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Ann. Rev. Public Health. 1984.5:215-36
Copyright © 1984 by Annual Reviews Inc. All rights reserved

MODIFYING AND
DEVELOPING HEALTH
BEHAVIOR
Annu. Rev. Public Health 1984.5:215-236. Downloaded from www.annualreviews.org

Lawrence W. Green]
Center for Health Promotion Research and Development, The University of Texas,
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Health Science Center at Houston, Houston, Texas 77225

INTRODUCTION

Public health has turned more and more in recent years to the social and
behavioral sciences for a better understanding of the forces shaping lifestyle,
conditioning health habits, influencing the diffusion of health knowledge,
attitudes and practices, and providing support or pressure for the adoption of
healthy and unhealthy behavior. This review examines recent developments
specifically in those applications leading to interventions designed to modify or
develop health behavior.
Modifying and developing health behavior both imply change of a conscious
and planned nature, as distinct from change that occurs unconsciously in the
natural history of growth and adaptation (51, 131, 132). This distinction has
become blurred in modem societies that are conscious of and sophisticated
about behavior, its causes, and ways to influence it. Individuals, families,
health practitioners, health agencies, private organizations, and governments
all have expanding repertoires of understanding and tools to modify and
develop their own behavior and the behavior of their members, constituents,
and consumers. At the same time, all of them may be developing conscious and
unconscious repertoires of defense and resistance to the attempts of others to
change them.
Because these repertoires have become so enriched and diverse, this review
can only offer a superficial coverage of the major lines of recent advances. This
is attempted first by outlining some alternative and complementary frameworks
for organizing theory, research, policy, and practice in behavioral change for
health. Second, some of these frameworks, notably those of the life span and

II would like to thank for helpful comments Patr icia Mullen and for assistance Blair Carter.

215
0163-7525/84/0510-0215$02.00
 216 GREEN

the settings for health promotion, are used to present examples of the applica­
tion of behavioral change strategies for health enhancement, and to highlight
some issues of policy, ethics, and research confronting future applications of
behavioral change in public health.

FRAMEWORKS TO ORGANIZE THE LITERATURE

Processes of Change
In an earlier attempt (58) to review and organize the diverse theoretical models
Annu. Rev. Public Health 1984.5:215-236. Downloaded from www.annualreviews.org

and research literature related to change processes in health behavior, variables

from psychology, sociology, anthropology, and their hybrids were arrayed
under Kelman's (80) three processes of individual change: internalization,
identification, and compliance. In returning to the literature for a similar review
eight years later, one encounters again the problem of language: "One of the
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issues with which one must deal in the integration of models from the different
disciplines, is not whether one or the other is more correct, but whether they are
talking about the same thing in different languages" (58, p. 7). What Kelman
called the "compliance" process of change, others refer to as environmental or
economic contingencies, coercion, paternalism, passive controls on behavior,
prescribed or proscribed norms or customs, and various neologisms (79, 99,
107, 111, 129, 131, 189). Kelman's "identification" process of change has
been recast in social leaming theory (6, 143) to include modeling, vicarious
reinforcement, and the normative or social influence of significant others (25,
45,47, 57, 98). Kelman's "internalization" process of change has come to be
associated with terms and concepts such as value congruence, self­
actualization, information processing, and informed consent (40, 49, 68, 86,
111, 112). All of these have served to describe and explain instances of
behavioral change in relation to health, and some have been used as the
theoretical rationale in the design of interventions.

Organizational and Theoretical Levels of Change

A second typology used to array the variables and concepts of change at several
levels of aggregation considers organizational levels of change or units of
analysis: the individual system, the group system, and the institutional or
community system. The internal dynamics of the individual system are limited
to psychological variables. Patient counseling, behavioral therapy, and mass
media strategies in health have all derived largely from psychological theory
and research. Changes in informal and membership groups reSUlting from
individual and group effects are reflected primarily in the theories and variables
of social psychology. Group instruction, social support strategies, and self-help
groups have evolved with particular influence from social psychology.
Changes at the institutional or community level include variables from sociolo­
gy, anthropology, economics, and political science.
 MODIFYING HEALTH BEHAVIOR 217

