# Lesson 1: The Links Between Health and Behavior

*Companion-podcast transcript • Sarah & Kiffer*  
*Office Hours episode to listen to after working through the lesson*

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**Sarah:** Picture a workshop on healthy choices in a remote northern community, where feeding a family can cost about twice what it costs in the south.

**Kiffer:** I know where you're going with this. You think it puts the weight of a structural problem on the people living with it.

**Sarah:** I do. By 1977, Robert Crawford was calling that kind of thinking victim blaming.

**Kiffer:** It's a real risk. I'm still less ready than you are to write off programs aimed at individuals, because structural changes still depend on people acting.

**Sarah:** Welcome to Office Hours. I'm Sarah.

**Kiffer:** And I'm Kiffer. We're on Lesson one, The Links Between Health and Behavior, and Sarah's going to start us somewhere more basic.

**Sarah:** Question one. Is a health behaviour always about health? I'll admit that before I thought about it carefully, I assumed that anything called a health behaviour was something people did for their health.

**Kiffer:** That's the natural reading of the label, and it's worth seeing why it misleads. Health behaviour is a category. It covers any behaviour that affects health, in either direction, so smoking and needle sharing belong in it as much as brushing and vaccination. The label describes the behaviour's effect on health. Why anyone does it is a separate question. Sam, from the toothbrushing scene, had six candidate motives for one habit, and on the night of the party, the cultural image or the attraction was probably what drove him.

**Sarah:** And there are four ways a health behaviour can relate to health. It can be motivated by health, by health mixed with other concerns, by concerns that have nothing to do with health, or by an idea of health that differs from the standards of Western medicine.

**Kiffer:** Let's try those four on a made-up example. Four invented people all cook dinner at home most nights. Maya cooks at home because her doctor told her to cut back on salt for her blood pressure. Tom cooks because it's cheaper, because he enjoys it, and because he likes knowing how much salt and fat goes into his food. Ana cooks because she's the one in her family who hosts, and feeding people is how she shows she cares. And Joe, a grandfather, cooks big, rich meals for his grandchildren, because where he grew up, food was often short, and a well-fed, larger child was a child who was doing well.

**Sarah:** Maya is the easy one. That's health. Tom is health mixed with other concerns, since money and enjoyment sit alongside the salt and fat. Ana's reason is hospitality and care, so she's acting on a concern unrelated to health.

**Kiffer:** So here's a question for everyone listening. Which of the four possibilities does Joe's cooking fit? Take a few seconds.

*(Pause)*

**Sarah:** The fourth one. His cooking is motivated by health, because Joe wants his grandchildren to be healthy. What differs is his picture of a healthy child, so it's an idea of health that differs from the standards of Western medicine.

**Kiffer:** That's right, and it's easy to misfile as unrelated to health. A message telling him to feed his grandchildren less would sound to him like a request to make them unwell. For people whose history includes food shortage, thinness can be a sign of hardship, and a program that ignores that meaning asks them to pursue what they understand as illness.

**Sarah:** So a campaign about salt and blood pressure would reach Maya, probably Tom, and it would speak past Ana and Joe.

**Kiffer:** And notice that handing Ana or Joe more facts about salt would change very little. Until the late 1970s and early 1980s, health promotion focused mainly on individual knowledge, attitudes and motivation. The reasoning was that people who knew the risks would act to avoid them. That reasoning works best when concern about the risk is what's driving the behaviour.

**Sarah:** There's also a case that none of the four possibilities covers. Suppose a fifth person would like to cook at home and can't, because she works two jobs and rents a room without a kitchen.

**Kiffer:** Then her motivation is beside the point. Her circumstances set the terms before any motive gets a say, which is the same point as the rural woman with no screening provider within reach. That kind of complexity is what the ecological model was built to organize.

**Sarah:** Question two. What does the word environment mean in the ecological model? I ask because the word seems to do two different jobs.

**Kiffer:** It does. In the definition of the model, environment means everything that exists outside the individual. That includes family, peers, institutions, laws and prices, along with air and water. In the list of five groups of factors, environmental is the name of one group, and that group is narrower. It holds physical conditions such as pollution, disasters, and the conditions that let an infectious disease spread.

