Social Behavioral Theory
and Its Roots
Health Promotion: Individuals and Communities
Learning objectives for this lesson:
- Define theory as it is used in social science and explain why, following Karl Popper, a theory is tested by attempts to falsify it rather than by collecting cases that confirm it.
- Explain why a theory is a kind of account, why hypotheses can be derived from any coherent account, and why judging a theory always depends on the ground rules of a historical, social, or cultural context.
- Describe the four assumptions that theory inherits from the Western scientific tradition (order and regularity, predictability, empirical data, and progress) and trace the history that produced each one.
- Distinguish empiricist, rationalist, and phenomenological answers to the question of how we know what we know, and identify which one underlies scientific theory and what it leaves out.
- Describe the contributions of behaviourist, cognitive, humanistic, and social psychology to health behaviour theory, naming the key figures and ideas behind each.
- Describe the contributions of sociology and cultural anthropology to public health theory, including social structure and class, group influence, social capital, cultural competency, and the study of culture and illness.
- Explain how ecology and human ecology gave public health the ecological model, and apply the principle of interdependent systems to a health promotion problem.
This course was developed by Dr. Kiffer G. Card, Faculty of Health Sciences, Simon Fraser University, to accompany Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones & Bartlett Learning. This lesson follows Chapter 3 of the text.
Glossary: Key Terms, People & Concepts
📚 Reference page, available throughout the lesson
This glossary collects the key concepts, people, and ideas you will meet in this lesson. Use it as a reference while you work through the material, or as a review before assessments. Type in the search box to filter entries.
Thinking About Theory: What a Theory Is and How It Is Tested
⏱ Estimated reading time: 15 minutes
Getting our terms straight
Learning objectives for this section
- State the social science definition of theory and identify its parts: constructs, definitions, propositions, and relations among variables.
- Explain Karl Popper’s claim that a theory is tested by falsification, and why collecting confirming cases is a weak test.
- Describe theory as an account, and show how hypotheses can be derived from any coherent account, including a myth.
- Explain why judging a theory depends on contextual ground rules, using Wittgenstein’s language games and Foucault’s idea of discourse.
Lesson 1 used the word theory repeatedly without stopping to define it. This lesson stops. Before the course turns to specific theories of health behaviour, we need a shared understanding of what a theory is, how one is tested, and by what standards anyone decides that one account of behaviour is better than another. This section covers the groundwork: the scientific meaning of theory, Popper’s test, theory as a story or account, and the uncomfortable question of who gets to set the rules.
Theory in the scientific sense
The idea of theory is most closely associated with its use in the scientific method, and that association gives the term a specific meaning. A widely used definition oriented to social science, drawn from Kerlinger, runs as follows: a theory is a set of interrelated constructs (concepts), definitions, and propositions that presents a systematic view of phenomena by specifying relations among variables, with the purpose of explaining and predicting those phenomena. Each part of that definition does work. A construct is a concept the theory names and defines. A proposition states how constructs relate. The whole set is systematic, which means the parts fit together rather than sitting in a list. And the purpose is twofold: to explain what has happened and to predict what will.
The philosopher of science Karl Popper framed theory in the way most commonly used in scientific inquiry today. For Popper, a theory is a proposed explanatory solution to a problem. The important move is what follows. A theory’s validity is not established by proving it true, because that is easy: confirming cases can be found for almost any claim. The real test is trying to falsify it. A theory is therefore an explanatory proposition that can be tested, and tested by falsification. If, over time and in situations relevant to what it claims, it is not falsified, it remains part of the ongoing body of scientific knowledge. If it is falsified, it is reworked or discarded. Either way, Popper argued, science advances.
Common confusion: "it’s only a theory"
In everyday speech, a theory is a guess. In science the relationship runs the other way. The theory is the general explanatory account, and the hypothesis is the specific, testable prediction derived from it. A theory that has survived repeated attempts at falsification carries more weight than a hunch, not less. When someone dismisses an explanation as "only a theory," they usually mean it is only a hypothesis, or only a belief.
This is Popper’s central demand. "Fear-based warnings reduce smoking" is falsifiable: a trial in which warnings produce no change would count against it. "Our program changed lives in ways that cannot be measured" is not, because no observation could ever count against it. The second statement may be sincere, but it is not a scientific theory.
Popper’s test carries a condition that is easy to miss: a theory earns its place only if it has been tested in situations relevant to its claims. A theory of adolescent smoking tested only among middle-aged adults in one country has not really been tested. The condition returns in later lessons when we ask whether theories developed in one population transfer to another.
A falsified theory can be reworked, which is how most theories in this course developed: constructs were added, relations redrawn, and the revised version tested again. Or it can be discarded. The point is that both outcomes move science forward, because both tell us something the untested account could not.
Theory as an account
Before going further, ask what theory is in a more basic sense. Boiled down, definitions of theory refer to a kind of story, or, to use a broader word, an account. A theory is an account that is said to explain something and to posit connections between phenomena. Two examples: apples and other objects fall from trees because a force called gravity acts on them; substances called carcinogens cause cells to mutate and grow abnormally, out of control. From theories you can derive more specific applications: hypotheses, principles, and constructs. Click each card for a working definition.
Seen this way, theory is an ancient human activity. A key characteristic of modern humans since prehistoric times has been the creation of tales, myths, and stories that describe an entire cosmological system, explain the creation of society, or explain how men and women came to be what they are. These are theories in the broad sense, because they present a coherent account from which more specific judgments can be drawn. Consider a myth in which men were created from fire and women from water. From that account one could derive hypotheses: that men are emotional and prone to conflict while women are better at stopping conflicts (water on fire); that men destroy while women nourish; that men provide what is needed in adverse conditions while women provide the sustenance needed all the time.
Most of us would dismiss this as folktale. The harder question is: by what standards? We would probably say there is no proof, and that the account contradicts known facts about the origins of gender. But that answer assumes a set of rules about what counts as proof and what counts as a known fact. The rules are doing the work.
