IS THERE really ever anything new? or is there just a continuing process of rediscovery of that which has been understood in the past and then forgotten? It's fascinating to find current researchers coming up with some amazing new idea only to discover that someone long ago had the same concept. This has happened once again in the vital young discipline of health education.
Before explaining how this occurred, we need to take a brief look at an important development in the field of behavior change.
B. F. Skinner, in Beyond Freedom and Dignity, pleads for a "technology of behavior" that would quickly solve the problems confronting the world today. In objecting to what appears to him to be an exaggerated emphasis on the importance of the mind in our time, he complains that behavior is not recognized as a subject in its own right. However, he, in turn, seems to exaggerate the importance of behavior itself. Believing that behavior is determined not from within but from without, he concludes that freedom and free will are no more than illusions. Whether man likes it or not, he is already controlled by external influences, and can be conditioned to avoid everything that is harmful. 1
It was probably time that someone challenged those whose limited view point has been that "internal" variables explain behavior. But Skinner's theory places too much value on the ability of behaviorists to fully control the learning situation. It focuses almost entirely on the biological side of man and seems to almost completely ignore the social and relational dimensions of learning.
Common sense and health data combine to demonstrate that there is a positive relationship between attitudes and beliefs on the one hand, and behavior on the other. Yet we cannot ignore the fact that recent investigations carried out in the area surrounding Orlando, Florida, concerning the impact of anti-smoking television commercials on behavior help establish some limits to this relationship. According to this re port, a little more than 50 per cent of those predisposed toward giving up smoking felt that the commercials had an effect and reinforced or strengthened their predisposition. Although nearly 70 per cent of the smokers sampled sub scribed to the belief that smoking is harmful to health, the fact that attitudes and beliefs do not lead inexorably to corresponding behavior changes was evident in the finding that two thirds did not change their smoking habits. The investigators saw this as evidence that many people are able fairly easily to endure a sizable amount of psycho logical discomfort when they feel it is worth ignoring.2
In this controversy, as to whether or not behavior is determined from within or without, it isn't really necessary to take an either/or position. External social and biological influences are not necessarily opposed to the internal psychological ones. Obviously, all these factors can influence health behavior change, and their strength or weakness must vary according to the individual differences of those being influenced.
A Behavior-Change Model
There is growing emphasis today on the use of and need for conceptual models that enable those analyzing them to imagine the reality they represent through a likeness that helps make them clear. Models, of course, are limited in that many details must necessarily be omitted in order to represent the points being made.
One model that nicely demonstrates the more balanced view of behavioral change strategies presented above is that developed by Dr. Lawrence Green. He is associate professor of Public Health Administration at Johns Hopkins University, and after much re search and study he developed the health-education model reproduced in the diagram on page 32.3
This model and its explanation may seem somewhat complicated at first but if you study it through carefully you will discover a remarkable parallel to a parable Jesus taught. In explaining his model, Green points out that in this scheme an individual can be placed at a point on the vertical axis according to the amount of "psychological readiness" he has toward adopting a preventive health practice. His position on the horizontal axis is determined by the amount of social support he has for the practice. If both his own psychological readiness and social support are positive, the individual would be placed in quadrant I on the diagram. We might characterize him as "well adjusted," both from the point of view of health practice and in the viewpoint of his social support.
At the other extreme are those who fall into the category of quadrant III. In their case both psychological readiness and social support are limited or lacking. These individuals likely would not adopt new preventive health practices and would be characterized as "hard to reach." They would, nevertheless, be well adjusted by the standards of their own social groups, having neither psychological nor social conflict in their preventive health behavior.
Green adds that as social support in creases, psychological readiness also tends to increase. He points out that these two dimensions tend to be naturally correlated with socioeconomic status, as indicated by the broken line in the diagram.
There is a tendency for those who undergo strong social pressure to change but are not internally convinced (see quadrant II), to adjust their attitudes and move toward quadrant I. Especially is this true if such an individual is rewarded for conforming to the group's norm.
Some people are always out in front, accepting and promulgating new ideas— these Green places in quadrant IV. There seems to be a tendency for others to follow along and adopt the attitudes and behaviors of these innovative thought leaders.
Of course, behaviors of those in quad rants I and III are quite predictable, but this is not true of people in quad rants II and IV. In these cases, education and situational considerations can make quite a difference in their response.
Green goes on to outline strategies that can be used to help people move from the other quadrants into quadrant I. These include both internal and external factors. Green's investigation centers around strategies for dealing with cancer education. Let's illustrate it with a health-education emphasis that is more familiar to Seventh-day Adventist ministers—Stop Smoking programs.
Because family or friends are pressuring him against his will to stop smoking, an individual in quadrant II might actually quit smoking. However, if he is to permanently overcome the smoking habit he needs information and educational input that will help build beliefs in what he is doing and enable him to justify and internalize his behavior.
Another possibility for the individual in quadrant II is to ignore or resist social pressures and those who "nag" him to give up his smoking habit. Studies have demonstrated that such "nagging" is not effective, in most cases, in helping an individual stop smoking. The one being "nagged" is most likely to continue to "sneak a smoke." He obviously needs help in developing a positive attitude toward stopping smoking. More frequent contact with groups composed of nonsmokers who don't make him feel guilty can help.
