Nightingale

Social and Behavioral

Sciences & Public

Health

Chapter 4

Slide show developed by:

Richard C. Krejci, Ph.D.

Professor of Public Health

Columbia College of SC

2.8.2016

Introduction

• What are some examples of how social or cultural influences affect health?

• How Is Public Health related to the Social and Behavioral Sciences?

• How does Socioeconomic Status affect health?

• What other social factors explain the differences in health and response to disease?

• What are some of the common obstacles in helping others to change Health Behaviors?

Introduction

• Why are some individual Health Behaviors

easier to change than others?

• How can individual behaviors be changed?

• What stages so Individuals go through in making

behavioral change?

• How can behaviors within a group be changed?

• How can we combine individual, group, and

social efforts to implement behavioral change?

Social Influence on Health

You travel to a country in Asia and find that

the culture affects most parts of life including

health. From the food they eat and their method

of cooking to their attitudes toward medical care

and their beliefs about the cause of disease and

the ability to alter it through public health and

medical interventions, this country is profoundly

different from the United States.

Social Influence on Health

You are trying to help your spouse quit smoking

cigarettes and your kids from starting. You know that

gentle encouragement and support on a one-to-one

basis are essential but are often not enough since

cigarettes cause addiction that produces withdrawal

and long term cravings. Like most addictions, quitting

requires a combination of individual motivation,

support from family and friends, and sometimes use

of medications. But you wonder: do warning labels

on cigarettes, taxes on cigarettes, and no smoking

zones in public places make any difference?

Social Influence on Health

Your efforts to convince teenagers to avoid

smoking or at least stop smoking focuses on

giving them the facts about how cigarettes cause

lung cancer, throat cancer, and serious heart

disease.

You are frustrated at how little impact you have

had and are surprised that others are more

successful by focusing on immediate impacts

such as stained teeth and bad breadth as well as

the loss of control that goes along with addiction

to nicotine.

Behavioral/Environmental Influences

on Health

Suppose that every day on your way to work,

you pass the same young homeless man on the

same corner. You notice that over the past few

weeks he has been coughing, and you figure he

must have a cold.

Today when you walk by his usual place on the

corner, he is not there, but someone has left a sign

that reads, “Rest in peace, Ramón.” You are

surprised, especially because he was so young.

You wonder whether there was anything that could

have been done to prevent his death.

Social Influence on Health

As a new parent you hear from your pediatrician,

nurses in the hospital, and even from the makers of

your brand of diapers that babies should sleep on

their backs. They call it “back-to-bed.” You are

surprised to find that it’s part of the class on

babysitting given by the local community center and

a required part of the training for those who work in

registered day care centers. It’s all part of a social

marketing campaign, you find out, and it has

reduced by half the number of deaths from SIDS.

How Is Public Health Related to the

Social and Behavioral Sciences?

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

Examples of Contributions of Social and

Behavioral Sciences to Public Health

health Social

Science discipline

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

Additional Examples

Social Science

discipline

Examples of disciplinary contributions to public health

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 health care systems

Communications Theory and practice of mass and personalized communication and the role of media in communicating health information and health risks

Additional Examples

Social Science

discipline

Examples of disciplinary contributions to public health

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 of 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?

• Complex interactions – We are constantly interacting with our surroundings,

including social systems composed of interactions we

have with other people, institutions, communities, and

policies

– Efforts aimed at improving population health require

an understanding of the complex relationship

between social systems and health

How Are Social Systems Related

to Health?

• Influencing behavior – Shaping norms and cultural expectations

– Enforcing patterns of social control

– Providing or not providing opportunities to engage in certain

behaviors

– Reducing or producing stress for which certain behaviors may be

an effective coping strategy (at least in the short term)

How Do Socioeconomic Status,

Culture, and Religion Affect Health?

• These three key components of the social system have a

strong relationship with health

• Broad social influences can affect an individual’s

response to disease

Socioeconomic Status and Health

Type Examples

Living conditions Increases in sanitation, reductions in crowding, better methods of heating and cooking

Overall educational opportunities

Education is 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

Socioeconomic Status and Health

Type Examples 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 Smaller family size traditionally associated with improved socioeconomic status and with a better overall health status

Socioeconomic Status and Health

Type Examples

Exposures to high risk behaviors

Social alienation related to poverty may be associated with violence, drugs, other high risk behaviors

Environmental Lower socioeconomic status associated with greater exposure to environmental pollution, “natural” disasters, and dangers of the “built environment”

What are Some of the Ways that

Culture May 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

Positive Food preferences—vegetarian, Mediterranean diet

Cooking methods Negative Influences-History of binding of feet in

China Female genital mutilation (FGM)

Role of exercise

Examples of Ways that Culture

May Affect Health

Ways that culture may

affect health Examples

Culture is related to response to symptoms, such as the level of urgency to recognize symptoms, seek care, and communicate symptoms

