Social Networks, Health Beliefs, and Preventive Health Behavior

Author(s): Jean K. Langlie

Reviewed work(s):
Source: Journal of Health and Social Behavior, Vol. 18, No. 3 (Sep., 1977), pp. 244-260
Published by: American Sociological Association
Stable URL: http://www.jstor.org/stable/2136352 .
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244 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
191-205in BarbaraSnellDohrenwend and and abruptcoronarydeath." Archivesof
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1974 "Recentlifechanges,miocardial infarction,

SOCIAL NETWORKS, HEALTH BELIEFS, AND

PREVENTIVE HEALTH BEHAVIOR *
JEAN K. LANGLIE
SyracuseUniversity

244-260
ofHealthandSocialBehavior1977,Vol. 18(September):
Journal

Multiple regressionanalysesareusedtoassess theabilityoftheHealthBeliefModeltoaccount

forobservedvariation in a varietyofpreventivehealthbehaviors(PHB) in a sampleofurban
adults(N = 383).In additiontotheimpactofthesocialpsychological attributespositedbythe
HealthBeliefModel,theeffects socialmilieuonPHB aremeasuredwithand
oftheindividual's
without controlsforage, gender,and situationalfactors.Theindependent variablesare tested
inrelationtotwodifferent kindsofPHB. Onedependent measureis labelledIndirectRiskPHB;
thisis a scale composedofindicators forseatbeltuse,exerciseandnutrition medical
behavior,
checkups,dentalcare,immunizations, and miscellaneousscreeningexams.Theotherdepen-
dentmeasureis calledDirectRiskPHB andincludesdriving andpedestrian behavior,personal
hygiene, andsmoking behavior. andsocial-group
Bothsocial-psychological are
characteristics
important inaccounting fordifferences RiskPHB, butexertlittleinfluence
inIndirect onDirect
RiskPHB. Conversely, appropriate DirectRiskPHB is stronglyassociatedwitholderage and
femalegender,althoughsomeofthesocial-psychological continueto havea small
attributes
independent effecton thiskindofPHB. A newmodelofPHB is tentatively proposedinorderto
accountfor thebi-dimensional characterof PHB and for differencesin theconsistency of
people's behavior.