None of these levels or units of analysis has gone without theoretical and
empirical scrutiny by one or more of the disciplines named,but the dominant
contributions to the literature on interventions in health have been,perhaps
regrettably,from psychology (6,10-15,2fr-29,35-39,43,47,54,62,70,74,
75,85,101,105,106,117-120,156,165-167,184,193,194). Sociologists,
whether for reasons of academic disdain or lack of opportunity,have contri­
buted for the most part only indirectly to the development of interventions,
though most of their theories and research are most significantly relevant to
public health (155). Even in large-scale community interventions such as the
Stanford three-community and five-community studies,the behavioral science
Annu. Rev. Public Health 1984.5:215-236. Downloaded from www.annualreviews.org

contributions to planning the interventions have been made primarily by

psychologists (41,121). The result is that the behavioral change interventions
have tended to emphasize the individual, and have been most useful in patient
education (4, 10, 13,29,43,54,59,64,101,113, 115, 116, 134, 135, 138,
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162,163,165). This concentration of behavioral science applications is some­

times at the expense of action on needed change in organizational, institutional,
environmental,and economic conditions shaping behavior.

Classification of Health-related Behavior

A third typology or framework for analysis of health behavior has emerged
since Parson's (145) description of sick-role behavior in sociological tenns,
and since Kasl & Cobb (78) distinguished the sick role from illness behavior
and health behavior. The call for finer distinctions has mounted. Baric (7)
added the "quasi-sick role" or "at-risk" behavior, which has come to be
associated in practice with risk reduction and "prospective medicine" (153,
137, 178). Others have struggled with the variety of overlapping fonns of
behavior,such that there has developed a specialized literature in "wellness"
behavior (e.g. 1,33,177),one in self-care behavior (56,102,112),and one in
"compliance" or adherance to medical regimens (10, 29, 64). Self-care and
compliance behavior generally refer to the opposite extremes of dependency on
therapists in sick-role behavior. When the relationships between patients and
therapists are added to the delineation of behavior,the complexities of classi­
fication multiply (113, 114, 165).
Table 1, developed from Kolbe (88), defines nine distinguishable,though
not entirely mutually exclusive,health-related types of behavior. Although
greater specificity of this kind is helpful in the scientific measurement and
analysis,and in the programmatic targeting,of behavior,there may be a
simultaneous need for pulling back to more generalized conceptualizations of
complex, overlapping behavioral patterns- related to health. This may be
particularly needed in the analysis of statistical and practical interactions
among the health practices making up the "lifestyle" risk factors for chronic
diseases (e. g. 34,76,77,87), for injuries and accidental death (e.g. 31,65,
154, 161), for addictions,homicides,suicides,mental illness, and social
 218 GREEN

Table 1 A typology of health-related behaviors'

Behavior Definition

Wellness behavior Any activity undertaken by an individual, who believes himself

to be healthy, for the purpose of attaining an even greater level
of health.
Preventive health behavior Any activity undertaken by an individual, who believes himself
to be healthy, for the purpose of preventing illness or detecting
it in an asymptomatic state.
At-risk behavior Any activity undertaken by an individual, who believes himself
Annu. Rev. Public Health 1984.5:215-236. Downloaded from www.annualreviews.org

to be healthy but at greater risk than normal of developing a

specific health condition, for the purpose of preventing that
condition or detecting it in an asymptomatic state.
Illness behavior Any activity undertaken by an individual, who perceives himself
to be ill, to define the state of his health and discover a suitable
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remedy.
Self-care behavior Any activity undertaken by an individual, who considers himself
to be ill, for the purpose of getting well. It includes minimal
reliance on appropriate therapists , involves few dependent
behaviors, and leads to little neglect of one's usual duties .
Sick-role behavior Any activity undertaken by an individual, who considers himself
to be ill, for the purpose of getting well. It includes receiving
treatment from appropriate therapists, generally involves a
whole range of dependent behaviors, and leads to some degree
of neglect of one's usual duties .
Family planning behavior Any activity undertaken b y an individual to influence the occur­
rence or normal continuation of pregnancy.
Parenting health behavior Any wellness, preventive , at-risk , illness, self-care, or sick-role
behavior performed by an individual for the purposes of ensur­
ing, maintaining, or improving the health of a conceptus or
child for whom the individual has responsibility.

Health-related social action Any activity undertaken by an individual singularly or in concert

with others (i.e. collectively) through organizational, legal, or
economic means, to influence the provision of medical ser­
vices , the effects of the environment, the effects of various
products, or the effects of social regulations that influence the
health of popUlations .

