To Health-Generating Life Patterns

A Framework for Prevention: Changing Health-DamagingTo Health-Generating Life Patterns

NANCY MILIO, PHD, RN

Abstract: A set of propositions is offered to pro-vide a frame of reference for proposed strategies to im-prove healthful behavior by placing personal choice-making in the context of societal option-setting.

The health status of populations at a given point intime is seen as a result of customary personal choice-making. These choices in turn are limited by both theperceived and actual options available to individuals,depending on their personal and their community's re-sources, from which to make choices. Most people,most of the time will make the easiest choices, i.e.,will do the things, develop the patterns or life-styles,which seem to cost them less and/or from which they

It is a paradox that health professionals, in their effortsto improve people's health-related practices, seem to expectmore of the ordinary consumer than they do of themselves.Almost all patient and consumer health education assumes,explicitly or implicitly, that if people know what is mosthealthful, they will do it.

Perhaps the most obvious test of this assumption is tolook at health professionals themselves. If knowing what ishealth-generating were directly related to doing, then surelywe in the health field would be among the most robust in thenation, slim, agile, nonsmoking, temperate eaters of com-plementary protein, low fat and cholesterol, low-sucrose,and nonrefined carbohydrate foods, avoiders of drugging lev-els of alcohol and other artificial mood-changers, evenlypaced in our daily patterns. This picture is obviously non-existent. Nor do we expect it to exist. Most will recognizethat it is not much more likely for a physician earning$85,000 a year to change his life pattern than for a $6,000 ayear hospital aide to do so. However, the potential for life-style change, the array of options available to these two indi-viduals, may differ considerably.

The point is that most human beings, professional or

Dr. Milio is Associate in Nursing, Simmons College, and Direc-tor, Alternatives in Health Care, 255 Massachusetts Avenue, No.1010, Boston, MA 021 15. Address reprint requests to her at theabove address. This paper, based on concepts presented by the au-thor in the Sybil Palmer Bellos Memorial Lecture at Yale UniversitySchool of Nursing, April 9, 1975, was submitted to the Journal onOctober 8, 1975, revised and accepted for publication January 16,1976.

will gain more of what they value in tangible and/or in-tangible terms.

The range of options available to them, and theease with which they may choose certain ones overothers, is typically set by organizations, public and pri-vate, formal and informal. The more powerful the orga-nization, i.e., the more effective it is in carrying out itspolicies, the more it affects the options available to oth-er organizations and populations, whether or not theseeffects are immediately perceived by individuals intheir day-by-day choicemaking. Implications forhealth education strategies are noted. (Am. J. PublicHealth 66:435-439, 1976)

nonprofessional, provider or consumer, make the easiestchoices available to them most of the time, and not necessari-ly because of what they know is most healthful. Thus, if it isagreed that health-promoting life patterns are a good thing,then the focus for changing behavior should be on the prob-lem of how to make health-generating choices more easy,and how to make health-damaging choices more difficult.

A Timefor Change

There is increasing national and even international inter-est in the problems of "primary prevention" of disease,"health education," "life-style changes," etc. This is occur-ring, in part, because of studies which indicate the historicand contemporary limitations of medical care for improvingthe health of populations. Those limits include the narrowingimpact that traditional, microbe and infestation-oriented pre-ventive programs can have on the modern profile of chronicand degenerative illness and violent deaths.'"8

A more immediate impetus for serious attention to ill-ness prevention is the uncontrolled rising costs of personalhealth services. This derives from the capital- and energy-intensive nature of the inpatient facilities and technologywhich dominate health care organization, and is aggravatedby inflation in the national economy. As greater shares ofhealth care financing come from governmental sources,more concerted efforts will be made to control costs. Onesuch major effort is to find ways to prevent major disease en-tities, principally chronic illnesses and accidents.

Two recent developments are focused on this issue. One

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is the National Health Education and Promotion Bill whichrequires health education in delivery systems and sets upmechanisms for nationwide development, testing, and dis-semination of methods to promote health-generating behav-ior. Another important event was the National Conferenceon Preventive Medicine. Studies cited above, the 1300 pagesof Senate health education hearings, and many ConferenceTask Force papers thoroughly review the "state-of-the-art"of disease prevention, and document the limitations of con-temporary health services. These will not be reiteratedhere.9' 10

Recommendations from these sources concerning whatneeds to be done cover a broad spectrum. Some groups rec-ommend educational programs in the elementary schools, inadult education classes, in health services settings usingsmall group techniques; or for the general public, using themedia and other advertising and mass communications meth-ods. Others emphasize federal policy changes not directly re-lated to personal health services or to conventional educa-tion-information-persuasion methods, such as placing a hightax on cigarettes, the funds to be used in the research andtreatment of lung disease.