Theory or hunch? A sorting exercise
Before moving to the question of rules, practise the distinction Popper cared about. Each statement below is a testable proposition (an observation could show it false), an untestable account (no observation could count against it), or an empirical observation (a datum, which describes but does not explain). Sort all twelve.
Testable proposition
An observation could show it false.
Untestable account
No observation could count against it.
Empirical observation
A datum: it describes, it does not explain.
Two things to notice. First, the untestable accounts are not necessarily false, and some are deeply meaningful to the people who hold them; they are simply not scientific theories in Popper’s sense, because nothing could count against them. Second, observations on their own are not theories either. A survey result describes; a theory says why. Public health needs both, and it needs to keep them apart.
Ground rules: who decides what counts?
Evaluating a theory or a proposition necessarily rests on some set of standards for making the judgment. In this sense, theories can be seen as language games of the kind described by the philosopher Ludwig Wittgenstein: statements with meaning, validity, and truth or falsity within a particular practice and its rules. Or, following Michel Foucault, as statements within the discourse of science. Foucault argued that discourse, the modes of expression of a period and how they are used, is the product of that period and its dominant institutions, and that each period’s discourse carries rules for what is true and false, normal and not normal. In the era of modern science, that discourse predisposes us to judge truth by rational or empirical criteria.
Theories, then, have meaning and validity within a specific historical, social, or cultural context, and to evaluate one you need to understand the contextual ground rules. This understanding is one of the most important tools you can have for assessing theories about human behaviour and deciding when and where they will be useful in practice.
Case study: A campaign built on a comparison
In 1973 the Canadian physical activity organization ParticipACTION (Wikipedia) ran a television spot claiming that the average thirty-year-old Canadian was in roughly the same physical shape as the average sixty-year-old Swede. The line became one of the most remembered pieces of Canadian public health advertising. It was also a rhetorical comparison rather than the result of a study that measured the two groups. Judged as a message, it worked: people talked about it for decades. Judged as a theory, it made no claim about why Canadians were inactive or what would change that. Later tobacco control in Canada took a different route, stating explicitly which influences it was targeting (price, packaging, smoke-free spaces, social norms) and evaluating each.
Which of the three categories from the sorting exercise does the Swede comparison belong to? What would a theory-based version of the campaign have had to state, and what observation could have falsified it?
Case study: Two accounts of cholera
In mid-nineteenth-century London, the dominant scientific account held that cholera spread through miasma, foul air rising from filth. The physician John Snow proposed that it was carried in contaminated water. Within the discourse of the day the miasma account was meaningful and widely held; Snow’s was resisted for years. What separated them was Popper’s test. Snow’s account generated a prediction that could fail: households drawing water from a contaminated supply would suffer more cases than neighbours drawing from a cleaner one. The prediction held, and the miasma account was falsified in that situation.
Both accounts were coherent stories that explained the same deaths. In the language of this section, what were the ground rules that made miasma seem correct, and what changed?
The next section takes up the question that follows: what, then, is the context in which we use theory, and what are its ground rules?
Reflection
A regional health authority in British Columbia proposes a campaign with this rationale: "Young people vape because they think it is harmless. If we tell them the harms, they will stop." Rewrite that rationale as a theory in the social science sense (name at least two constructs and state the proposition that connects them to behaviour). Then derive one hypothesis from it and state, in Popper’s terms, what observation would falsify the hypothesis. Finally, identify one ground rule the rationale takes for granted that a different account of vaping might not share.
Minimum 20 characters required.
Key Takeaways
- In social science, a theory is a systematic set of interrelated constructs, definitions, and propositions that specifies relations among variables in order to explain and predict; constructs are its named concepts and propositions are the statements that connect them.
- Following Popper, a theory is a proposed explanatory solution to a problem that is tested by attempts to falsify it, in situations relevant to its claims; confirming cases are easy to find and prove little.
- At its most basic, a theory is an account, a story that explains something and connects phenomena; hypotheses, constructs, and principles can be derived from any coherent account, including a myth.
- Judging a theory always relies on ground rules supplied by a context (Wittgenstein’s language games, Foucault’s discourse); understanding those rules is one of the most useful tools for assessing theories of behaviour and deciding where they will be useful.
1. A program evaluator reports: "We found dozens of participants who quit smoking after our workshop, so the theory behind the workshop is confirmed." From Popper’s point of view, what is the problem with this reasoning?
2. Which of the following statements is best classified as an empirical observation rather than a theory or a hypothesis?
3. From the account "men were created from fire and women from water" one could derive hypotheses about conflict, destruction, and provision. What point does this example make?
4. A colleague argues that a theory of health behaviour developed and tested only among university students in the United States has been "thoroughly tested" and can be applied unchanged in a remote First Nations community. Which condition of Popper’s test does this overlook?
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The Context of Theory in the Western Tradition
⏱ Estimated reading time: 18 minutes
Where the ground rules come from
Learning objectives for this section
- Explain why the term theory is situated within the Western philosophical and scientific tradition, and why doing so is not the same as privileging that tradition.
- Describe the four assumptions the tradition builds into theory: order and regularity, predictability, empirical data, and progress.
- Trace the history behind each assumption, from the Greek philosophers through the Middle Ages, the Enlightenment, and nineteenth-century positivism.
- Distinguish empiricism, rationalism, and phenomenology as answers to the question of how we know what we know, and explain what the empiricist standard of evidence may leave out.
The previous section ended with a question: if judging a theory depends on ground rules, what are the rules for the theories public health uses? The answer is plain. The term theory takes its meaning from Western philosophy and science, the tradition that began with the Greek philosophers and was carried forward largely in Europe and North America. Saying this does not privilege that tradition; it situates it in a social and historical context. The tradition has been influenced and paralleled by currents from outside its mainstream, including the Islamic scholars Avicenna (ibn Sina) and Averroes (ibn Rushd) and the Chinese philosophers Confucius and Chuang Tzu, but the concept of theory public health inherited is largely a Western product, and it can be boiled down to four elements. Click each card for a first pass.
regularityClick to learn more
dataClick to learn more
perfectabilityClick to learn more
Order and regularity
It would be silly to claim that the idea of order is unique to Western thought; Confucianism, Taoism, and Navajo cosmology all contain elaborate concepts of natural order. What happened in the West was a specific turn: the progressive discovery of an assumed order underlying nature, combined with the practical application of that knowledge to human ends, became the central project of philosophy and then of science. Use the timeline to follow that turn.