"From Kolbe (88).

well-being (3, 8, 9, 20, 32,35,45, 81, 94,100, ll4, 179-82, 185, 187, 192),
as well as those making up the various aspects of parenting (60, 73, 97, 98,
108, 126, 150, 158), and use of health services across the spectrum of primary
to tertiary care (97, 126,164).

Life Transitions Requiring Adaptations of Health Behavior

A fourth dimension for the organization of theory and research, which is
applied in this review, is a time dimension reflecting life transitions, particular-
 MODIFYING HEALTH BEHAVIOR 219

ly those of the life span (sometimes referred to as life cycle). This dimension
has particular utility in public health, because no demographic marker, includ­
ing sex or socioeconomic status, differentiates patterns of lifestyle and health
more significantly than age. Other transitions, such as residential mobility,
divorce, marriage, retirement, and sudden unemployment are comparable in
their impact on the needs for lifestyle adjustment and problems of coping, but
these too tend to be associated with stages in the life span.

Range of Interventions to Modify or Develop Health Behavior

Annu. Rev. Public Health 1984.5:215-236. Downloaded from www.annualreviews.org

A fifth dimension is the range of interventions for behavioral change. It has

long been the contention of public health educators that policies directing their
practice need to recognize that health behavior is shaped and buffeted by more
than individual motivation and choice (e.g. 140). Education directed only at the
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individual has been used intentionally in some policies as an alternative to more

appropriate interventions directed at organizations, industries, or environments
that control the resources or conditions compelling or constraining health
behavior (2, 40, 44, 47, 49, 55, 59-61, 90, 125, 152).
Since 1976, with the passage of P.L. 94-317 by the US Congress that year,
the term "health promotion" has taken on new meaning in public health, and
has breathed new life into health education. The Consumer Health Information
and Health Promotion Act of 1976 gave the federal government a broader
mandate for initiating programs and using a wider range of strategies to
influence health behavior than previous policies in support of health education
had provided in the United States. The informational role of government was
still paramount, but the placement of the new initiative in the Office of the
Assistant Secretary for Health opened new opportunities for policies to be
promulgated in support of organizational, economic, and environmental fac­
tors, which health educators had always complained stood between their best
efforts and effective development or modification of public health behavior.

Settings or Channels for Health Behavior Change

With these changes in the policies governing behavioral change strategies in
public health, the subject now can be addressed with more than theoretical and
political interest in the settings where economic and environmental factors
influence health behavior. There is, consequently, a widening acceptance in
practice of a definition of health promotion that encompasses these broader
influences on lifestyle, rather than merely information directed at individual
knowledge, attitudes, and behavior.
The definition of health promotion adopted for purposes of this review is
"any combination of health education and related organizational, economic and
environmental supports for individual, group and community behavior condu­
cive to health" (51, 60). The behavior in question ultimately is that of the
 220 GREEN

person whose health is at risk (or whose health enhancement is sought), but the
processes of change often must include institutional decision-makers and
collectivities of people acting in concert as groups, neighborhoods, organiza­
tions, communities, and electorates. Behavior at all of these levels and educa­
tion through all of these channels is the object of health promotion. The settings
in which health promotion may take place, then, become a primary considera­
tion for this review.
Settings for health promotion include most notably schools, worksites,
homes, and health care settings. They provide most of the services and resource
supports for health behavior, simultaneously with serving their primary institu­
Annu. Rev. Public Health 1984.5:215-236. Downloaded from www.annualreviews.org

tional functions. Channels for health promotion include the mass media,
parents, teachers, counselors, physicians, nurses, self-help groups, and other
individuals and media through which information, training, and persuasion
may predispose, enable, and reinforce voluntary adaptations of behavior (55).
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In addition to the organizational and educational components of the health

promotion approach to the modification and development of behavior, there are
aspects of the environment that require regulation beyond the voluntary control
of individuals and organizations. These include physical, economic, social,
and legal aspects of community life over which individuals may have little
personal control and over which organizations may have limited control but
may also have vested interests in not controlling, such as chemical wastes, or
allowing workers to exercise on company time. Organizations might view their
own gains from such reforms as too small to justify their costs. Regulation and
incentives may be required in such cases.
Some of these environmental factors, like chemical wastes, have a direct
effect on health; others, like facilities for employee fitness, influence health
through their influence on behavior. Those that influence health through
behavior are a part of health promotion. Those that influence health through the
environment are referred to as health protection.
Figure 1 expresses the relationships among these and health services in the
context of federal policy and the Objectives/or the Nation in disease prevention
and health promotion in the United States (48, 50, 72, 124, 170-172), which
represent a coordinated strategy of federal, state, local, voluntary, and private
sector activities in health. The three components of organization, behavior, and
environment in the United States' strategy approximate the "health field"
components of the Lalonde report (96), which initiated a similar shift in health
policy in Canada in 1974. Similar emphases on the behavioral or lifestyle
component of health policy were introduced in Great Britain with the "red
book" entitled Prevention and Health: Everybody's Business. 1976 (46), and in
Australia with Health Promotion in Australia 1978-1979 (30).
Health promotion received its most global extension in policy with the joint
declaration of the World Health Organization and UNICEF of a commitment to
the development of policies in "primary health care," which they defined to
 MODIFYING HEALTH BEHAVIOR 221