Cultural differences in seeking care and self-medication social, family, and work structures provide varying degree of social support low degree of social support may be associated with reduced health-related quality of life

Examples of Ways that Culture

May Affect Health Ways that culture

may affect health

Examples

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 non-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

Examples of ways that Religion

may affect Health Ways that religion

affects health Examples Religion may affect social practices that

put individuals at increased or reduced

risk

Sexual: circumcision, use of contraceptives Food: avoidance of seafood, pork, beef Alcohol use: part of religion versus Prohibited use Tobacco use: actively discouraged by Mormons and Seventh-Day Adventists as part of their religion

Religion may affect response to symptoms

Christian Scientists may reject traditional medical care as a response to symptoms

Examples of Ways that Religion

May Affect Health Ways that religion

affects health Examples

Religion may affect the types of

interventions that are acceptable

Prohibition against blood transfusions Attitudes toward stem cell research issue 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

What Are Social Determinants

of Health?

• Conditions in which people are born, grow up,

live, learn, work, play, worship, and age, as well

as the systems put in place to deal with illnesses

that affect health and quality of life

– They are shaped by a wider set of forces, including

economics, social policies, and politics

10 Key Categories of Social

Determinants of Health

• Social status

• Social support or

alienation

• Food

• Housing

• Education

• Work

• Stress

• Transportation

• Place

• Access to health

services

How Do Social Determinants

Affect Health?

• They contribute to a wide variety of diseases rooted in

lifestyle, environmental, and social factors

• Connected with health disparities, a type of difference in

health closely linked with social or economic

disadvantages

– Negatively influence groups with greater social or economic

obstacles

• Affect both physical and mental health

Disparities in Health: Non-Communicable

Disease & Environmental Safety

• Coronary heart disease

– Black men and women more likely to die of heart disease and

stroke

• Colorectal cancer screening

– Disparities exist based on education and income level; as

education and income increase, screening rates increase

• Air pollution

– Racial/ethnic minority groups more likely to live in the most

polluted urban areas and continue to experience a

disproportionately larger impact

Disparities in Health: Environmental

Safety & Communicable Disease

• Motor vehicle crashes – Men of all races/ethnicities are two to three times more likely to

die in crashes than women

– Death rates twice as high among American Indians/Alaska

Natives

• HIV – Minorities experience disproportionately high rates of HIV

diagnosis, as do men who have sex with men (MSM)

– Rates are increasing among black, American Indian/Alaska

Native, MSM groups

• Influenza vaccination – Whites aged 65 years and older have consistently higher rates of

vaccination coverage

Can Health Behavior Be Changed?

• Some health behaviors are intentional, whereas

others are not motivated by health concerns

• Behavioral change is possible

– Both for the better and for the worse

• Examples of behavioral changes

– Reduction in cigarette smoking

– Seatbelt use

– Back-to-Sleep practices for infants

• Some behaviors are easier to

change than others

Why Are Some Individual Health

Behaviors Easier to Change?

• Behavior change is easier when one behavior

can be substituted for similar one that is

considered acceptable and convenient

– Substitution of acetaminophen (Tylenol) for aspirin to prevent

Reye’s syndrome

• Incentives can encourage rapid acceptance and

motivate behavioral change

– Reduced cost, increased availability, improvements in ease of

use

Why Are Some Individual Health

Behaviors Easier to Change?

• The most difficult behaviors to change are those

that have a physiological component or addictive

element

– Binge Eating – Obesity

– Cigarette smoking

• Physical, social, and economic barriers can

stand in the way of behavior change

– Even if the individuals are motivated

How Can Individual Behavior Be

Changed?

• Individual behavior has connections with three

primary factors:

1. Downstream factors – directly involve an individual

and can potentially be altered by individual

interventions

2. Mainstream factors – result from the relationship of

an individual with a larger group or population

3. Upstream factors – grounded in social structures and

policies

How Can Individual Behavior Be

Changed?

• Behavior change requires more than individual

determination and motivation

– Encouragement and support from groups, such as

friends, family, coworkers, and peers are required

• Social policies and expectations may also need

to be changed in order to reinforce individual

efforts

How Can Health Behavior Be

Explained and Predicted

(Theories vs. Models)?