In 1966 Rosenstocksummarizedthe not). Since thattime,the Health Belief

on the use of preven-
availableliterature
tive healthservicesand concludedthat
differences in individual social-
psychological providethe
characteristics
best answer to the question of "why
peopleuse healthservices"(and somedo
* The datareportedherewerecollectedunderthe
auspices of the Officeof Community Research,
RockfordSchool of Medicine,Rockford,Illinois.
For helpfulcomments on earlierdrafts,I am espe-
cially gratefulto David Mechanic,University of
Wisconsin, andto JuliaMakarushka, SyracuseUni-
versity.
Model has become the predominant ex-
planationnot-onlyfordifferences in the
preventive use of healthservicesbutfor
differencesin preventivehealthbehavior
(PHB) in general.This model assumes
that"good health"is a goal moreor less
commonto all andthatdifferences inPHB
are due to differingperceptionsthatim-
pingeon the individual'smotivations to
engagein actionand on themorespecific
decisionsofwhataction(s)to taketo most
effectivelyreachthisgoal.
Less systematically developed is the
 SOCIAL NETWORKS
view thatvariationsin PHB are due to ceived vulnerability to and theperceived
differingcharacteristicsof the social seriousnessoftheconsequencesofincur-
group(s)withwhichtheindividual is affil- ringa.diseaseheighten the"psychological
iated,ratherthanto his or her personal stateofreadinessto takespecificaction,"
attributes. Originally employed by and (2) givena highstate.of "readiness,"
Suchman(1964),thismodelhas no agreed thespecificdirection actiontakesdepends
upon name but will be called the Social on the individual's beliefs abouttherela-
NetworkModel in the followingdiscus- tive effectiveness and the availabilityof
sion. alternativeactions known to the indi-
WhilemoststudiesofPHB haveexclu- vidual(perceivedbenefits andcostsofac-
sively employed social-psychological tion)(Rosenstock, 1966:98-99).
as theindependent
attributes variable,the An additionalclass ofvariablesconsist-
few studies that have also included ingof internal or externalcues is hypoth-
social-group propertiesgenerally findthat esized to be necessaryto convertintent
bothkindsof independent variablescon- .intoaction(Rosenstock,1966:101).Cues
tinueto havea significant impacton PHB per se are notmeasuredin thisstudy,nor
whentheotheris controlled (e.g., Moody is "perceived seriousness of conse-
and Gray, 1972; Tash et al., 1969; Bul- quences"; the formerare .difficultto
lough,1972); thus,it is improbablethat measurein cross-sectional researchand
therelationship betweenPHB andtheSo- thelatterhas notbeensuccessfully related
cial NetworkModel is spurious(and, to PHB in previousstudies(Beckerand
therefore, possible to ignore).It is also Maiman,1975).
unlikelythattheHealthBeliefand Social The findings ofstudiesusingthe.Health
NetworkModels exertcompletelyinde- BeliefModelaregenerally with
consistent
pendentinfluences on PHB sinceseveral thetheory(Rosenstock,1966;Beckerand
of their component variables are Maiman, 1975; althoughKirschtet al.,
related-e.g., feelings of "powerless- 1966,reporta negativecase), butthepro-
ness" to controleventshave been found portionofvariancein PHB accountedfor
to be inverselyrelatedto SES (Rotter, is fairlysmall.In an effort to improvethe
1966)and to social participation (Moody predictive power of the model, modifying
and Gray,1972). The present study sys- variables have been suggested.
tematically uses multivariate analysesto The most successfullyused of these
clarifythe directand indirecteffectson modifyingvariables is the personality
PHB oftheHealthBeliefand Social Net- characteristic of"perceivedinternal locus
workModels. In addition, the impact of of control" (PIC-a concept originally
individualvariablesfromthesemodelsis developedbyRotter,1966,ina non-health
examinedin orderto begina theoretical context)whichis analogousto "aliena-