What follows here is a preliminary effort to place in con-text, as an interrelated set of working hypotheses, the well-founded but seemingly divergent recommendations of nu-merous groups actively concerned with the problem of en-hancing health-promoting life patterns and/or discouraginghealth-damaging habits.

A Set ofPropositions

1. The health status ofpopulations is the result ofdepri-vation andlor excess of critical health-sustaining resources.Health-sustaining resources include the seminal ones (e.g.,food) or the synergistic ones (e.g., basic education, healthservices). In any population those subgroups which are de-prived of sufficient and safe food, water, shelter, and envi-ronment have great vulnerability to acute, infectious diseaseprocesses. The poor in Third and Fourth World countries arethe most stark examples. The population subgroups whichare affluent have disease resulting from too much food (e.g.,obesity and hypertension) of the highest cost varieties (e.g.,meat, concentrated sucrose, refined carbohydrates, andfats); alcoholic, caffeinated and other drinks, and other dan-gerous relaxants (e.g., drugs, smoking, passive use of lei-sure); too rapid transportation and communication-often re-sulting in accidents and in stressful work overloads dealtwith in sedentary posture. Excessive environmental pollu-tion arises from the production-consumption patterns of thisaffluent way of life. Affluent urban Americans are the bestexample.

Somewhere between the very poor and the affluent arethe population subgroups, having a low-income but living ina relatively affluent or "advanced" society. Low-incomeAmericans are not only more vulnerable to acute diseaserelative to their affluent counterparts, but also sustain moreof the chronic degenerative illnesses and accidents which areintegral to the affluence of the wider society. The cigarettes,

sucrose, cars, pollutants, and tensions are readily availableto the poor, while at the same time they are deprived of thelevel of protection afforded by the quality of food, shelter,and environment which sustain the more affluent. The poornot only succumb more readily to virtually all disease proc-esses, they also possess fewer options for getting the damagerepaired or contained through the medical care system.These socioeconomic realities thus form the basis for the typ-ical life-style or behavior patterns which result in the varyingillness profiles of different population subgroups.' -16

2. Behavior patterns ofpopulations are a result ofhabit-ual selectionfrom limited choices, and these habits ofchoiceare related to: (a) actual and perceived options available; (b)beliefs and expectations developed and refined over time bysocialization, formal learning, and immediate experience.

Ordinary, "average," day-to-day behavior stems fromdaily choices that are relatively set and no longer con-sciously made. These choices have been limited by what isactually available to groups of people and what they perceiveto be available or possible. Their knowledge of the possibleand their perceptions are influenced by what they havelearned in the past, informally and non-verbally as well asformally, and by what they experience.17

Applied to consumers, this is a point at which newhealth information and knowledge may influence individualchoice-making under certain conditions.

3. Organizational behavior (decisions or policy-choicesmade by governmentallnongovernmental, nationallnon-na-tional; non-profit/for-profit, formallnon-formal organiza-tions) sets the range of options available to individuals fortheir personal choice-making. Organizational decisions di-rectly affect the options available to people and/or theirawareness of those options and/or the ease with which theymay make daily, habitual, selections.'7" 8

For example, federal policy decisions concerning tax-ation, business subsidies, tax incentives, and import-exportrestrictions affect whether and how much of such items ascigarettes and palatable soy protein will be available, howwidely distributed and advertised, and at what price. Thesedecisions set the array of options available to various eco-nomic and geographic populations concerning the ease withwhich they may or may not choose such items.

As another example, combinations of policy choices bysuch organizations as city government and public and pri-vate housing, transportation, and banking firms concerningland use set the range of options available to population sub-groups concerning where they may or must live and work,and the means and speed of their transportation (thereforehow physically active they may be, how fatiguing or com-pact their day, how clean their air). Such policies also deter-mine which of the available array of options are the easier.

National governmental decisions concerning the politi-cal economy in a country such as China stand in marked con-trast to those in the U.S.A. The result in China has producedforms of social organization such as rural communes and ur-

ban neighborhood and industrial-worker networks which fa-cilitate collective decision-making within organizations. Col-lective or small-group decision-making can then become a

mechanism by which participants can develop new options

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for themselves as well as be supported in the reinforcementof the new choices which they make, concerning communityand personal health care among other things.'9 -22

4. The choice-making of individuals at a given point intime concerning potentially health-promoting or health-damaging selections is affected by their effort to maximizevalued resources. Choice is therefore related to the type andamount of:

(a) their personal resources: their awareness, knowl-edge, beliefs and skills; those of family, friends, and of oth-er primary (small, face-to-face) groups; available moneyand time; convenience concerning distance, travel, trans-portation; the urgency of other priorities; and

(b) societal (community and national) resources: theavailability of health-sustaining services and resources interms of cost, distance or location, type, comprehensive-ness, program outreach components (e.g., food, housing,income maintenance, environmental protection, healthservices); alternatives to formal services; penalties or loss-es incurred, or rewares given, for selection or failure to se-lect given options.