Select an era
Start with Classical Greece, or press "Step through" to follow the sequence.
Two things about this history matter for practice. The shift from divine to secular explanation coincided with the Industrial Revolution and with a shift in power from church and monarchy to those who exploited science and technology: ways of knowing and arrangements of power moved together, which is Foucault’s point from the last section. And the idea of theory today is inseparable from the idea of order, even among those who argue that the human sciences should differ from the physical sciences.
Predictability
Predictability is the child of order and regularity: if nature is ordered and we discover the rules, then in principle we can predict what will happen. The idea is so ingrained in common sense that few people notice it is an idea, yet every weather report and every prescription assumes that someone is using science to predict. It was Auguste Comte who institutionalized prediction as a goal for the human sciences. In his account, human thought had passed through three stages on the road to modern science.
| Comte’s stage | How phenomena are explained | The same outbreak, explained three ways |
|---|---|---|
| Theological | Events and phenomena are attributed to the supernatural. | The illness is a punishment or a visitation, and the response is prayer, sacrifice, or penance. |
| Metaphysical | Phenomena are attributed to fundamental energies or ideas. | The illness is an imbalance of humours or a corruption in the air, and the response is to restore balance or purify the air. |
| Positive | Phenomena are explained by observation, hypothesis, and experimentation. | The illness follows exposure to a contaminated water supply; the hypothesis is tested by comparing households, and the response is to change the supply. |
In Comte’s view, the orderly application of a positivist approach would eventually make it possible to predict, and therefore to shape, society. That ambition is the ancestor of every program that promises to change behaviour by applying a theory, and it is also what later critics distrusted, because a science that can shape society raises the question of who does the shaping.
Empirical data
Here we need the word epistemology: ideas about how we know what we know. Do we know something because we can see and touch it, because the thought exists in our minds, or because a sacred text says so? The three questions correspond to empiricism, rationalism, and a theological or deist orientation. Scientific theory developed within the empiricism of John Locke and David Hume. Use the tabs to compare the positions.
Empiricism: knowledge comes through the senses
The tradition of the British empiricists John Locke and David Hume. There is an objective reality out there to be perceived, and our ideas about existence stem from those perceptions. Science in this tradition relies on observable, tangible data as evidence, and a theory is expected to say something about the observable relationships between phenomena. This standard of evidence is built into most of the theories in this course.
Rationalism: reality is grounded in the mind
The tradition of René Descartes, in which reality is based in the mind rather than in an objective world out there, and knowledge is reached through reasoning. It survives in health behaviour theory in the assumption that people reason their way to decisions, which the cognitive theories of Lesson 3 depend on.
Phenomenology: reality is experienced reality
The tradition of Wilhelm Dilthey and Edmund Husserl. Because individuals do the perceiving, and individual perception is shaped by biology, life experience, culture, and history, perception is never objective, and what we know of reality can never extend beyond our experience of it. This is the main challenge to the empiricist standard, and the reason qualitative and community-based methods have a place in health promotion research.
Theological or deist: knowledge is revealed
Something is known to be true because a sacred text or revelation says so. In the Middle Ages this orientation and the inquiry into natural order were the same project. Many people health promotion works with hold beliefs about health and healing within this orientation, and the point about ground rules from the previous section applies: such beliefs are meaningful within their context, whether or not they meet an empirical standard.
Is the standard of evidence always enough?
The discussion of empirical data closes with a question. The standard of evidence is embedded in many of the theories we will study, and we must also ask if it is always enough. Phenomenology supplies one reason for doubt: if perception is always shaped by culture and history, then one observer’s "objective" data carry that observer’s ground rules with them. Keep the question open; it returns in the lessons on culture and on evaluation.
Progress and perfectability
Progress in some form belongs to many traditions; in Buddhist and Hindu thought the soul progresses through reincarnation toward enlightenment. In the West, Plato’s cave pictured knowledge as an ascent from shadows to light, and Francis Bacon, in the late sixteenth and early seventeenth centuries, proposed replacing a framework of unchallenged superstition and style over substance with one built on empiricism, progress, and the practical use of knowledge. From the Enlightenment onward almost every major thinker built progress into theory: Darwin and natural selection, Spencer and social Darwinism, Hegel and the progression of spirit, Marx, Weber, and Durkheim on the stages of societies, Freud and Erikson on the stages of psychological development. For all of them, time does not stand still. Doing science, by definition, involves a continuous accumulation of knowledge, and theory is the tactic used to generate investigation.
Case study: Whose evidence counts?
A First Nations health organization in British Columbia runs a land-based wellness program for youth, built around time on the territory with Elders, language, and traditional foods. A funder asks for an evaluation showing measurable, generalizable outcomes, ideally with a comparison group. The organization describes what the program does in terms of relationship, identity, and balance, and it draws on Etuaptmumk, or Two-Eyed Seeing, a guiding principle brought forward by Mi’kmaw Elder Albert Marshall: seeing with the strengths of Indigenous knowledge from one eye and the strengths of Western knowledge from the other, and using both together. The evaluation team must decide what evidence to gather.
Which of the four assumptions of the Western tradition is the funder’s request drawing on most heavily? Which does the community’s account challenge, and which does it share? What would an evaluation designed with two eyes look like?
This part of the lesson closes with a question you should now be able to answer: can you see how theory, in this context, incorporates order, predictability, empirical data, and progress? The next two sections turn from the ground rules to the specific disciplines that produced the theories public health uses.