reformulation ofthedeterminants ofPHB. tion" (in the sense of powerlessness;
Unlikemostpreviousstudies, PHB is rep- Seeman, 1959). The hypothesisis that
resentedby a wide varietyof behaviors personswho view themselvesas having
ratherthanbya singleindicator or kindof somecontroloverwhathappensto them
behavior.Thisallowsa morerigorous test are likelyto perceiveactionas efficacious
of the hypothesized relationships which and are morelikelyto perceiveand proc-
should providenot only theoreticalbut ess information relevantto engagingin
practicalinsightsforthose interestedin specificactions(Seeman, 1963).
increasingthe proportionof persons Kegeles(1969)suggeststhat"saliency"
engagingin appropriate PHB. ofhealthmaybe an important modifierof
theHealthBeliefModel;he hypothesizes
themotivation to engageinPHB may
Hypothesesto be Tested:A Reviewofthe that be operativeonlyamongthoseforwhom
Literature vis-
healthis salient,or has highpriority
The HealthBeliefModel specifiestwo a-visotheractivitiesin life.
basic typesof beliefswhichare hypoth- Presumably, personspossessingall of
esizedto motivate individuals toengagein the specifiedsocial-psychological attri-
particularpreventivebehaviors:(1) per- butesare mostlikelyto engagein appro-
246 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
priatePHB; thosepossessingnonearethe tive variableis differential propensity to
least likely,and thosewithintermediateinteract(in formalorganizations). Sallo-
valueson-all or highon somebutlow on way and Dillon (1973) presentsome evi-
otherswill have intermediate levels of denceto supportthehypothesis thatfre-
PHB. quent interactionwith non-kin(as op-
posedto relatives)is positively associated
with PHB.
The Social NetworkModel of PHB
Whilerelationships betweenPHB and
In spiteof thelip servicethatvirtually single social-groupvariableshave been
everyonepays to theimportant influence exploredpreviously, theirjointimpactis
thatthefamily and itskinship,friendship,unknown.Giventherudimentary theoret-
andorganizational networks arepresumed ical development of the Social Network
to have on individualbehavior, few Modelandthecrudelevelofmeasurement
studieshave systematically specifiedthe of some of these variables (especially
relationships betweensocial groupprop- family/conjugal structure)in this study,
ertiesand PHB (McKinley,1972:129). the reportedresultscan provideonly a
Perhapsthebest knownof the studies tentative assessmentof theutility of this
linkingsocial-group properties to PHB is modelratherthana comprehensive testof
thatof Suchman(1964,1972)whohypoth- its influence on PHB.
esized thatindividualswho belongto a Futureresearchshouldbe able to esti-
"parochial" social group (indicatedby mate the magnitudeof the impactthat.
ethnicexclusivity,friendship solidarity, social-groupcharacteristics exerton PHB
and traditional/authoritarianfamilyrela- and specifythe mannerin whichthese
tions)are morelikelyto have "popular" characteristics actuallyinfluence theindi-
health orientationsand, therefore,are vidual'sPHB. At thispointthe modeof
muchless likelyto adhereto thenormsof influence is open to speculation.One hy-
themedicalprofession concerning appro- pothesisis thatsocialgroupsdiffer bothin
priatePHB thanare thoseaffiliated with termsoftheirnormsregarding PHB andin
"cosmopolitan"social groups. theirabilityto exertpressureto conform
More recentstudieshave successfully to thesenorms;thushighSES and "cos-
employedsomewhat socialgroup mopolitan"groupsare assumedto have
different
propertiesto accountfor differences in PHB normsthataccordwiththoseof the
PHB. Pratt(1972)foundthatcoupleswith medicalprofession and by virtueof their
traditionalconjugalrelationships (unequal greaterpropensity forinteraction outside
powerin decisionmaking,strongsex role thefamily circleare able to exertpressure
differentiation,and low companionship)to conformwith these norms (Green,