• Theory

– A set of interrelated concepts that presents a

systematic view of relationships among variables in

order to explain and predict events and situations

• Model

– Combination of ideas and concepts taken from

multiple theories and applied to specific problems in

particular settings

The Three Levels of Influence

1. Intrapersonal – Focusing on individual

characteristics

– Knowledge, attitudes, beliefs, motivations, self-

concept, past experiences, skills

2. Interpersonal – Focusing on relationships

between people

– Other people influence behavior by sharing their

thoughts, advice, feelings, and emotional support

3. Population and community – Focusing on

factors within social structures

– Norms, rules, regulations, policies, laws

Five Key Theories & Models Used

to Address Health Behavior

1. Health Belief model

2. Stages of Change (Transtheoretical model)

3. Theory of Planned Behavior

4. Social Cognitive theory

5. Diffusion of Innovation theory

(1) Health Belief Model

• Intrapersonal model focuses on individuals’

perceptions and thought processes prior to

taking health-related action

• People are more likely to take action if they

believe:

– They are susceptible to the condition and it has

serious consequences

– Taking action would benefit them, and the benefits

outweigh the harms

– They have the ability to successfully perform the

action (self-efficacy)

Health Belief Model and Osteoporosis

Data from National Cancer Institute. U.S. Department of Health and Human Services. Theory at a Glance: A Guide for Health Promotion

Practice. 2nd edition. Available at: http://www.cancer.gov/cancertopics/cancerlibrary/theory.pdf. Accessed August 5, 2013.

Construct Description Example: osteoporosis

Perceived

susceptibility

An individual’s opinion of getting

a condition

“Osteoporosis only

happens to old women, not

me.”

Perceived severity An individual’s opinion of how

serious a condition is and its

consequences

“Osteoporosis is not a big

deal.”

Perceived benefits An individual’s belief in the

advised action to reduce risk

and/or severity of condition

“Screening for

osteoporosis will catch it

early so I can continue to

live an active lifestyle.”

Perceived barriers An individual’s belief of the costs

(tangible and psychological) of

the advised action

“Screening for

osteoporosis takes too

much time.”

Table 4.6 p. 85

Health Belief Model and Osteoporosis

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

Construct Description Example: osteoporosis

Modifying

variables

Individual

characteristics that

influence personal

perceptions

“Women in my culture are

viewed as strong; therefore,

we do not concern ourselves

with osteoporosis.”

Cues to action Strategies/events that

encourage one’s

readiness to act

“My sister was recently

diagnosed with osteoporosis,

so I should get screened.”

Self-efficacy Belief in one’s ability to

take action

“If I am diagnosed with

osteoporosis, I know

I can manage it.”

Table 4.6 p. 85

(2) The Transtheoretical Model: Stages of

Lifestyle Change

Individuals have no intentions of making a change in

the next six months.

Precontemplation

Individuals intend to change a problem

behavior within the next month.Preparation

Individuals are modifying their

behavior according to their plan but

not consistently.

Action

Individuals have continued to

work at changing their behavior

and have avoided relapse for at

least six months.

Maintenance

Often after two to five years

behaviors can become so

deeply ingrained that a person

cannot imagine abandoning it.

Termination/ Adoption

Point of Behavior Change

Contemplation Individuals are aware they have a problem behavior and are considering changing within

the next six months.

The Transtheoretical Model can be a

Model of Progression or a Model of

Relapse Prevention

Source: Prochaska JO, DiClemente CC, “Stages and Processes of Self-change of Smoking”, Journal of Consulting

Clinical Psychology, 1983.

Stages of Behavioral Change

Stage of change Actions Example—Cigarette Smoking

Precontemplation Prognosticate Strategies

Individuals 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 contemplation Phase.

Stages of Behavioral Change

Stage of change Actions Example—Cigarette Smoking

Contemplation Motivate Change Strategies 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 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.

Also 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

Stages of Behavioral Change

Stages of change Actions Example—Cigarette Smoking

Preparation Plan Change Strategies Prepare for action including developing a plan and setting a timetable

Set specific measurable and obtainable goals with deadlines

Quit date or possible tapering if heavy smoker

Two or more well chosen simultaneous interventions may maximize effectiveness

Family support, peer support, individual planning, medication, etc. may reinforce and multiply impacts

Recognize habitual nature of existing behavior and remove associated activities

Remove cigarettes, ashtrays, and other associated smoking equipment; Remove personal and environmental impacts of past smoking, such as teeth cleaning and cleaning of drapery; Anticipate temptations, such as associations with food, drink, and social occasions

Stages of Behavioral Change Stages of change Actions Example—Cigarette

Smoking

Action Reinforce Change Strategies 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 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

cravings and have plan including use of medications; 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

Stages of Behavioral Change

Stages of change Actions Example—Cigarette Smoking

Maintenance Maintain Change Strategies New behavior needs to be consolidated as part of permanent lifestyle change

Practice/reinforce methods for maintaining new behavior

Avoid old associations and prepare/practice response when encountering old circumstances

Recognize long term nature of behavioral change and need for supportive peers and social reinforcement

Negative social attitudes toward smoking among peers and society along with social restrictions, such as limiting public indoor smoking and social actions, such as taxation, help prevent smoking and reinforce maintenance of cessation

Stages of Change—Individual, Group and

Population/Social Interventions to Change

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