Reflection
A provincial ministry of health announces that it will fund only health promotion programs whose theory has been "validated by randomized trials with measurable outcomes." A community organization serving newcomers argues that its program, which builds on how families themselves explain illness and healing, cannot be judged on those terms alone. Using the four assumptions of the Western tradition and the three epistemologies in this section, explain what each side is assuming about how we know what we know. Then suggest a standard of evidence that takes seriously the question of whether the empirical standard is always enough, without abandoning falsification.
Minimum 20 characters required.
Key Takeaways
- The term theory takes its meaning from the Western philosophical and scientific tradition; situating it there places it in context and does not rank it above traditions such as Confucianism, Taoism, or Navajo cosmology, all of which hold elaborated ideas of natural order.
- Four assumptions are built into theory in this tradition: order and regularity (nature has a discoverable, usable order), predictability (know the rules, forecast the outcome), empirical data (knowledge comes through the senses), and progress (knowledge accumulates).
- The history runs from Democritus and Aristotle, through the church-centred Middle Ages and Aquinas, to the Enlightenment shift from divine to secular explanation, and then to Comte’s positivism and the ambition of a science of society that could predict and shape behaviour; the shift in ways of knowing coincided with shifts in power.
- Epistemology asks how we know what we know: empiricism (Locke, Hume) grounds knowledge in the senses and underlies scientific theory; rationalism (Descartes) grounds it in the mind; phenomenology (Dilthey, Husserl) holds that perception is never objective and that reality is experienced reality.
- The empirical standard of evidence is embedded in most health behaviour theories, and it is fair to ask whether it is always enough; that question is worth carrying into every evaluation you design.
1. A health unit forecasts that raising the price of sugary drinks will reduce consumption, because past increases in tobacco prices reduced smoking. Which assumption of the Western tradition is doing the most work in that forecast?
2. What characterized inquiry into the order of nature during the Middle Ages, and what changed during the Enlightenment?
3. A researcher argues: "Because every observer perceives through the filter of their own culture, history, and experience, what we know of health can never extend beyond how it is experienced." Which epistemological tradition is this?
4. Darwin, Spencer, Hegel, Marx, Weber, Durkheim, Freud, and Erikson were grouped together in this section. What do these thinkers have in common?
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Antecedents I: Psychology and Social Psychology
⏱ Estimated reading time: 18 minutes
The disciplines behind the theories
Learning objectives for this section
- Identify the schools of psychology that have shaped health behaviour theory, and explain why Freudian psychology has not.
- Describe behaviourist psychology, including classical and operant conditioning, reinforcement, shaping, and behaviour modification, and name Pavlov and Skinner’s contributions.
- Describe cognitive psychology, Piaget’s assimilation and accommodation, and the cognitive assumption behind the Health Belief Model, the Theory of Planned Behavior, and Social-Cognitive Theory.
- Explain the humanistic view of agency and Maslow’s hierarchy of needs, and connect it to the philosophy of health promotion.
- Summarize what social psychology contributes: social influence, group conformity, and the links among attitudes, intentions, and behaviour.
With the ground rules established, we turn to what can be called antecedents: the more specific lines of thought that feed current behavioural theory in public health. The primary fields are psychology and social psychology, so they come first. Psychology has many subfields, and only some have left a mark. Freudian psychology has contributed little to public health behavioural theory. Behaviourist, cognitive, ecological, and humanistic psychology have all contributed a great deal, and so has social psychology. Use the tabs for the three psychological schools, then read on for social psychology.
Behaviourist psychology: the black box
An early school dating from the late nineteenth century, in which behaviour is learned or conditioned through stimulus-response mechanisms. Thinking and emotion are given little importance because they are not considered essential to behaviour change; what matters is the effect of the environment on the brain’s reflexive responses. Internal mental processes are treated as a black box: a stimulus goes in, a behaviour comes out. The first behaviourists were Russian, most famously Ivan Pavlov (1849 to 1936). Pavlov rang a bell while placing meat powder on a dog’s tongue, which made the dog salivate. After many repetitions, the bell alone produced salivation: the conditioned stimulus had become associated with the meat powder. This is classical conditioning. In the United States, Edward Thorndike and John Watson were well-known early behaviourists.
B.F. Skinner (1904 to 1990) developed the modern approach, operant conditioning. It rests on the same assumptions about reflexive links between environment and behaviour, but it involves more steps. A behaviour is conditioned through positive and negative reinforcers; reinforcers can be delivered on different schedules, which have different effects on how well a behaviour is maintained; a behaviour can be learned through shaping, by reinforcing approximations that come closer and closer to the target; and behaviours can be deconditioned. The whole approach is called behaviour modification. Behaviourist methods are used today in smoking cessation and other addiction treatment, and the basic assumptions about learning through reinforcement appear in a number of health behaviour theories.
Cognitive psychology: inside the box
Cognitive psychology treats the thinking process itself as the source of behaviour. Where behaviourism regarded internal processes as insignificant, here the inside of the black box is exactly what is of interest: perception, memory, decision making, interpretation, reasoning, and judgment, among other faculties. Jean Piaget, one of the most influential thinkers in this school, described two ways we process information. Assimilation fits new information into existing categories of knowledge; accommodation changes or adapts existing beliefs to incorporate the new information. A student who hears that vaping carries risks and files it under "everything is supposed to be dangerous now" is assimilating; a student who revises the belief that vaping is harmless is accommodating. Piaget is also famous for his stages of cognitive development: sensorimotor, preoperational, concrete operational, and formal operational.
Cognitive psychology is an important part of the Health Belief Model, the Theory of Planned Behavior, and Social-Cognitive Theory, among others. All of them assume that internal processes, to one degree or another, determine behaviour: calculations of risk and benefit, expectations about outcomes, and so on. When Lesson 3 asks you to name the constructs of the Health Belief Model, you will be naming cognitions.