Processes o' Objectivos lor Surgeon

Strategies
change intermediate outcomes General's
(Immediate objectives) Report

Health Access to
services - - -
preventive
services
Healthy
Health Predisposing People
Educa· Health (Surgeon
- Enabling - -
tion promotion General's
Reinlorcing goal lor
t990)
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Health
protection
- - -

Improved health Increased public Reduced Health

services, resources and prolessional risk lactor status
and activityawareness objectives (46) objectives (56)
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(46)
objective. objectives (42)
�I------�i�---J' �'------�i--�'�'----Ti--�
Process objectives Impact objectives Outcome objectives

Figure 1 Structure and logical relationships of the objectives for the nation in disease prevention
and health promotion,

include health education and participation of the public as essential elements

( 19 1). The so-called Alma-Ata Declaration set into motion a long-range
strategy of "Health for All by the Year 2000," and a dedication of the World
Health Assembly's Technical Discussions of 1982 to the topic of alcohol
consumption (129) and in 1983 to the topic "New Policies for Health Education
in Primary Health Care" (61). This was the first time in 22 years that the World
Health Assembly Technical Discussions had been devoted to educational and
behavioral aspects of health.
Figure 2 reflects the placement of health education and health behavior in the
global strategy of WHO. The emphasis here is on participation of the public in
planning and evaluating the primary health programs for their localities (61,
173, 191 ). The clear understanding is that participation is necessary to assure
that the programs reflect the felt needs and cultural perspectives of the people
for whom they are intended, and that health education is essential to the
effective participation of people.

Some Cautious Generalizations

In summary, change in health behavior has been studied and attempted in
public health from a variety of vantage points, theoretical inclinations, organi­
zational levels, and disciplinary backgrounds; in a variety of settings; and with
a variety of interventions. No single theory, method, or strategy has been found
to hold any universal superiority over others. A few principles might be drawn
from the elements common to most successful strategies, such as the principle
of participation, which asserts that people are more likely to change and
 222 GREEN

National

� r
social and economic L-------- ==== ---r---'
development policies r-
and strategies Community Development Economic
-;::= :::::;-
particiPation sectors r- and Social
objectives (e.g. Communit y goal, and
Health educa- development needs
education, etc.)
r------,

Health education
:�
:��c:��o���tlon r-
____'� ::��;:.:�'
colll!clively Health.

strategies f:�;'
i; _C
L-
E:�
_

National obl "

health policies
=== == ::� I . �L-ye_
and strategies �= === === === --- L- - --�
Annu. Rev. Public Health 1984.5:215-236. Downloaded from www.annualreviews.org

Intermediate Ultlmat
Process tmpact Outcome objectives.
L- ....J

objectives
___

Immediate objectives of health education

Figure 2 Logic imd rationale for the assumed relationships among strategies and objectives for
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new policies in health education as related to primary health care and the global strategy for "Health
for All by the Year 2000. "

maintain the change in their behavior if they have participated actively in

setting the goals and plans for the change. If one is seeking highly generalizable
rules to guide public health programs directed at behavioral change, the
principle of participation, like the principle of individualizing and tailoring
interventions, is no generalization at all. It says, in effect, beware of gener­
alizations. Idiosyncracy has reigned in most behavioral science applications to
health, as it has in medicine. Hence, the majority of the contributions by
behavioral scientists to the health literature have been by psychologists, whose
business is individual behavior, and most of their publications are based on
studies carried out in clinical and other highly controlled settings.
Public health seeks another level of generalization, or at least ways to apply
the psychological generalizations to populations and in settings or institutions
other than just clinical or medical settings. Renewed interest in worksites,
schools, and other community settings and institutions that can affect behavior
is evident. Such epidemiological, sociological, organizational. and environ­
mental perspectives have been addressed in the most recent round of policy
initiatives in disease prevention and health promotion in several English­
speaking and European countries, and in the global policies of the World
Health Organization.
The common elements of these new policies reflect some of the generaliza­
tions that have been drawn, with or without the explicit guidance of empirical
evidence from the behavioral sciences:
1. Behavior, especially in its more complex lifestyle manifestations, accounts
for a much larger proportion of the total mortality and morbidity of most
societies than is reflected in the allocation of resources to modify or develop
health behavior.
2. Effective programs to modify or develop health behavior in popUlations
 MODIFYING HEALTH BEHAVIOR 223