All of these resources implicitly or explicitly limit orwiden the array of options available to individuals for retain-ing or altering health-related habitual choices, and determinethe ease with which new, possibly more healthful choicesmay be made. Any change in pattern would involve some ef-fort or cost and some actual and/or perceived gain.

An example might be the $85,000 a year physician andthe $6,000 a year aide, both ofwhom have mild hypertensionand each of whom would benefit by a more healthful lifestyle. Given that both are made aware of what shifts in be-havior would be most likely to have health-enhancing ef-fects, it is quite apparent that the physician has a potentiallygreater opportunity to adopt a more health-promoting pat-tern of daily choices because of his personal resources.

The physician may conceivably slow the pace of his lifeby choosing to live closer to his work in the urban medicalcenter in a quiet townhouse. He may take more frequent va-cations as a means to relax and thereby diminish the need forcigarettes, alcoholic drinks, or other drugs. He would haveno serious financial problem in obtaining palatable mealswithin caloric-cholesterol-sodium limits in restaurants or spe-cially prepared for him alone. Medical center fringe benefitswould allow him ample sick leave, medical insurance, pen-sion, and other supportive resources.

The aide earning $6,000, typically a woman, possiblywith adolescent children, has fewer options for making newchoices. There is virtually no chance for her to find even alow-paying job in a less hectic environment. Without rapidtransit, moving the household to a less congested area is outof the question, even if such housing were available. Towork fewer hours is not an option since her husband is spo-radically employed at best. Besides, taking too much timeoffmay risk herjob security. There is little extra time or mon-

ey to change the family's customary diet, and food and ciga-rettes are two of the very few options left for relaxation andpleasure. Neither friends nor family, though willing, haveenough resources to share to make a difference. The medical

clinic which diagnosed her condition has no consistent meth-ods to intervene and offer help in her home situation.

For either individual, the physician or the aide, the per-sonal and societal resources will not determine whether ornot they will alter their life patterns. But those resources willmake the likelihood that each one can change-given an ini-tial moderate willingness to do so-either more or less a pos-sibility. This is because of the array of options before them,and because some of those options, health-promoting orhealth-damaging in their net effects, are easier to choosethan others.

5. Social change may be thought of as changes in pat-terns of behavior resulting from shifts in the choice-makingof significant numbers ofpeople within a population.

In order then for life-style patterns to alter among indi-viduals in numbers sufficient to affect the incidence of majordiseases, new, health-promoting options must be available,and more readily so than health-damaging options, i.e., insuch a way as to be less costly in dollar and other costs.People also must be aware of the new options and of whatthey can gain from selecting them relative to their formerchoices.

6. Health education, as the process of teaching andlearning health-supporting information can have little signifi-cantly extensive impact on behavior patterns, that is, on per-sonal choice-making of groups of people, without the easyavailability of new, or newly-perceived alternative health-promoting options for investing personal resources.

Typically, what has been regarded as health educationhas focused on providing consumers with information orknowledge in order to make them aware of the costs and ben-efits to their health to be derived from particular behaviors.The relative lack of other options from which to choose newbehavior patterns has not been dealt with realistically, partic-ularly for outcast groups, such as rural and lower income. Itis not enough to make people knowledgeable about health-promoting choices. The other side of the coin is to provideready access to health-promoting options.'0023-25

The strategy of making health-promoting options easieris implicit in the small group approach to behavior change,e.g. weight-reduction, cessation of smoking or alcohol con-sumption. By becoming an integral part of a group which ap-proves of certain choices, individuals can more easily makesuch choices. Thus by choosing low calorie foods they gainthe short term reward of group approval and avoid its dis-approval, as well as gaining the longer term reward of weightreduction. The reward is apparently greater than in the typi-cal individual counseling method, making the group ap-proach the more successful.'0

However, the small group approach is limited for sev-eral reasons. It is costly to individuals in both time and mon-ey, and would be very costly to the delivery system were itapplied extensively enough to impact on the behavior oflarge populations. Its benefits, measured in terms of impacton groups of people, are not very efficient. This approachhas successfully reached just over an estimated 2 per cent ofall smokers; further, as another common example, up to 4out of 5 members of weight control groups may drop out.There is also some question as to whether the changes in be-

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havior that do occur are large enough to be clinically signifi-cant.26-28

In one report, a mass media approach was combinedwith small group techniques for clinically high-risk groups.There was an increase in knowledge and change in attitudesconcerning health-relevant choice-making, but relativelylittle change in actual behavior. Change included a lessening,but not cessation of smoking, and a drop in the number ofeggs eaten-a change which also occurred in the non-experi-mental population apparently related to the economic situ-ation of the communities involved.29 Choice-making regard-ing physical activity and exercise was unchanged.

