effects of vaccines, the United States has adopted a no-fault financial compensation system. This system is designed to provide financial support for those who experience known side effects of a vaccine without having to go through the court system. The no-fault system can be seen as a way to use financial incentives to reduce vaccine hesitancy. Incentives are not limited to financial inducements. Ease of access can be an important incentive. The easy availability of vaccination sites and paid time off for the administration of the vaccine and short-term side effects have been used. Availability through multiple sources, including integration into the healthcare system, can provide greater reassurance to patients. Combining vaccinations such as those for influenza and COVID-19 may increase vaccine acceptance. Obligation: Efforts to legally enforce vaccination through vaccine mandates have been an important and controversial component of the effort to achieve universal vaccination. Vaccination for entry into education from K–12 through higher education has been widely used for children, adolescents, and young adults for many years. The initial focus of COVID-19 vaccination was on adults, where it met considerable resistance at the individual as well as the legal level. Selective mandates including those for healthcare workers, where the need may be clearest, were endorsed by the Supreme Court, but more general mandates for workers were not. Innovation: COVID-19 vaccines can themselves be viewed as an important innovation. Additional innovations are possible and are being investigated. Avoiding the need for an injection or “jab” has been the focus of considerable effort. Nasal sprays, pills, and administration through the skin without an injection have become a key focus of efforts to increase vaccine acceptance through innovation. Developing and testing new innovations often takes considerable time and cannot be relied on as a short-term strategy for increasing vaccine acceptance. Changing behavior can be a complicated and at times frustrating process. However, as illustrated by acceptance of COVID-19 vaccines, there are a full range of tools from education to innovation that can be used to effectively change behavior for most if not all individuals. Given the availability of multiple approaches to changing behavior, it is important that the implementation of interventions be evaluated to determine whether they actually achieve their goals. Table 4.7 outlines examples of using each of the options for implementation to achieve vaccine acceptance. Often, two or more of these approaches will be needed. TABLE 4.7Approaches to Vaccine Acceptance Type of approach Meaning/examples Education Communications Providing science-based information and combating incomplete information, misinformation, and disinformation for individuals and populations Motivation Cost Providing vaccines at no cost to individuals or financial incentives such as payments for vaccination or increased insurance premiums for failure to vaccinate Convenience Making easily available, reducing time required Coordinated with health care Integrate into routine health care or hospital care, including use of electronic health records Obligation Coercion Requirement for economic, educational, or social participation Innovation Increase in compliance Alternative, more acceptable routes of administration such as nasal sprays, skin patches, or pills How Can Efforts to Change Individual Behavior Be Evaluated? The PRECEDE-PROCEED planning framework provides a structure to design and evaluate health education and health promotion programs through a diagnostic planning process followed by an implementation and evaluation process. There are nine steps of the framework, divided into two phases: PRECEDE and PROCEED.15,e Table 4.8 illustrates the nine steps of the PRECEDE-PROCEED framework using the example of gun violence in the absence of effective gun control legislation. The initial five PRECEDE steps are a diagnostic process designed to collect data and information to understand societal needs. The four PROCEED steps focus on the process of implementation and the evaluation of the success of the intervention. TABLE 4.8PRECEDE-PROCEED Framework and Application Step Description Example: gun violence Diagnostic phase: PRECEDE 1: Social assessment Assess people’s perceptions of their own needs and quality of life through data collection activities such as surveys, interviews, focus groups, and observation. Gun violence emerged as a major concern among community members through focus groups that were conducted to explore health and safety concerns in the community. 2. Epidemiological assessment Determine which health problems are most important for which groups in a community, often by analyzing data from vital statistics, state and/or national surveys, etc. This step should assist in identifying subpopulations at high risk and provide data to set measurable objectives for the program. Data from death certificates and crime reports reveals that the majority of deaths among males aged 24 years and younger in the community are due to gunshot wounds. 3. Behavioral and environmental assessment Identify factors, internal and external to the individual, that contribute to the health issue of interest. Literature searches and theory application provide guidance during this step. A literature search provides insight into factors contributing to gun violence among males aged 24 years and younger. Gang-related behavior is found to be frequent in populations with similar socioeconomic status as that of the target population. 4. Educational and organizational assessment Preceding and reinforcing factors that initiate and sustain behavior change are identified, such as an individual’s knowledge, skills and attitudes, social support, peer influence, and availability of services. Interventions aimed at males 16 years and younger are found to be most successful. Young males with older male positive role models are more likely to view gangs as negative and more likely to participate in sports and community service. 5. Administrative and policy assessment Identify policies, resources, and circumstances that may help or hinder implementation of the intervention. Communication system recently established between school system and law enforcement to report truancy and criminal behavior among the student population may assist in identifying subgroups to target intervention. Implementation and evaluation phase: PROCEED 6. Implementation The intervention is implemented. After-school program implemented that incorporates educational, service-oriented, and physical activity components, led by males from the community. The program is tailored for males 12–16 years of age. 7. Process evaluation Process evaluation assesses the extent to which the intervention was implemented as planned. Evaluate how program activities were delivered and attended. 8. Impact evaluation Impact evaluation assesses the change in the factors identified in steps 3 and 4. Evaluate subsequent gang membership or relationship among participants in the after-school programming. 9. Outcome evaluation Outcome evaluation assesses the effect of the intervention on the health issue of interest. Evaluate deaths due to gun violence in the community before and after intervention. Data from Green LW, Kreuter MW. Health Promotion Planning: An Educational and Ecological Approach. 3rd edition. New York, NY: McGraw-Hill; 1999. As we have seen, understanding human behavior and applying social and behavioral theories are central to public health. Study and use of social and behavioral sciences play an important role in improving population health. Analyzing the factors that influence health behavior assists in developing targeted interventions to promote healthy behavior and reduce health disparities. Additional planning frameworks, such as social marketing and PRECEDE-PROCEED, are also employed throughout the development, implementation, dissemination, and evaluation processes, contributing to successful health behavior interventions aimed at preserving, promoting, and protecting the health of populations. e PRECEDE is an acronym for predisposing, reinforcing, enabling constructs in educational/environmental diagnosis, and evaluation. PROCEED is an acronym for policy, regulatory and organizational constructs in educational and environmental development.