must include some combination of health education and organizational,

economic, and environmental supports for the behavior.
3. Policies addressing health behavior cannot be made a substitute for the
provision of basic, primary health care services or regulation of environ­
mental factors influencing health. Instead, these components of health
services and environmental health policy can support health behavior at the
same time that they are directly addressing health through biomedical and
environmental interventions.

These generalizations are summarized in Table 2 which combines some of

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the essential features of Figures l and 2 and much of the preceding discussion.
It does not address questions of when or how to intervene to modify or develop
health behavior. It also does not suggest who the target groups for intervention
should be. These are unavoidable questions for any public health strategy and
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are taken up in the remainder of this review.

Table 2 Essential elements of comprehensive policies combining organizational, educational,

economic, and environmental supports for health behavior

Settings/channels Interventions Function Impact Outcome

�
�
Organizations Services & To enable.--- Biological

�
Worksites resources development
Health care or tion
Schools
etc .
Channels Education
TT
To predispose-Behavioral- Health,
Parents development quality
Mass media and change of life
Teachers

/j
Counselors
Physicians

/
Nurses
Self-help groups
etc.

Environments Regulation To protect _ Environmental

Political & development and reinforce development
Physical & enhancement
Economic
Social
Legal

TIME-AND-PLACE STRATEGIES TO MODIFY OR

DEVELOP HEALTH BEHAVIOR
The Life Span
The ideal intervention in public health in general, and in health promotion in
particular, is one that anticipates health problems or needs and prepares the host
 224 GREEN

to resist the problem or to provide for the need. If the environment can be
structured to preclude the need for any action on the part of the host, so much
the better. If the agent can be isolated and neutralized, better yet. Unfortunate­
ly, the agents of the new behavioral morbidities are pervasive and tightly
woven parts of the fabric of modem living, such as rich foods, alcohol, drugs,
sedentary work and leisure, stress, guns, and automobiles and other machinery.
Few societies have been willing to tum back the clock on such agents. Some
can be controlled through environmental regulation of their distribution, pric­
ing, taxation, and public use, but most of these agents are used privately. There
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is little choice, then, but to supplement organizational, economic, and environ­

mental strategies with interventions designed to build host resistance.
Anticipating potential health problems or needs of individuals or populations
requires prediction of probabilities based on past experience with other people
who have been exposed to the same agents under similar circumstances. As
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suggested in a preceding section, the best predictor of health or behavioral

problems or needs is age. Transitions from one age range to another could be
the most propitious times to intervene for purposes of primary prevention.
The life span is a natural-in the literal sense-approach to the study of
human behavior (5, 16, 24, 57, 126). The life span has been applied in the US
Surgeon General's Report (170) to the design of national goals and health
policy. As shown in Table 3, the life span may be divided into numerous
phases, demarcated by important transitions or events, each with a different set
of coping tasks and health consequences if behavior is not adequately adapted.
The number of stages and the specific boundaries of the stages will vary from
one population or culture to another, and from one investigator or health
professional to another. Vaillant ( 175, 176), Levinson ( 103), and Loevinger
( 109) have delineated in much greater detail the phases and stages of adult
development, as Kohlberg & Mayer (86), and Piaget (147) have done with
children.
The following discussion divides the life span, somewhat arbitrarily but in
keeping with the Surgeon General's Report (170), into five stages: infancy (less
than one year old), childhood ( 1-14 years), adolescence and young adulthood
( 15-24 years), adulthood (25-64 years), and older adults (65 years and older.
Table 4 arrays these five age groups against the settings in which behavioral or
health promotion interventions are possible, with examples in each intersect,
based on an analysis by Mullen (130). Two points are illustrated by this matrix:
first, none of the age groups are dependent on any single setting for interven­
tion, and second, none of the settings is limited to a single age group in the
opportunities it presents for health promotion interventions.
Two principal threats to infant health are low birth weight and congenital
disorders including birth defects. Public health programs lay emphasis on
strategies supporting prenatal health behavior, including the reduced misuse of
alcohol, tobacco, and drugs during pregnancy, to reduce both of these prob-
 MODIFYING HEALTH BEHAVIOR 225