Humanistic psychology: agency and growth
Humanistic psychology developed partly as a reaction to what some saw as the mechanistic and determinist character of behaviourism, cognitive psychology, and Freudian psychology. It draws on a philosophical tradition that emphasizes individual agency, the capacity of people to make choices and determine their future. Its basic assumption is that human beings ultimately desire to grow and attain their potential. Abraham Maslow’s hierarchy of needs adds a condition: before people can pursue that higher-level growth, they must first satisfy a set of needs, from basic physiological needs through emotional and social ones.
The ties between this school and any specific public health theory are not always direct. Its influence is on the philosophy of public health, visible in definitions of health promotion as improving quality of life for the public and promoting healthy lifestyles and choices. Health promotion, in part, therefore involves promoting the conditions, including housing, employment, and access to health care, that allow people to live healthier and higher-quality lives. That is Maslow’s hierarchy expressed as policy.
Reinforcement, seen from the outside
The behaviourist legacy is easy to spot once you know the vocabulary. A quitline that phones back at set intervals is working a reinforcement schedule. A program that rewards a week without smoking, then two weeks, then a month is shaping. A person who reaches for a cigarette every time the phone rings is displaying a conditioned association that a cessation counsellor will try to decondition. None of these programs needs to ask what the person is thinking, which is both the strength and the limit of the approach.
Social psychology: the individual in the group
Psychology as a whole is concerned with the mental processes and behaviour of individuals. Social psychology is concerned with how individuals, and their mental processes, interact with their social surroundings: groups, relationships, and other social units. Its subject matter includes group dynamics, authority and legitimacy, emotion and its expression, aggression, self and identity, motivation, gender, group prejudice (the process of othering), norms, and attitudes. Health behaviour is often complex and socially motivated, so this subject matter connects directly to several theories in public health. A few illustrative lines of work stand out. Click each card.
obedienceClick to learn more
groupthinkClick to learn more
intentionsClick to learn more
otheringClick to learn more
The obedience studies (Milgram, 1963) and the dissonance experiments (Festinger and Carlsmith, 1959) remain among the most cited in the discipline. The Fishbein and Ajzen proposal deserves a diagram, because it reorganized the attitude-behaviour question in a way that health promotion adopted wholesale. Rather than asking whether attitudes cause behaviour directly, it placed intention in between, with attitudes and perceived norms acting on intention.
Which school is behind this program?
Each school makes a different assumption about where behaviour comes from, and programs inherit those assumptions whether or not their designers say so. For each program described below, choose the school of thought whose core assumption it relies on. Some programs draw on more than one; pick the one doing the most work and read the feedback.
A quitline offers small gift cards for each verified week without smoking, with the value rising for each consecutive week.
A screening decision aid lays out the chances of benefit and of harm so that each person can weigh them before choosing.
A program provides permanent housing immediately, without requiring sobriety or treatment first, on the premise that people cannot work on recovery while unsheltered.
A campus campaign publicizes accurate figures on how many students actually drink heavily, to correct exaggerated beliefs about peers.
A children’s dental clinic follows every checkup with a short, enjoyable activity so that visits become associated with something pleasant.
A vaccination program asks people who say they support vaccination to write down when and where they will get their dose.
A youth program begins by asking each participant who they want to become, and organizes its supports around that goal.
A nutrition program discovers that participants fit every new food message into the belief that "healthy food is expensive," and redesigns its lessons to change that belief directly.
Putting the schools side by side
| School | Where behaviour comes from | Key figures | Where it appears in health promotion |
|---|---|---|---|
| Behaviourist | The environment acting on reflexive responses; conditioning and reinforcement | Pavlov, Thorndike, Watson, Skinner | Smoking cessation and addiction treatment; reinforcement assumptions inside several theories |
| Cognitive | Internal processes: perception, memory, judgment, calculations of risk and benefit | Piaget | Health Belief Model, Theory of Planned Behavior, Social-Cognitive Theory |
| Humanistic | Individual agency and a drive toward growth, once basic needs are met | Maslow | The philosophy of health promotion: quality of life, healthy choices, and the conditions that allow them |
| Social psychology | Interaction between the individual and groups, norms, authority, and relationships | Milgram, Janis, Crandall, Fishbein and Ajzen | Theories built on norms, social influence, and the attitude-intention-behaviour chain |
Case study: At Home/Chez Soi
Between 2009 and 2013, the Mental Health Commission of Canada ran At Home/Chez Soi, a large randomized study of Housing First for people experiencing homelessness and serious mental illness, in Vancouver, Winnipeg, Toronto, Montréal, and Moncton. Housing First reverses the usual sequence: participants are offered permanent housing immediately, with supports, rather than being required to complete treatment or demonstrate sobriety first. The design is a wager about human motivation. It assumes that a person without shelter cannot be expected to work on anything higher up, and that once basic needs are secure, people will move toward recovery and the lives they want.
Which school of psychology supplies the core assumption of Housing First, and which construct from that school names it? What would a behaviourist or a cognitive designer have proposed instead, and what would each have missed?
The psychological schools share one feature: their unit of analysis is the individual, even when, as in social psychology, the individual is placed among others. The next section moves to the disciplines whose starting point is the group, the culture, and the system.
Reflection
A school district in Manitoba asks you to design a program to reduce vaping among grade 9 students. Sketch three short program ideas, one built on the behaviourist assumption, one on the cognitive assumption, and one on the social psychological assumption about where behaviour comes from. For each, name the core assumption in one sentence and one construct or process from this section that the design uses (for example, reinforcement, accommodation, perceived norms, intention). Then say which single idea you would choose if you could fund only one, and what Maslow’s hierarchy would lead you to check before launching any of them.
Minimum 20 characters required.
Key Takeaways
- Psychology and social psychology are the primary sources of public health behavioural theory; behaviourist, cognitive, humanistic, and social psychology have each contributed, while Freudian psychology has left little mark.
- Behaviourism (Pavlov, Thorndike, Watson, Skinner) treats the mind as a black box and explains behaviour through classical and operant conditioning: reinforcers, schedules, shaping, and deconditioning, together called behaviour modification; its reinforcement assumptions live on in addiction treatment and inside several theories.