havemuchpoorerPHB whenSES is con- 1970b; Suchman, 1964). Alternatively,
trolledthando coupleswithmoreegalita- possessingspecificinformation improves
rianconjugalrelations.Moststudieshave PHB (Leventhal,1970)and particular in-
found strongpositive associations be- teractionpatterns(withinthe egalitarian
tweenSES and PHB, even whereno fi- household,withnon-kinratherthankin,
nancial outlays are required (Nikias, etc.) mayprovideinformation ofpractical
1968). Green (1970b) hypothesizesthat utilitysuch as how to preventdisease,
thisrelationship is due to botha higher whereto go forpreventive services,etc.,
propensityfor interaction with non-kin ratherthantransmitting normsor exerting
and moreappropriate PHB normswithin pressuretoconform (SallowayandDillon,
the highersocial strata; unfortunately,1973; Pratt, 1972). Our data cannot
PHB normsarerarelymeasuredandthere providea resolution to thisproblem.
is some evidencethattheydo not differ Demographiccharacteristics may also
verymuchby SES, race,or ethnicgroup influencePHB; youngeradults,whites,
(cf., Dodge, 1970; Brunswick, 1969; and womenappearto have higherutiliza-
Freidsonand Felman,1961;Goeringand tionratesforpreventivehealthservices
Coe, 1970). Moody and Gray (1972) (Rosenstock,1966:96).Yet demographic
suggestthattherelationship betweenSES characteristics are not alwayscontrolled
and PHB is spuriousand thattheopera- in PHB research(Fabregaand Roberts,
 SOCIAL NETWORKS 247
1972:221);norhave thesevariablesbeen manualjobs. Inflation between1970and
theoretically incorporated intoeitherthe 1973morethanaccountsforthedifference
HealthBeliefor Social NetworkModels. inmedianfamily income.Nonrespondents
The "situationalcontext" -in the sense were similarto respondents in termsof
ofheavyroutineobligations on one's time sex,butweremorelikelytobe overage 65
and energy (two jobs, large family, (17percentversus13percent), morelikely
etc.,)-may also limittheopportunities or to be out of the labor force(39 percent
increasethe costs of PHB. These con- versus34 percent)and,ifemployed, were
straintshave not been previouslyex- less likelytobe inprofessional/managerial
plored. occupations(23 percentversus 27 per-
The presentstudyreteststhezero-order cent).
relationships betweenPHB and theinde-
pendentvariablesspecifiedin the litera-
ture,controlling forage, sex, and situa- OperationalDefinitions of the Variables
tionalcontext.However,theprimary task The dependentvariable,PHB, is de-
is to findout whetherthe individual's finedhereas anymedically recommended
social-psychologicalattributescontinueto action,voluntarily undertaken bya person
have an impacton PHB whenthe social who believeshimselfto be healthy,that
group characteristics are held constant tends to preventdisease or disability
and, ifso, whichspecificattributes inde- and/ordetectdisease in an asymptomatic
pendently or jointlywithSocial Network stage.This is a modification of Kasl and
variablesaccountforobserveddifferencesCobb's definition (1966:246).
in PHB. MoststudiesofPHB haveused a single
behavior(or, at most,two or morebe-
haviorsfromthe narrowrangeof utiliza-
METHODS
tionof preventive healthservices)as the
A 14-pagequestionnaire was mailedto dependent measure;themajorexceptions
a systematic randomsampleof theadult are the studies by Pratt (1971) and
populationof Rockford,Illinois,in the Williamsand Wechsler(1972).The use of
springof 1973. A preliminary letterex- a singledependentmeasure,withtheas-
plaining thattheresearchwas beingspon- sumptionthata givenbehavioris repre-
sored by the new RockfordSchool of sentativeofthe(unidimensional) universe
Medicinewas sentto the 617 personsin of PHB has been severlycriticizedby
thesampleone weekpriorto mailingthe several researcherswho contend that
questionnaire.Telephone and personal PHB maywellbe composedofessentially
follow-upswere made untila response independent behaviors(cf. Freemanand