Table 3 Examples of issues for health promotion related to life span transitions

Major tasks of coping

Developmental transitions and adaptation Health consequences

Infant __ child Avoidance of hazards Safety and injury control

Preschool __ school Selection of foods Dental caries , obesity, nutri­

tional deficiencies

Elem. __ jr. high (early adoles­ Resistance to peer pres­ Smoking, alcohol, drugs,
cence) sure; changing bodily pregnancy
functions
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Jr. high __ high school (middle Development of auton­ Substance abuse, pregnancy,
adolescence) omous identity and auto accidents , sexually
confidence transmitted diseases
High school __ work or higher Development of auton- Suicide, homicide, alcohol­
education omous function and ism, addictions
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role; coping skills; up­

rooting
Single __ married and/or pregnancy Curtailed freedom & in- Congenital defects, infant
and parenthood creased responsibility mortality, low birth
for lifestyle; uprooting weight, obesity
Young adult __ middle age ("mid­ Reduced parenting roles, Hypertension, digestive dis­
life" transition) changing bodily func­ ease, atrophy, obesity,
Parent __ "empty nest" tion, reduced activity alcoholism
Working adult_retired adult or Reduced social roles; Loneliness, reduced self­
widowed sedentary living; be­ esteem, atrophy, loss of
reavement reasons for living and the
will to live, or zest for
living

lems. The behavioral change and health promotion issues in prenatal care and
reproductive health are reviewed by Mullen et al ( 133). Some issues of
measurement and evaluation on the impact of interventions to improve prenatal
care are reviewed by Peoples & Siegel (146).
The primary preventable health threat to children 1-14 years is injuries.
Injuries account for 45% of total childhood mortality: "By itself, a 50 percent
reduction in fatal accidents would be enough to achieve the goal of fewer than
34 deaths per 1 00, 000 by 1990" ( 170, p. 33). Another behavioral priority for
this age group is improved exercise to enhance growth and development. The
literature regarding behavioral change in this group was reviewed for the Select
Panel on the Promotion of Child Health by Mullen (131, 132), for schools by
Iverson & Kolbe (72) and Kolbe (88), Kreuter & Christianson (93), and in
general by Bruhn & Parcel (23). Some recent evaluations (27, 42,63, 67, 82,
110, 122, 127, 142, 148, 151, 174, 183) and meta-evaluations (39, 52, 69, 7 1,
104, 141, 157, 159, 168; L. J. Kolbe, in preparation) of school health educa­
tion are more encouraging than earlier reports (cf 84, 160, 190). Programs,
 Table 4 Examples of health promotion activities in various settings for major age groups'
N
N
Adolescents 0'\
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Infants Children and young adults Adults Older adults

Schools o Support programs for • Comprehensive o Development of overall o Health education pro­ o Extension of s�hool
a
adolescent parents health education cur­ school climate of discipline grams through com­ meal programs to
• Parenting education
in school curricula
(for hoth hoys and
ricula with emphasis
on positive health be­
haviors
o
and achievement
School health education cur­
ricula with emphasis on
munity colleges and
high school evening
programs
•
older adults
Volunteer service
opportunities to
�
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girls) o Physical fitness test­ positive health behaviors o Extension of high promote interaction
ing, training and o Establishment of peer-group school exercise facili­ between older adults
awards programs counseling efforts ties for adult use and children
o Health screening and • Health education
immunization pro­ classes through col­
grams leges and universities
o Healthful snacks in
vending machines