- Cognitive psychology (Piaget) locates behaviour in thought, including assimilation and accommodation of new information, and supplies the core assumption of the Health Belief Model, the Theory of Planned Behavior, and Social-Cognitive Theory: internal calculations of risk, benefit, and expected outcome shape behaviour.
- Humanistic psychology (Maslow) emphasizes agency and a drive toward growth once basic needs are met; its influence is on the philosophy of health promotion, including the conditions, such as housing and employment, that make healthy choices possible.
- Social psychology studies the individual among others: obedience to authority (Milgram), groupthink and conformity (Janis, Crandall), the adjustment of attitudes to behaviour, and Fishbein and Ajzen’s placement of intention between attitudes, perceived norms, and behaviour.
1. A cessation counsellor notices that a client reaches for a cigarette every time she pours a morning coffee, and works with her to break the link between the two. Which idea from behaviourist psychology is the counsellor applying?
2. The Health Belief Model, the Theory of Planned Behavior, and Social-Cognitive Theory share an assumption inherited from cognitive psychology. What is it?
3. A person who continues to smoke gradually comes to believe that the health warnings are exaggerated. Which social psychological idea best describes this shift?
4. A provincial health promotion strategy states that its goal is to improve quality of life by ensuring access to housing, employment, and health care so that people can make healthy choices. Which school of psychology is the general influence behind this philosophy?
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Antecedents II: Sociology, Cultural Anthropology, and Ecology
⏱ Estimated reading time: 18 minutes
Group, culture, and system
Learning objectives for this section
- Contrast sociology and cultural anthropology with psychology in their focus, methods, and unit of analysis.
- Describe sociology’s contributions to public health theory: social structure and class, group influence, social capital, and social organization.
- Describe cultural anthropology’s contributions: behaviour in context, cultural competency, and the study of how specific cultural settings and conditions shape health problems.
- Explain how ecology and human ecology produced the ecological model, and apply the principle that behaviour exists within interdependent systems.
The psychological schools of the last section share a starting point: the individual. The disciplines in this section start elsewhere. Sociology and anthropology both focus on the social, societal, or cultural aspects of behaviour, in contrast to the more individual focus of psychology. Neither is a clinical discipline, so their research and theory rely on different methods. From there they diverge. Sociology has generally focused on domestic social phenomena, while cultural anthropology has addressed both global and domestic themes, often comparatively. Sociologists are interested in social groups, hierarchies, structures, and the nature of social interaction. Cultural anthropologists are interested in the role of culture in behaviour, in how life patterns are organized, in systems of knowledge and belief, and in language, symbols, and the other ways we represent life and its meaning. The section closes with ecology, a field from biology whose central idea holds the whole course together.
Sociology: structure, group, capital, organization
Four influences from sociology on public health stand out. Click each card.
and classClick to learn more
of the groupClick to learn more
organizationClick to learn more
Notice how different the sociological questions are from the psychological ones. A cognitive psychologist asks what a person believes about the benefits of cancer screening. A sociologist asks whether the person’s class position leads them to expect screening at all, whether their network includes anyone who has been screened (social capital in the sense of Coleman, 1988), and how the health system is organized to deliver it. Both questions are legitimate. The ecological model, which closes this section, is the framework that lets a program ask both.
Cultural anthropology
Anthropology has addressed public health since early in its history. The discipline as a whole has four subfields: sociocultural anthropology, archaeology, physical (biological) anthropology, and anthropological linguistics, of which cultural and physical anthropology have interacted most with public health. Open each panel to follow the line of work and the three contributions it produced.
In the early twentieth century Franz Boas laid the groundwork in his fight to counter racist stereotypes and to help the public understand varieties of cultural patterns on their own terms. Margaret Mead, perhaps the most public of anthropologists, used her research on childrearing, adolescence, and gender to influence the American debate about how to understand and work with adolescents. Both established a habit of mind that public health still relies on: before judging a behaviour, learn what it means to the people who do it.
A group of mid-twentieth-century anthropologists, including Ruth Benedict, Margaret Mead, Abram Kardiner, Cora DuBois, John and Beatrice Whiting, Irving Hallowell, and Anthony F.C. Wallace, studied the connections between culture and personality and its expression in behaviour. Cognitive and psychological anthropologists such as Ward Goodenough, Roy D’Andrade, Melford Spiro, Claudia Strauss, Dorothy Holland, and Naomi Quinn continued the line, looking at the cultural models people refer to in patterning their behaviour. A different direction, the materialist tradition exemplified by Marvin Harris, focused on the relationship between human behaviour and systems of production.
The first contribution is the whole-context approach to health behaviour reflected in what is known as the ecological model: the idea that human behaviour can never properly be understood outside the social, cultural, and situational context in which it occurs. Anthropology supplied the insistence on context; ecology, below, supplied the language of systems.
The second is the idea of cultural competency, or culturally appropriate programs and care. Concepts of what is healthy or not healthy, classifications of disease and illness and their causes, which treatments are appropriate and who counts as a health provider, and how to interact with someone who is ill are all heavily shaped by culture. Given the diversity of patient populations, understanding the health beliefs and practices a person brings, and how to interact with diverse populations, is a central part of developing health promotion and treatment programs. In Canada this idea has been extended, in the training of health professionals, into cultural safety, which asks providers to examine the power they hold as well as the beliefs their patients hold.
The third is the study of how specific cultural settings and practices relate to health problems. Merrill Singer and Paul Farmer have been deeply involved in research on the link between conditions of poverty and oppression and the spread of HIV/AIDS. Mark Nichter is known for his work on culture and adolescent smoking. Arthur Kleinman pioneered the study of the sociocultural nature of disease and illness and of how these are experienced and treated across cultures, including the observation that the patient’s explanation of an illness and the clinician’s explanation may be two different accounts of the same event.