rateof 62 percent(N=383) was reached Lambert, 1965; Steele and McBroom,
approximately monthslater.
41/2 1972;Williamsand Wechsler,1972).
Comparedto thetotaladultpopulation In thisstudy,PHB is measuredby 11
of the RockfordUrbanArea (U.S. Cen- additivescales representing (1) Driving
sus, 1972),the respondents in thisstudy Behavior(signalsturns,doesn'tspeed,no
are morelikelyto be female(59.4 percent ticketsformovingviolations),(2) Pedest-
versus53.6percent),tohavesomecollege rian Behavior (doesn't jaywalk/cross
education(27.9 percentversus 19.4 per- streetagainstlights),(3) Smoking(packs
centof thoseage 25+), and to be under of cigarettes/day), (4) Personal Hygiene
age 65 (86.6 percentversus83.9 percent). (washeshandbeforetouchingfood/after
Differences in employment (66.3 percent usingtoilet,doesn't sharedrinking cup/
versus60), typeof occupation(55.3 per- hairbrush/towels, avoidscoughing people,
centnonmanual versus48.3), and median doesn'tpick pimples),(5) Seat Belt Use
familyincome ($11,298versus $10,934) (usuallywearson highway/in town,wore
are more apparentthan real. The U.S. yesterday),(6) Medical Checkups (re-
Censusfigureson employment and occu- cencyofroutinephysical,usualreasonfor
pationinclude16to 18yearolds-a group visitingdoctor, voluntaryor pressured
notincludedin thesample-whoare least routinevisits),(7) DentalCare (frequency
likelyto be employedor to hold non- of toothbrushing, recencyof dentalcheck-
248 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
up, usual reason for makingvisit, (8) scales, are the operationalmeasuresof
Immunizations (recencyofpolio,tetanus, PHB.
fluand smallpoxvaccines),(9) Screening In addition,respondents wereclassified
Exams (recencyof hearing,vision and as behaviorally consistent ifat least8 out
T.B. tests), (10) Exercise (numberof of the 11 subscalescoreswere: a) above
blockswalkedyesterday, choosesto walk themeanforhis/her. sex (consistently high
to thirdfloorratherthan-use elevator), PHB), b) belowthemean(low),orc)-within
and (11)Nutrition (VitaminC, VitaminA, one standard deviation of the mean
and proteinintake). (medium). If the scores were about
Examinationof the intercorrelations equallydistributed(some 2 s.d.'s below
amongthese 11 scales revealedthatpre- themean,someabove, etc.), or ifthere-
ventivebehaviorsare notindependent of spondentwas missingmorethanone sub-
one another.However,ratherthancon- scale score, he/shewas classifiedas be-
stitutinga singlephenomenon, PHB ap- haviorallyinconsistent.Amongthe be-
pearsto have twodimensions: scales 1-4 haviorallyconsistent,Directand Indirect
formone constellation, whilescales 5-11 Risk PHB are.postivelycorrelated(.38),
formanother(Table 1). In thecase ofthe of course. However, ratherthan being
former dimension, inappropriatebehavior randomlyinconsistent, thesedimensions
involvesa directrisk (e.g., drivingor are inversely correlated(-.39) amongthe
walkingrecklesslyor puttingyourselfin behaviorallyinconsistentgroup. Since
contactwithsmokeor germshas a direct somewhatdifferent variablesare associ-
potentialforproducing injuryor disease); ated withthe two kindsof PHB and the
these4 behaviorscales are combinedinto relationships differwithintheconsistency
a "Direct Risk" PHB Scale. Failureto groups,analysesare runseparately rather
followmedicalrecommendations in the thanforthesampleas a wholeorforPHB
case ofthe7 behaviorscomposing thelat- per se.
terdimensionis nothazardousin and of The Health Beliefvariablesare meas-
itselfin the Americancontext(failureto uredby additivescales also. The format
be immunizedcould be a directriskin developedbyGochman(1970)was usedto
somesocieties);thistypeofbehaviorhas measureperceivedvulnerability; respon-
been labelled "Indirect Risk" PHB. dentswereasked: "Duringthenextyear,
Thesetwocompositescales,composedof how likely are you to .... (be in a car
standardizedand equally weightedsub- accident,be so sick you can't do your