Worksites o Employer-sponsored o Family health and • Family use of worksite exer- . • Health promotion and • Expansion of work­
day care programs, safety topics in cise facilities employee counseling site health promotion
including parent health promotion pro­ o Aexible work policies to programs programs to retirees
education and sup­ grams maximize opportunities for o High blood pressure o Lifting mandatory re­
port groups adolescents detection and treat­ tirement age
o Maternity/paternity ment programs o Aexible work sched­
leave and related pro­ • Provision of exercise ules to ease retire­
grams that facilitate facilities ment transition
family fonnation • Organization-wide
o Policies that facilitate policies designating
breastfeeding nonsmoking areas
• Notification of em­ o Cafeteria programs to
ployees ahout repro­ promote good nutri­
ductive risks associ­ tion
ated with work en­ o Policies and pro­
vironments grams to help ensure
o Aexible work sched­ a safe and healthy
ules for parents work environment
• Reduction of exces­
sive stress in the
work environment
 Health •
Nutrition counseling • Counseling for par- • Adolescent health counseling •
Education and • Improved training of
care settings and guidance in risk ents on normal child- programs counseling programs health care providers
Annu. Rev. Public Health 1984.5:215-236. Downloaded from www.annualreviews.org

reduction for preg- hood growth and de- to reduce risk and for geriatric practice
nant women and par- velopment maintain therapeutic • Development of
ents of infants •
Education for parents regimens home care altema-
• Information and sup- on health habit • Education about un- tives to institutional-
port for breastfeeding formation and child necessary surgery ization
• Parent counseling on safety and procedures;
by 125.162.124.185 on 09/23/14. For personal use only.

infant screening to • Classes for parents second opinion pro-

identify high risk about home care of grams
families minor acute illness • Self-care education
• Poisoning prevention and injuries
programs • Involvement of chil-
• Community outreach dren in decisions
and education about their health
care

Communities Nutrition programs Public service Volunteer service opportuni- National Health Meals on Wheels and
::::
0
• • • •
•

for pregnant and lac- announcements ties Promotion Training other nutrition sup- 0
tating women countering advcrtise- • Targeted media programs, Network, e.g., health port programs :;yj
• Media campaigns ments directed at such as the 1982 Alcohol education and sup- • Education on >-<:
-
such as "Healthy children Abuse Prevention campaign port programs spon- hypothermia and heat Z
Mothers, Healthy • Assistance for par- • Adolescent health education sored by coalitions of stress 0
Babies" eots in educating programs sponsored by local organizations • Walking groups and ::I:
Support and educa- their children about youth serving agencies •
Media campaigns exercise programs tTl
>
•

sex and family life such as "HealthStyle" designed for older

tion for parents t"""
• Injury control pro- • After-school recrea- • Improved nutrition adults >-l
grams and ordinances tion programs information through • Promotion of positive ::I:
food labeling, print attitudes toward ag- t::C
tTl
and electronic media, ing and the elderly
::I:
and advertising • Bereavement >
• Community interven- counseling <:
-
tion programs for • Senior health promo- 0
specific health risks, tion volunteer pro- �
such as the Trilateral grams
High Blood Pressure • Promotion of drug
N
Education Program profile records
N
-.J

aFrom Mullen (130).

 228 GREEN

measurement instrumentation, and evaluation designs have all shown impress­

ive development in recent years (53, 89, 149). Debates con- tinue on the
appropriate outcome measures for school health interventions among cogni­
tive, behavioral, and epidemiological criteria (89, 90, 93, 169, 186).
Adolecents entering the 15-24 year age range can be expected to face
potential problems of motor vehicle crashes and temptations to take up alcohol,
tobacco, and drugs ( 136). This is the only age group in the United States that
has experienced an increase in mortality in the recent past. The modification
and development of health behavior in this age group are reviewed most
extensively and recently in Botvin & McAlister (19), Coates et al (28), Kolbe &
Annu. Rev. Public Health 1984.5:215-236. Downloaded from www.annualreviews.org

Iverson (91), and Kovar (92). Brachman and associates (3) provide the most
extensive longitudinal data on this critical transition.
Adulthood is the age of chronic disease. Substantial health promotion
intervention is warranted for the reduction of mortality and morbidity resulting
by 125.162.124.185 on 09/23/14. For personal use only.

from heart disease, cancer, and strokes. These, together with accidental deaths,
make up the four leading causes of premature death in the United States. The
risk factors for all of these are primarily associated with behavior. Life span
analyses of health behavior change in this age range include Breslow &
Enstrom (21), Breslow & Somers (22), Green (57), and Vaillant ( 176). The
most impressive advances in the development of population-based interven­
tions to support behavior conducive to health in this age range, besides the
patient education programs referred to in previous sections, have been in
worksites ( 144).
As the elderly population grows, the health concerns of this age group are
bound to become increasingly salient. Reducing premature death from influen­
za and pneumonia, reducing injuries due to falls, and increasing the population
of very elderly who can function independently are high priority items for the
promotion of health in this age range. Recent reviews of the research literature
on health behavior modification and development in the elderly include Borgat­
ta & McClusky ( 17), Borup & Gallego ( 18), Nickoley-Colquitt ( 139), and
Windsor and associates ( 188). Contrary to the stereotypes held by many health
workers, the elderly are found in evaluative research studies to be as much if not
more responsive to behavioral change supports than younger patients or sub­
jects ( 128).