Case study: Vancouver’s Downtown Eastside, 1997
In 1997 the Vancouver/Richmond Health Board declared a public health emergency in response to the spread of HIV among people who inject drugs in the Downtown Eastside. An individual-level account explained the epidemic through needle sharing, a behaviour, and pointed to education about sterile equipment. A second account, in the spirit of Singer and Farmer, looked at the conditions in which the behaviour occurred: concentrated poverty, unstable housing, the criminalization of drug use, the loss of income-support and mental health services, and a neighbourhood where people who used drugs had been pushed together and out of sight. The response that eventually took shape combined both: expanded needle distribution and, in 2003, North America’s first sanctioned supervised injection site, Insite (Wikipedia), alongside housing and treatment initiatives.
Which discipline’s contribution frames the epidemic as a product of conditions rather than choices? What does the ecological model add that neither account provides on its own?
Case study: Two accounts of diabetes
A community health centre notices that many patients with type 2 diabetes do not follow the dietary and medication plan they agreed to. Interviews, in the spirit of Kleinman, reveal that patients hold their own accounts of the illness: some describe it as "sweet blood" that runs in the family and cannot be changed, some as a consequence of grief, and some as the result of a change in food since moving from the countryside. The clinical account is insulin resistance managed by diet, activity, and medication. None of the patients’ accounts is a refusal of care; each is a theory in the broad sense from Section 1, with its own implications for what a person should do.
How would a culturally competent program use the patients’ accounts rather than argue with them? Which of the three anthropological contributions is most directly at work here?
Ecology and biological systems
In a different vein, the fields of ecology and human ecology have shaped the way health behaviour is now conceptualized: as an outcome of a complex system of influences from several domains, including policy and regulation, sociocultural factors, the physical environment, and individual factors. This is the ecological model, and it is the prevalent general framework in public health for understanding health behaviour. Green and Kreuter, Bronfenbrenner, and Lewin are among its sources.
Ecology is the study, within biology, of how living organisms function within systems. The food chain is the obvious example: many organisms depend on other organisms and on a specific physical environment for their existence, and when the system is disrupted, because one organism becomes extinct or a body of water dries up, the entire system and everything in it is affected. Human ecology applies the same focus to how humans function as part of a biophysical and social environment. Human existence cannot be conceptualized separately from the environment in which we live. From both fields the general principle is the same: life, and the behaviour of living organisms, exists within interdependent systems.
The point of the diagram is the grey lines. Each domain is connected to the others, so a change in one moves through the rest. Use the interactive below to test that claim on a small community food system.
The idea of ecology should help you tie together every kind of theory in this course. Each theory is useful for describing or understanding one piece of the puzzle. The way the pieces work together is the key. That is why this course teaches individual theories and social, cultural, and environmental theories side by side, and why Lesson 6 returns to the ecological perspective explicitly.
Four disciplines, four starting points
| Discipline | Starting point | Typical question about smoking | Contribution to public health theory |
|---|---|---|---|
| Psychology and social psychology | The individual, alone or among others | What does this person believe about the risks, and what do they think their friends do? | Cognitive constructs, reinforcement, norms, intention |
| Sociology | Groups, hierarchies, structures, interaction | How does class position shape who takes up smoking, and what networks and resources help people quit? | Social structure and class, group influence, social capital, social organization |
| Cultural anthropology | Culture, meaning, systems of knowledge and belief | What does smoking mean in this setting, and how do local ideas of health frame it (Nichter)? | Behaviour in context, cultural competency, cultural settings and health problems |
| Ecology and human ecology | Interdependent systems | How do pricing, packaging laws, retail environments, norms, and individual factors act together on smoking? | The ecological model |
With the roots in view, the final section brings the lesson together and asks you to use all of it at once: to recognize a theory, to judge it by the ground rules of its tradition, and to identify which discipline’s assumptions a program is carrying.
Reflection
A health unit in northern Ontario reports that fruit and vegetable intake in a small fly-in community is far below provincial averages and proposes a cooking-skills course. Using this section, write a short critique. First, name one contribution from sociology and one from cultural anthropology that the proposal ignores, and say what each would add to the assessment. Then apply the principle of interdependent systems: identify at least three domains of the ecological model that act on what people in the community eat, and explain why a change in one of them would move through the others. Finish by proposing one addition to the program that reaches a domain the cooking course does not.
Minimum 20 characters required.
Key Takeaways
- Sociology and cultural anthropology begin with the group and the culture rather than the individual; sociology has focused on domestic social structures and interaction, anthropology on culture, meaning, and systems of belief, often comparatively, and neither is a clinical discipline.
- Sociology contributed four ideas to public health theory: social structure and class (Marx, Engels, Weber, Bourdieu), group influence through norms and conformity (Durkheim), social capital (Bourdieu, Coleman, Putnam), and social organization (Durkheim, Weber).
- Cultural anthropology, from Boas and Mead through the culture-and-personality and cognitive anthropology traditions, contributed the insistence that behaviour cannot be understood outside its context, the idea of cultural competency, and the study of how settings and conditions shape health problems (Singer and Farmer on poverty and HIV, Nichter on smoking, Kleinman on illness across cultures).
- Ecology and human ecology supplied the principle that life and behaviour exist within interdependent systems, which became the ecological model: behaviour as the outcome of influences from policy and regulation, sociocultural factors, the physical environment, and individual factors.
- Each theory in the course describes one piece of the puzzle; the way the pieces work together is the key, and the ecological model is the frame that lets a program ask the psychological, sociological, and anthropological questions at once.
1. A study finds that people in a low-income neighbourhood rarely seek cancer screening, and interviews suggest they simply do not expect preventive care to be something people like them receive. Which sociological contribution best captures this finding?
2. A community health centre trains its staff to ask each patient how they understand the cause of their illness, what treatment they consider appropriate, and who they consider a healer, before proposing a plan. Which contribution of cultural anthropology is this most directly applying?
3. Which statement best expresses the general principle drawn from ecology and human ecology?
4. A provincial ministry proposes to reduce youth smoking with a classroom lesson on health risks. Applying the principle that each theory describes one piece of the puzzle and that the way the pieces work together is the key, what is the strongest critique?