The individual who fits quadrant IV but does not give up smoking is convinced that smoking is harmful to his health. Yet social and environmental pressures make it very difficult for him to stop smoking. This is one reason why group stop-smoking plans have been successful for some individuals who were unable to quit on their own. Family support can also be especially beneficial for the individual in this category.
The quadrant IV individual who does stop smoking would characteristically be the first in his group to do so. He is the innovator, and pride in his position as an innovator may reinforce his decision as well as his resistance to those who are making fun of him, be cause he is doing something they aren't. Unless he can get the group to follow him, however, his position after a while can become so difficult to maintain that he will either give, up his group or give up his newly adopted practice.
A Bible Model
When we contacted Dr. Green about using his model in this article he told us that he was unaware that in developing it he was "plagiarizing" Jesus. But long ago, in the Biblical parable of the sower, Jesus "said it first." He illustrated the concepts outlined in this supposedly recently discovered model as He spoke of the seed of truth falling in different kinds of ground. Some fell among thorns. It took root, but was soon choked out. If adopted, it was not really internalized (dissonant adopter) or, owing to conflicting interests that had higher priority, it was not adopted (deviant non-adopter). This represents quadrant II in the model.
Quadrant IV may be found in the parable of the sower in the seed that fell on stony ground. Although initially joyfully received by the hearers, they gave it up when they began to be persecuted for their stand.
Quadrant III is in turn represented by the seed that fell upon the hard-beaten path. It is neither internalized nor seen as acceptable, so it is ignored. But quadrant I is evidently the good ground in the parable. It includes not only those who have high psychological readiness and receive strong social sup port for what they are doing, but share with others that which they have gained.
In our smoking clinics, we have learned that one of the most successful strategies for helping those who stop smoking to continue in this pattern is to get them involved in helping others in their community to follow their example. As more individuals stop smoking, pressure increases for others not to smoke in their presence as is illustrated by movements now in process to designate non-smoking sections in public transport and in public places. This in turn makes it more comfortable for the new nonsmoker to maintain his decision.
The similarity of this model with that of the parable of the sower is interesting in that the parable points out an element not obviously included. Jesus not only said it first, but He came up with a more complete and holistic model. He included the conversion experience. The main point of the parable of the sower, as understood by many New Testament scholars, is that the seed is the Word of God. The Word of God often comes in collision with an individual's ingrained habits. But the good-ground hearer, and all the others represented in the other quadrants in the model, can be changed through the work of spiritual forces and by the power of the life in the seed if the ground is broken up and cultivated and the seed is given a chance to take root. Here, then, we find spiritual or religious values that can help overcome both psychological unreadiness and lack of social support.
The Value of Religion
The value of religion is, of course, not always recognized by social scientists nor is it understood in the same way by those who do recognize it. Kingsley Davis sees the value of religion in its contribution to social integration. He defines it as "an imaginative creation of corporate man functioning to meet only the tension-reduction needs of the socio-cultural system." 4
Based on studies done in Detroit, Gerhard Lenski comes up with a contrasting view. He sees religion as formative of the core-value system of a given social order and interacting with attitudes and social norms. Goals, values, beliefs, and action patterns, though acquired in one institutional context, he points out, frequently manifest themselves in others. "What is possible, what is probable, and what is inevitable in any given secular organization is a function, in part, of the socio-religious groups to which they be long." 5
Others tell us that in order to under stand the power of socio-religious groups, it is essential to recognize their capacity to absorb primary groups, usu ally the family, as subunits in their organizational system. Because of this, the norms of socio-religious groups are constantly being reinforced in these primary groups. Religion is looked upon, then, as giving meaning and coherence to the norms of the social system. Of course, to the believer, religion involves a motivating force that is much more significant than the explanations given by social scientists.
Today's health problems are admittedly more difficult to cope with than the epidemics of the past, since they involve socio-economic factors and our whole way of life. For too long many practitioners of health care have, it seems, been deliberately ignoring one of the most useful and effective motivational instruments in health behavior change—religion. Recently, this fact has been receiving attention and growing recognition. The subsequent development of the holistic approach to health care, which includes the spiritual along with the physical, mental and social, gives great promise of developing a truly effective approach to the prevention and treatment of today's health problems.
1 B. F. Skinner, Beyond Freedom and Dignity (New York: Alfred A. Knopf, 1971), p. 5.
2 M. Timothy O'Keefe, "The Antismoking Commercial: A Study of Television's Impact on Behavior," Public Opinion Quarterly, XXXV (Summer, 1971), pp. 242-248.
3 Lawrence W. Green, "Should Health Education Abandon Attitude Change Strategies?" Health Education Monographs, XXX (November, 1970), pp. 27-29.
4 Kingsley Davis, Human Society (New York: MacMillan Co., 1960), p. 529.
5 Gerhard Lenski, The Religious Factor (Garden City: Doubleday and Co., 1961), p. 310.