Other Transitions
In addition to life span transitions, there are transitions from one status, role, or
circumstance to another that require adaptations of lifestyle and problems of
stress and coping similar to those of the life span. The high degree of mobility in
American life presents individuals, families, social groups, organizations, and
communities with problems of uprooting, discontinuity of social support,
isolation, confusion, and economic insecurity. A general model for the dis­
tribution of health promotion concerns over the natural history of transitions in
 MODIFYING HEALTH BEHAVIOR 229

time, place or role is presented in Table 5. It is suggested as a framework to

integrate the life-span approach and the life-events approach to the prevention
of health problems by building host resistance and providing the necessary
organizational, economic, and environmental supports for behavioral adapta­
tions that are constructive rather than destructive.
The fIrst row of Table 5 identifIes stages in the natural history of coping with
transitions or stressful events. The second row suggests the ways in which
health promotion, as defIned in this paper, can anticipate and intervene at each
of the stages of the natural history. The third row states the objective of health
promotion or behavioral interventions at each stage, from primary prevention
Annu. Rev. Public Health 1984.5:215-236. Downloaded from www.annualreviews.org

through rehabilitation.
The major advantage of the life transitions or events approach to health
promotion is that it is not specific to any particular disease, but can anticipate a
great number of potential problems known to compromise host resistance and
by 125.162.124.185 on 09/23/14. For personal use only.

resources and to lead to risk factors for most of the leading causes of death and
disability. Combined with the organization.of interventions around settings for
health promotion, this framework encompasses both the time and place dimen­
sions of for public health strategies to modify or develop behavior.

SUMMARY

The literatures on both behavior modifIcation and behavioral development have

engendered innovations in public health programs, addressing problems of
patient adherance to preventive and therapeutic regimens, delay in seeking
diagnosis of illness symptoms, risk-taking behavior, and other aspects of

Table 5 Proposed framework for analysis of problems in health behavior

Primary prevention Secondary prevention

Natural history: Critical transition Environmental and Coping and adapta- Health effects
or event internal demands tion
on personal reo
sources

Health promotion Anticipatory guid- Social support and Professional and in· Patient education
interventions: ance and self-care educa- stitutional re- and mutual self-
education tion sponse; organiza- help groups
tional, economic
and environmen-
tal supports

Objectives: Prevent exposure Strengthen personal Compensate for in- Treatment and re-
or build "host resources adequate personal habilitation to
resistance" to resources, or hasten return to
stress or risk reinforce success- maximum func-
ful adaptation tioning
 230 GREEN

lifestyle associated with health. Because most of this literature derives from
psychology, there has been a distinct bias in the constructio'
pointing them directly at individuals, usually in a counseling or small group
mode of delivery. These developments served public health well enough during
a decade or so when the preoccupation was with utilization of health services
and medical management of chronic diseases.
With the publication of the Lalonde Report in Canada in 1974, the passage of
Public Law 94-317 in 1976 in the United States, and similar initiatives in other
English-speaking and European countries, the recognition of the greater com­
plexities of lifestyle development and modification in the absence of symptoms
Annu. Rev. Public Health 1984.5:215-236. Downloaded from www.annualreviews.org

has taken hold. Policy makers and public health workers seek a more efficient
and equitable set of strategies to meet the behavioral health challenges of
modem society without placing the entire weight of responsibility for behavior
on the individWll or on therapeutic practitioners. Concurrently, on a more
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global scale and in the developing countries, a concern has emerged for
strategies that give individuals, families, and communities a greater role in
deciding their own health priorities.
The convergence of these two trends-one seeking to distribute responsibil­
ity for lifestyle more equitably and the other seeking to distribute responsibility
for planning health programs more equitably---calls for policies, strategies, and
interventions that will place similar emphasis on health education and organiza­
tional, economic, and environmental supports for health behavior. The com­
bination of these elements of support for behavior calls, in tum, for research
and more inventive applications of theory from sociology, political science,
economics, and anthropology. Public health workers will need to become more
conversant and facile in these social sciences, as they have in psychology and
its applications in the recent past.

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