**Sarah:** And students coming from epidemiology sometimes hear a third meaning, the ecological fallacy.

**Kiffer:** That's a statistical error, inferring something about individuals from data about groups. The ecological model comes from a different tradition. It's a claim about where the causes of behaviour lie, at many levels at once. The levels themselves vary from one author to another. A well-known 1988 paper by McLeroy and colleagues used five, running from the individual through interpersonal relationships, organizations and communities to public policy. Levels like these are sorting tools, and the habit they build is asking what acts on a behaviour at each level.

**Sarah:** Let me try some sorting, then. Give me a case.

**Kiffer:** Here's a made-up one. A family lives on an acreage outside a small town and gets its drinking water from a private well. They've never had the water tested. There are five facts. One, the parents don't know that private wells should be tested regularly. Two, none of the neighbours test their wells, and the general feeling along the road is that well water is purer than town water. Three, the nearest lab that tests water is a two-hour drive away, and a test costs about a hundred dollars. Four, the province in this made-up case has no rule requiring owners to test private wells. Five, the bedrock in the area contains arsenic.

**Sarah:** Okay. The parents not knowing is an individual factor, awareness and knowledge. The neighbours, and the shared feeling about well water, are social, cultural and group factors, a peer pattern and a shared belief. The arsenic in the bedrock is environmental, a physical hazard. The missing rule about testing comes from outside the family, and the model defines environment as everything outside the individual, so I'd put that one with the environmental factors too.

**Kiffer:** Check that one with the two meanings of environment we just talked about.

**Sarah:** Right. I used the broad meaning. In the five groups, environmental factors are the physical ones. A rule about testing is a regulation that affects health risk, so it belongs with the political factors, the same group as a ban on selling cigarettes to minors.

**Kiffer:** That's the right correction, and it matters beyond the label, because where you file a factor shapes who you think can change it. No one can take the arsenic out of the bedrock, and a government can change a testing rule. That leaves the third fact, the two-hour drive and the hundred-dollar test. Which of the five groups does it belong in? Take a few seconds.

*(Pause)*

**Sarah:** Socioeconomic and structural. It's about money and about access to services, the same group as access to health care and access to clean water. A family that knew all about well testing and wanted to do it would still face the drive and the cost.

**Kiffer:** That's where I'd put it. Now watch the factors work together. Suppose the health unit mails the family a pamphlet about well testing. The parents now know. The drive is still two hours, the test still costs a hundred dollars, the neighbours still don't test, and no rule prompts them. The pamphlet changed one of the five facts. Three of the others still hold the behaviour in place, and the arsenic is still in the rock, which is why any of this matters.

**Sarah:** Question three. Education-only programs for obesity had moderate short-term success and didn't hold up in the long term. The obvious fix seems to be to keep the education and add an environmental program alongside it. Why doesn't that necessarily solve the problem?

**Kiffer:** Because behaviour and environment act on each other. Two programs that run side by side without being designed together can each stall on a barrier the other one never touches. An ecological intervention designs its parts so that a change in the environment supports a change in behaviour.

**Sarah:** Then let's appraise a package and see whether its parts actually connect.

**Kiffer:** Here's a made-up one. A city of about eighty thousand people wants more residents to cycle to work, and it runs three things. One is a spring media campaign about the health benefits of cycling, aimed at the whole city. The second is a new protected bike lane along the waterfront, which is mostly a weekend recreation route. The third is a bike-to-work week with prizes for employees at city hall, which sits across town from the waterfront.

**Sarah:** On paper that looks ecological. There's an individual-level message, a change to the built environment, and something organizational at a workplace.

**Kiffer:** It does touch three levels. Here's the question for listeners. Do the three parts of this package support each other? Take a few seconds.

*(Pause)*

**Sarah:** They don't support each other. The lane doesn't connect where people live to where they work, so the campaign is asking people to ride routes that haven't changed. The campaign talks about health benefits, when the major factors in whether people take up regular activity are cost, time, safety and access. And the bike week is at a workplace the new lane doesn't reach. I'd change the lane first, although before that I'd want to find out what the barriers actually are.