This non-change is understandable in terms of the ear-lier discussion about gains and losses of resources. Activitypatterns reflect daily concentrations of work, job, leisure,housing location, available transportation, family responsi-bilities, etc. As such, they are integral to both family andcommunity choice-making. Even a strong desire by an indi-vidual to alter and increase his or her physical activity wouldrequire a sustained effort if the readily available options inthe family-home, job-community favor time-consuming andsedentary or light activities. Under these conditions, a burstof effort at increased exercise is likely to subside and accom-modate again to customary, more readily-taken options forless physically exerting activity patterns of household andcommunity.30

The small group approach seems somewhat more effi-cient when applied to patients, especially those who are seri-ously ill.9 31 This again is understandable. III people have rel-atively more to gain by making choices which will diminishtheir symptoms and restore their ability to live more pain-lessly and with less effort.

As awareness of the limitations of traditional health edu-cation grows, a contemporary concept is developing whichincludes, along with information and motivation, change-making in the living environment, conceivably to the broad-ening of healthful options for personal choice-making.32There is also evidence of more comprehensive and plannedapproaches to health education, with increasing emphasis oncost-effectiveness and the evaluation of results, including themeasurement of changes in behavior and health stat-us. 9'33-37

Summary

These hypotheses provide a framework in which healthstatus of populations at a given point in time is viewed as theoutcome of customary personal choice-making. Thesechoices in turn are limited by the actual and perceived op-tions available to individuals, which reflect their personaland their community's resources. Most people, most of thetime will make the easiest choices, that is, will develop thepatterns of behavior or life-styles which seem to cost themless and/or from which they will gain more of what they val-ue in tangible and/or intangible terms.

The range of options available to populations, and theease with which they may choose certain ones over others, istypically set by organizations, public and private, non-profit

and for-profit, formal and informal. This is done through theorganizations' capacity to determine policy choices which af-fect the allocation and distribution of various kinds ofamounts of goods and services and their price, direct or in-direct, to the user. The more powerful the organization, thatis, the more effective it is in carrying out its policies, themore it affects the options available to other organizationsand populations, whether or not these effects are immediate-ly perceived by individuals in their day-by-day choice-mak-ing.

Implicit in this view of organizational decision-makingand individual choice-making as they affect health-relevantpatterns is the notion of a pyramid of decisions. The deci-sions taken at the "higher", more powerful organizationallevels, set the range of options available at lower levels. Thismay be seen in the ways in which both federal government ormultinational and large scale corporation policies concerningfood, energy, transportation, or antipollution enforcement ul-timately affect not only the policy-choices of public and pri-vate bodies at state and local levels, but also the individual inhis and her daily choices about diet, residence, exercise andpace of life. ' 8

Implications

Given this framework, strategies for encouraginghealth-promoting choices may also be put in perspective.Their minimal aim, for example, might be to broaden therange of options available to people and to make health-promoting choices easier and/or to diminish health-damagingoptions by making them more difficult to choose. For themost widespread impact, the focus might be on national-lev-el policy-making which would in turn change the range of op-tions for the largest number of people, i.e., the national popu-lation. Selected populations, those most vulnerable to illhealth because of the limited healthful options available tothem, might also receive special attention.

This frame of reference can also help assess or projectthe relative effectiveness of various efforts at behaviorchange. For example, a local effort at conveying more knowl-edge about healthful diets is not likely to result in changes ofeating patterns unless it is accompanied by a combination ofhealthful, low cost, readily available foods-changes whichrequire effort beyond the individual or small group methods,and extend to the community public and private organiza-tional structure.

The question may be raised that this perspective sug-gests a manipulation of behavior, a constraint on freedom.Quite the contrary, since as this discussion shows, currentpolicy and allocative decisions clearly constrain personalchoice-making, even if not so perceived by many people.This framework rather suggests strategies which will en-hance the freedom to choose, making it readily possible forindividuals and groups who now have difficult options to

create healthful lifestyles. Those who wish to pursue health-damaging patterns would still be able to do so.

These are working hypotheses, not yet sufficiently re-

fined to be fully testable. Hopefully, passage of an adequate

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National Health Education and Promotion Act will makepossible the development and testing of such models in orderto help health professionals and consumers focus effectivelyon the prevention of disease rather than on its repair or con-tainment.

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