Lawrence W. Green and Robert A. Hiatt

Oxford Textbook of Public Health

Target of public health approaches. The shifting role of behaviour ( simple-complex) Behavioural risk factors (itself- determinant-

consequent) determinants of behaviour Public health strategies to influence determinants of

behaviour The interaction of socioeconomic status (SES),

environments, and behaviour Denormalizing behaviour Public health interventions and conclusion

control or cajole the health-related behaviour of individuals.

protect individuals from the behaviour of others, and

mobilize the behaviour of groups to influence health-related social and physical environments.

Simple or discrete behaviours ( injuries- infections)

complex behaviour (chronic diseases)

the simple and discrete behavior can be influenced directly by health education targeted at individuals and groups.

complex behavior required combination of educational, organizational, economic, and environmental interventions in support of changes in both behaviour and conditions of living.

Some behaviour clearly increases the risk of developing disease.

Other behaviours correlate with and precede better health, but their causal link is more tenuous.

many behaviours are, in fact, contributing causes (causal risk factors) of specific diseases.

the easiest examples of clear causal linkages are those established for single action behaviours such as ingesting a contaminated food

Sep 20, 2007 issue of the New England Journal of Medicine, Dr. Steven A.

Sep 20, 2007 issue of the New England Journal of Medicine, Dr. Steven A.

Behavioral Causes

Physical, social and environmental causes

Health-care environmental causes

Health,Disease, Injuries orDeath

intentionally most dramatic (automobile, gun)

Unintentionally most dramatic (toxic substances, slippery surface)

Less dramatic , but no less lethal (DI, smoking, alcohol, inactivity)

behaviour remains a critical mediator of the relationships between environmental measures and health outcomes.

improvement of the socioeconomic condition is accompanied by a shift in mortality

the three most important predictors of infant mortality rates were households sanitation, literacy rate, and safe water.

Genes, via their influences on morphology and physiology, create a framework within which the environment acts to shape the behavior of an individual.

Genes also create the scaffold for learning, memory, and cognition that can be used in shaping behavior.

The environment can affect morphological and physiological development; in turn behavior develops as a result of that mechanism.

Predisposing factors

Enabling factors

Reinforcing factors

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1- Educational strategies inform and educate the public about issues of concern such as :

the dangers of drug misuse, the benefits of automobile

restraints, the relationship of maternal

alcohol consumption to foetal alcohol syndrome.

…..

2- Automatic-protective strategies are directed at controlling environmental variables, that minimize the need for individual decisions in structuring each behaviour, such as:

milk pasteurization, fluoridation, infant immunizations, and the burning of marijuana crops. ……………….

3- Coercive strategies employ legal and other formal sanctions to control individual behaviour, such as:

required immunizations for school entry, mandatory tuberculosis testing of hospital employees,

compulsory use of automobile restraints. arrests for drug possession or use. …………

Population behavioural and educational diagnoses enable public health to intervene strategically on the behaviour of populations.

But health problems have other determinants in the environment and in genetics.

Behaviour also can play a role in influencing those determinants.

Through Human Genome Project genetics information became available to individuals.

The first assumption remains to be supported by true evidence of effectiveness

(susceptibility to illness-sensitivity to drug)

The second assumption, that having such information would motivate more concerted effort to change one's behaviour

the limited influence of the genes so far implicated in specific mortality or morbidity outcomes, and their interactions with the environment .

the ethics of offering such information to the individual with anything more than a cautionary note of possible relevance to their reproductive decisions or their behavioural choices

The threshold effects are sometimes found beyond income or other SES indicators.

The gradient adheres whether the SES measure is education, income, occupational status, or place of residence

SES as a predisposing determinant of behaviour

SES as an enabling determinant of behaviour

The educational enabling influence of SES on behaviour

The cultural-environmental predisposing influence of SES

SES as a reinforcing determinant of behaviour

The ‘status identity factor’ and social norms

‘denormalization’ of smoking behaviour in public places. legal restrictions- social norms

The combination of new smoke-free or

‘clean air’ ordinances and by-laws with mass media emphasizing the carcinogenic properties of second-hand smoke and the rights of non-smokers

These differences cannot be attributed solely to biological determinants related to sexual differentiation

The social construct of gender, as opposed to the biological categories of sex, was conceptualized to refer to cultural and social conventions, roles and behaviours assigned to men and women

The gender interactions with SES and health have been variously attributed to differential occupational experiences

The dynamic relationships among the specific measures creates a complex system of social, economic, cultural, and behavioural factors.

The system interwoven with disease risk factors and health status, and influenced by the healthcare and physical environments.

public health programmes shuold plan for behaviour change in three categories of determinants:

direct communications to influence the knowledge, attitudes beliefs, and perceptions of the population concerning the behaviour-health relationship;

indirect communications through social organizations, parents, peers, employers, and others who control rewards and approval that would reinforce behaviour.

legal, engineering, financial, organizational levers and resource development that would enable or prohibit the behaviour.

Behaviour is an inescapable link in the chain of causation between most environmental and genetic determinants and the health outcomes in which they are implicated.

The social environment presents a further complexity in the mediating and moderating of behaviour and environment in their determination of population health.

The individuals are acting upon, and in reaction to, each other as their health outcomes are being shaped by their actions.