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Final Review & Assessment
⏱ Estimated time: 25 minutes
Bringing It All Together
This lesson did the work that Lesson 1 postponed: it defined the word theory. In the social science sense, a theory is a systematic set of interrelated constructs, definitions, and propositions that specifies relations among variables in order to explain and predict. Following Karl Popper, a theory is a proposed explanatory solution to a problem, and its test is falsification rather than confirmation, carried out in situations relevant to what it claims. At the same time, a theory is an account, a story that explains, and stories of that kind are as old as humanity. What separates a scientific theory from a myth is the set of ground rules used to judge it, which is why the lesson brought in Wittgenstein’s language games and Foucault’s discourse: a theory has meaning and validity within a context, and understanding that context is one of the most useful tools you can carry into practice.
The context for public health theory is the Western philosophical and scientific tradition, and the lesson traced the four assumptions that tradition built into theory. Order and regularity came from the Greek search for a discoverable, usable order in nature, survived the church-centred Middle Ages, and emerged from the Enlightenment as the clockwork universe. Predictability is order’s child, institutionalized by Comte’s positivism as the goal of a science of society. Empirical data reflects the empiricist epistemology of Locke and Hume, against which rationalism and phenomenology stand as alternatives, and the lesson asked whether the empirical standard of evidence is always enough. Progress, from Plato’s cave to Bacon to Darwin, Marx, and Freud, makes science a continuous accumulation of knowledge in which theory is the tactic that generates investigation.
The last two sections named the disciplines from which health behaviour theory descends. Behaviourism (Pavlov, Skinner) gave reinforcement and behaviour modification; cognitive psychology (Piaget) gave the assumption that internal calculations of risk and benefit shape behaviour, which underlies the Health Belief Model, the Theory of Planned Behavior, and Social-Cognitive Theory; humanistic psychology (Maslow) gave agency, growth, and the philosophy of health promotion; and social psychology gave social influence, conformity, and the chain from attitudes and norms through intention to behaviour (Fishbein and Ajzen). Sociology contributed social structure and class, group influence, social capital, and social organization; cultural anthropology contributed behaviour in context, cultural competency, and the study of how settings and conditions produce health problems; and ecology contributed the principle of interdependent systems that became the ecological model. Each theory describes one piece of the puzzle. The way the pieces work together is the key.
Key Takeaways from this lesson
- A scientific theory is a systematic account built from constructs and propositions to explain and predict; its test is falsification in situations relevant to its claims, and confirming cases prove little.
- Every judgment about a theory rests on ground rules supplied by a historical, social, or cultural context; recognizing those rules, in your own tradition and in others, is a practical skill for assessing theories of behaviour.
- Theory in the Western tradition assumes order and regularity, predictability, empirical data, and progress; each assumption has a history tied to shifts in power, and phenomenology asks whether the empirical standard is always enough.
- Behaviourist, cognitive, humanistic, and social psychology each make a different assumption about where behaviour comes from, and those assumptions reappear inside the named theories of Lessons 3 and 4.
- Sociology and cultural anthropology shift the starting point from the individual to structure, group, network, and culture, contributing class, social capital, group influence, cultural competency, and the insistence on context.
- Ecology supplies the principle of interdependent systems and, through it, the ecological model; each theory explains one piece, and the way the pieces work together is the key to designing programs that reach more than one domain.
Reflection
A regional health authority in Alberta asks you to review a proposal to reduce alcohol-related harm among young adults in a college town. The proposal rests on this reasoning: "Young adults drink heavily because they underestimate the risks. A social media campaign about the risks will change their minds, and once their minds change, their drinking will change." Write a review that (1) restates the reasoning as a theory, naming its constructs and its proposition, and states what observation would falsify it; (2) identifies the school of psychology whose assumption it carries and names two other antecedent disciplines whose contributions it ignores, with one specific idea from each; (3) identifies which of the four assumptions of the Western tradition the proposal relies on most, and what a phenomenological objection would sound like; and (4) uses the ecological model to propose one addition that reaches a domain the campaign does not.
Minimum 20 characters required.
Final Knowledge Assessment
This assessment covers all material from this lesson. You must score 100% to complete the lesson. Review the feedback for any incorrect answers and try again.
1. Which of the following best states Popper’s view of how a theory earns its place in scientific knowledge?
2. A colleague says: "Our program worked, and any evaluation that fails to show it simply measured the wrong things." In the terms of Section 1, what kind of statement is this?
3. In the social science definition of theory drawn from Kerlinger, what is the role of propositions in a theory?
4. Why are Wittgenstein’s language games and Foucault’s idea of discourse relevant to evaluating a theory?
5. Which of the following is the best description of positivism?
6. The Enlightenment shift from divine to secular explanation coincided with a particular economic and political change. What was it?
7. A health researcher insists that only outcomes an outside observer can measure count as evidence, because the senses report an objective reality that is out there. Which epistemological tradition is she working within?
8. Which assumption of the Western tradition is expressed in the claim that doing science involves a continuous accumulation of knowledge, with theory as the tactic used to generate investigation?
9. A smoking cessation program gives participants a small reward for each verified smoke-free week and increases the reward for consecutive weeks. Which antecedent and process does this design draw on?
10. Piaget distinguished assimilation from accommodation. Which example below illustrates accommodation?
11. Which of the following is the contribution of Fishbein and Ajzen to the study of attitudes and behaviour?
12. Humanistic psychology developed in part as a reaction to something. To what?
13. A newcomer family knows no one who has used the Canadian health system and has no one to ask how to find a family physician, while a second family with relatives already settled here is registered within a month. Which sociological concept explains the difference?
14. Which pair correctly matches an anthropologist with the work for which they are known?
15. A health unit designs a program to increase physical activity that combines a bylaw funding winter-maintained trails, a workplace challenge with team norms, and an app that sets personal goals. Which idea from the lesson best justifies combining these elements?
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