**Kiffer:** That's the identify step from the three-step logic, and it comes first. Suppose a made-up survey of commuters finds two main barriers. There's no safe route from the two largest residential neighbourhoods to downtown, and the larger employers have no showers. What would the package look like then?

**Sarah:** Build the protected lane on the commuter corridor between those neighbourhoods and downtown. Work with the biggest employers along it to add showers, change rooms and secure bike parking. Aim the campaign at people who live along the new corridor, and make the message about the new route and the new showers, since those were the barriers. Then run the bike-to-work week at those employers in the month the lane opens. Each part now makes the others more likely to work.

**Kiffer:** That's an ecological intervention. The lane makes the message believable, the message brings people to the lane, and the showers remove the last barrier at the other end of the trip.

**Sarah:** I want to push back on the model a little here, though. If everything interacts with everything, how does anyone know where to start?

**Kiffer:** That's a standard criticism of ecological models. A 2020 handbook chapter by Jo Salmon and colleagues notes that many ecological models lack the specificity of behavioural theories, and that they've often been paired with theories such as social cognitive theory. I think that's fair. I see the ecological model as a framework for assessment, broad on purpose. The specific answers come from the assessment and from the theories chosen to fit it, which is why the three steps run in the order identify, choose, design.

**Sarah:** Question four, and this is our harder example. Can the parts of a multilevel package undercut each other? Kiffer, set it up.

**Kiffer:** Here's a made-up neighbourhood in a mid-sized city, where fights involving young people aged fourteen to nineteen have been rising. An invented assessment found five things. Part-time jobs for teenagers are scarce. In one group of older teens, backing down from an insult costs you standing. Many students say they've seen someone seriously hurt nearby. The community centre closes at six and runs nothing for teenagers. And the students involved in fights are mostly ones who've already fallen behind at school.

**Sarah:** Let me sort those and match them to explanations where I can. Scarce jobs are socioeconomic and structural, which is where the socioecological explanation puts the cause. The rule about backing down is a social and group factor, one of the codes of the street. Seeing someone hurt reflects neighbourhood violence, a social stressor in the socioeconomic and structural group, and it's a risk factor in the risk and protective factor explanation. The centre's hours are structural too, a matter of access to services. And falling behind at school is an individual factor that fits the self-concept explanation. If school doesn't seem to lead to any future you can picture, violence can become another route to standing.

**Kiffer:** That's a careful sort. Now here's the proposed package. First, a classroom curriculum modelled on the Fourth R, the grade nine program from Ontario, which uses role play to teach students to respond to provocation without aggression. That draws on the social-cognitive explanation. Second, a drop-in program at the community centre from after school until nine at night, with mentors and help finding part-time work. Third, the school board adopts a zero-tolerance rule, under which any student involved in a fight gets an automatic five-day suspension.

**Sarah:** That covers three levels. There's individual skill building, community and structural support, and a school policy, which I'd put with the political factors, or at the organizational level in the McLeroy scheme.

**Kiffer:** Here's the question for everyone listening. Which component in this package undercuts another one, and how? Take a few seconds.

*(Pause)*

**Sarah:** The suspension rule. The students most likely to be suspended are the ones already involved in fights, who are exactly the ones the other two components most need to reach. A suspended student misses the classroom sessions and spends the school day outside any supervised setting, since the drop-in doesn't open until school is out. And connection to school is one of the protective factors. The rule cuts that connection for the same young people the mentors are trying to connect.

**Kiffer:** And it feeds the self-concept problem you found. A student who was already behind loses another week of school, and a future built on school looks further away. So for the young people at highest risk, the policy level pushes them out of the settings the other two levels depend on.

**Sarah:** So how would you make the three reinforce each other?

**Kiffer:** I'd keep a clear response to fighting and change what it does. A student involved in a fight stays in a supervised setting at school, and a referral to a drop-in mentor becomes part of the response. The mentors practise the same role-play skills the classroom teaches, so what students learn in class gets rehearsed where the conflicts happen. And because standing in that peer group is part of the problem, I'd recruit older teens that group respects as peer leaders at the drop-in, so a calm response doesn't cost anyone status.