TABLE 1. ROTATED FACTOR STRUCTURE OF 11 SPECIFIED BEHAVIOR

SCALES (PRINCIPAL COMPONENTS, OBLIQUE ROTATION) *

Behaviorally Behaviorally
Total Sample Consistent Inconsistent
BehaviorScale I II III (h2) I II (h2) I II III (h2)
Pedestrian -.00 -.69 .13 .49 .11 [.67 .45 -.73 -.35 .06 .65
Driving .17 - .57 .14 .37 .22 .61 .37 _-.59 .13 .05 .35
Hygiene .29 -.50 .31 .38 .42 .60 .43 -.55 .13 .06 .33
Smoking .12 -.12 .35- .14 .34 .33 .17 .02 -.02 -.27 .08
Immunizations .29 .38 .22 .24 .46 -.08 .26 -.07 .32 .49
DentalCare .57 .21 .51 .45 .68 .26 .46 .40 [53 .16 .42
MedicalCheckups .64 -.07 .24 .42 .52 .36 .31 .00 .5S9 .29 .37
Misc.Exams .57 .02 .19 .33 .52 .26 .29 .06 .37 | .45
Seat BeltUse .27 -.05 .48 .23 .63 .29 .41 -.00 -.09 -.16 .03
Nutrition .14 .05 .49 .25 [ 50 .20 .26 .13 -.23 -.20 .09
Exercise .21 .25 .17 .11 .29 .04 .09 .39 .21 .01 .19
21.0 17.6 10.6 49.2
PercentageVariance: 29.7 13.8 43.5 23.1 15.2 10.1 48.4
* Loadingsgreaterthan?.45 areemphasizedin boxes.
 SOCIAL NETWORKS .249
regularworkfora week,getcancer,getan above .70 and thediscriminant validity-
electricalshock, become too fat or too calculated according to Bohrnstedt's
thin,sprainyourankle,have hearttrou- (1969) method-is fairly good (i.e.,
ble, feel nervous,get polio, have gum covariationis less than.36 in all cases.)
trouble,take a bad fall, feel tiredand The Social Networkvariables were
listlessforseveralweeks,gettetanus,get operationalized in the followingmanner.
T.B.)?" The perceivedbenefitsof PHB Neighborhood SES is measuredby a fac-
scale is based on theextentof agreementtorscoreforthecensustractinwhichthe
withstatements concerningthe potential respondent resides;thesescoresarebased
healthbenefits ofbrushingteethaftereach on Cowen's (1973)analysisof25 commu-
meal,eatingthe"rightfoods,"eatingfruit nityvariables.The FamilySES scale is a
daily,eatingvegetablesdaily,dailyexer- modification of Green's(1970a) in which
cise, enoughsleep,sharingdrinking cups, SES = .5 (respondent's education) + .3
dentalcheckups,wearingseat belts,an- (occupation)+ .3 (familyincome)[or .7
nual T.B. tests,immunizations, and an- (education)+ .4 (income)whereoccupa-
nual physical exams. The perceived tionis unknown].Siegel's (1971)occupa-
barrierslcosts of PHB scale also consists tionalprestigescoresweresubstituted for
of 12 items; respondentswere asked: theU.S. Censusscoresandthefamily was
"How difficult woulditbe foryouto... assignedthehighestprestigescorepossi-
(wear seat belts, exercise, get annual ble ratherthanautomatically usingtheoc-
physicalexam, wash your hands after cupationofthemaleheadofhousehold.In
usingtoilet,eat proteinfoodstwicea day, thissample,theweighted and unweighted
getT.B. tests,getvariousimmunizations,SES scales correlate.99.Non-kininterac-
avoid sharing drinking cups,dentalcheck- tionis a scalebasedon howfrequently the
ups, eat fruittwicea day, eat vegetables respondent interacts with neighbors,
twice a day, and wash hands before friends,and people who live outsidethe
eating/preparing food)?" A slightlymod- county.Kin interaction is represented by
ifiedversionofAndersen's(1968)"Value a singleitem.Dummyvariableswerecon-
ofGood Health" scale was used to meas- structedto indicate4 patternsof interac-
ure saliency.Two PIC scales were con- tion:social isolation,frequent interaction
structed usingitemsprimarily drawnfrom withkin only,frequentinteraction with
theindexpresented byDabbs andKirscht non-kin only,or frequent interactionwith
(1971:960);First-Person PIC is based on bothkinand non-kin.Conjugalstructure
the extentof agreementwithfive state- is crudelymeasuredby3 dummy variables
ments(e.g., "I workat it to stayin good (single, egalitarian/wife works, and
health"),whileThird-Person PIC is com- traditional/wife doesn'twork).A reexam-
posed of responsesto 8 statements (e.g., inationofSuchman'sdata(1964)indicated
"People have no controlover whether thatreligion-rather thanethnicity-may
they become sick or not.") Attitudes be an important variable;regardlessof
towardprovidersof health services is ethnicidentification, non-Catholics in his
measuredbyextentofagreement withtwo samplehave moreappropriate PHB and
statements: "I dislikegoingto visit. . . more "cosmopolitan" social networks
(the doctor, the dentist)." Positive or thando Catholics.Therefore, religiousaf-
negativeattitudestowardprovidersmay filiation (dichotomizedas Protestant/
reflectpriorhealthbehavior/experiences non-Protestantdue to thesmall- number of
whichseveralstudiessuggestare impor- thelatter)is includedin thisstudy.
tantinfluenceson presentPHB (Leven- Situationalcontextis represented by(a)
thal, 1970: Kreisberg and Treiman, a BusynessScale based on numberofde-
1960:161;Gochman,1972:292;see Dabbs pendentsin thehouseholdand numberof
and Kirscht,1971,fora negativefinding); instrumental taskstherespondent has and
in any case, negativeattitudeswouldbe (b) residentialmobilitywithinthe past
an emotional"barrier"to use of health year.Age andsex are includedas control
services. variables,but not race due to the ex-