**Sarah:** And the job help gives young people a possible self worth protecting.

**Kiffer:** Those supports matter for the classroom piece too. In the 2009 Ontario trial of the Fourth R, David Wolfe and colleagues reported less physical dating violence, and the effect on peer violence wasn't statistically significant. So for neighbourhood fights, the classroom piece leans on the others.

**Sarah:** And the suspension rule belongs to the school board, a different organization from the one running the drop-in, which makes the conflict easy to miss.

**Kiffer:** That's why the identify step should include every interest holder whose rules touch the problem, the school board included. Then check each pair of components and ask whether one makes another harder.

**Sarah:** Okay. Now the part where Kiffer and I don't entirely agree. My worry is that programs aimed at individuals put too much weight on personal responsibility. The Lalonde Report is a good example. In 1974, Marc Lalonde, then the federal Minister of National Health and Welfare, set out a health field concept with four elements: human biology, environment, lifestyle, and the organization of health care. Giving lifestyle its own box invited programs aimed at personal choices. By 1977, Robert Crawford was calling this kind of thinking victim blaming.

**Kiffer:** That's a fair reading of the history. Where do you see the same problem in programs today?

**Sarah:** Think about the fly-in community case from the lesson. In remote northern communities, feeding a family can cost about twice what it costs in the south. A workshop on healthy choices there puts the weight of a structural problem on the people living with it.

**Kiffer:** I agree that's a real risk, and the critique of the lifestyle box is fair. Where I'd push back is on writing off individual-level work. Structural changes still depend on people acting. In January 2018, British Columbia began providing pre-exposure prophylaxis, or PrEP, at no cost to people at high risk of HIV. That removed a cost barrier at the structural level. People still have to get tested, start the medication and keep taking it. Programs that help with those steps work at the individual level, and they help the structural change pay off.

**Sarah:** That example supports my side, though. In your example, the individual-level work comes after the barrier is removed. In a lot of programs, the message is the whole program.

**Kiffer:** That's fair, and it's where we overlap. The McLeroy paper I mentioned made both points. It assumed that changes in the social environment produce changes in individuals, and that the support of individuals in the population is essential for putting environmental changes in place. The Ottawa Charter in 1986 listed developing personal skills as one of its five action areas, and the other four reach well beyond the individual. I'd keep individual-level programs as one part of a package that also changes the level where the main barrier sits.

**Sarah:** I'd go further than that. If a health unit can afford only one thing, I'd want a strong reason before it chose a message. Messages are cheaper and easier to run, and I suspect that's part of why they get picked.

**Kiffer:** I think that's a reasonable default when the barrier is clearly structural, and I wouldn't argue with it there. Where the main barrier is a gap in what people know, such as not knowing that a free service exists, a message may be the right single choice.

**Sarah:** So here's the rule we agree on. Before funding anything aimed at individuals, name the level where the main barrier sits. If it sits above the individual, the individual-level piece goes in only alongside a change at that level, designed to support it.

**Kiffer:** Let's pull it together with three things to take away from this episode.

**Sarah:** First, health behaviour is a category, and the label says nothing about motive. The same behaviour can be driven by health, by health mixed with other concerns, by something unrelated to health, or by a different idea of health, and sometimes circumstances matter more than any motive.

**Kiffer:** Second, sort influences carefully, and watch the word environment. In the model's definition it means everything outside the individual, and as one of the five groups it means physical conditions. Where you file a factor shapes who you think can change it.

**Sarah:** And third, an ecological intervention designs its parts at different levels to support each other. Check every pair of components, because a part at one level can undo a part at another, the way a suspension rule can push young people out of the settings a drop-in program is trying to bring them into.

**Kiffer:** If you'd like more practice, go back to the private well problem from this episode. Rewrite the five facts for a family in a different setting, sort each one into a group, and then say which facts a pamphlet would change and which it would leave in place.

**Sarah:** Next time, it's Lesson two, Social Behavioral Theory and Its Roots, where we ask what a theory actually is, how it's tested, and where behavioural theory came from.

**Kiffer:** Take care, everyone.

**Sarah:** See you in Lesson two.