The internalreliabilities(Cronbach's tremelysmall numberof nonwhitere-
Alpha)of theHealthBeliefScales are all spondents.
250 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
Data AnalysisProcedures PersonPIC are inversely relatedto Direct
The hypotheses Risk PHB, contrary to the hypothesis.
are testedby meansof
correlationanalysis,bothzero-order and It is clear (Column 2) that despitesig-
multiple."CommonalityAnalysis" was nificant zero-order correlations, notall of
used to assess therelativecapabilitiesof the independent variablescontinueto be
the modelsto accountindependently for significantly relatedto PHB when con-
thevariationin PHB. Thisis a methodto trolled for the effectsof theothersocial-
determinethe relative importanceof psychological characteristics. In particu-
explanatory variablesin nonexperimentallar, the perceivedvulnerability and sa-
researchwhere intercorrelations among liency variables do not make a singificant
-independent variablescause difficulties in impacton PHB; theyare not highlyre-
interpretation.The commonvarianceis lated to any of the otherattributes, and
equal to the total explained variance dropping themfromthemodel(column3)
minusthe sumof theproportion of vari- does not significantly reducethepropor-
ance uniqueto each model;in the three tion of variance in PHB explained.
variablecase, the uniquecontribution of Basically, the multivariate analysis
variable 1=R 2 -R 2 (Kerlinger and indicates (columns 4 and 5) that the
Pedhazur,1973:298). Pair-wisedeletion specific social-psychological attributes
of missingcaseswaschosensincemissing thataffectPHB are (a) theperception that
data do not seem to be concentrated by one has some control over one's health
case or by variable. (withtheexceptionof IndirectRiskPHB
Parametricstatisticsareusedsincethey amongtheinconsistents), and (b) theper-
providea more'-powerful" tooland there ception that the benefits of PHB are high
is apparently verylittleerroreven when or thatthe costs (includingattitudesin
theassumption of an interval-level meas- relationto IndirectRiskPHB) are low,or
urement scaleis violated(Labovitz,1967). both.Together,thislimitedset of social
Each bi-variaterelationship was examined psychologicalvariables accounts for a
forcurvilinearity; thelack ofa significantsignificant and fairlysubstantial(19 per-
linear relationshipin the following cent to 34 percent) proportion ofthevari-
analysisis notdue to curvilinearity. ance in PHB, compared to previous
studies.
I Ofthedemographic andsituational con-
text variables,only age is related(in-
FINDINGS
versely)to IndirectRisk PHB and then
HealthBeliefsand PHB onlyamonginconsistents. Controlling for
age does not alterthe relationships be-
The Health Belief Model, including tweenthe social-psychological variables
modifications, predictsa positiveassocia- and the IndirectRisk PHB of inconsis-
tion betweenPHB and high perceived tents.Although thedemographic and situ-
vulnerability, highperceivedbenefitsof ationalvariablesare significantly related
PHB, low perceivedbarriers to PHB, "in- to DirectRisk PHB, holdingthemcon-
ternality,"saliency of health,positive stant cancels only the relationshipbe-
attitudestowardsprovidersof care, and tweenPIC and DirectRisk PHB among
the total numberof appropriatesocial thebehaviorally inconsistent.
psychological characteristics possessed. The datasupportthehypothesis thatthe
Amongthebehaviorally consistent, the greaterthenumberof appropriate social-
hypothesized zero-order relationships are psychologicalcharacteristics possessed,
generally supported byourdata;themajor themorelikelytheindividual is to engage
exceptionis that low ratherthan high in PHB. This relationship is more pro-
levelsofperceivedvulnerability are asso- nouncedamongconsistentsthanamong
ciatedwithappropriate PHB (Column1, inconsistents and forIndirectthanforDi-
Table 2). Amongthebehaviorally incon- rectRiskPHB. Possessionofa particular
sistent,social-psychological attributes are constellation of attributes is moreimpor-
less-likelyto be relatedto PHB and both tantthanquantity per se, however.Re-
attitudestowardsprovidersand Third- gardless of their scores on the other
 TABLE 2. RELATIONSHIPS OF HEALTH BELIEF VARIABLES TO INDIRECT AND DIRECT RI
(PHB), ZERO-ORDER AND MULTIVARIATE

Consistents
TypeofPHB (1) (2)4 (3)a (4)' (5)b (1)
andVariables r Beta Beta Beta Beta r
IndirectRisk PHB
HighVulnerability -.26* -.09 -.05 -
HighSaliency .22* .06 -.05
Low Costs .36* .14* .17* .17* .19* .10
HighBenefits .29* .07 .07 .18*
PositiveAttitudes .41* .27* .29* .29* .28* .36*
Third-PersonPIC .29* .12 .14* .16* .17* .03 -
First-Person
PIC .40* .23* .23* .26* .25* .03 -
R2 .344 .332 .328 .335
df 7/202 5/205 4/206 4/207 7
F-Ratio 15.126* 20.450* 25.134* 26.040*
DirectRiskPHB
HighVulnerability -.17* -.10 .06
HighSaliency .20* .09 .08
Low Costs .26* .11 .14* .15* .14* .02 -
HighBenefits .22* .05 .05 .13* .15*
PositiveAttitudes .14* .00 .02 -.17 -
Third-PersonPIC .09 -.08 -.05 -.21* -
First-Person
PIC .42* .36* .37* .38* .36* .28*
R2 .220 .204 .200 .218
df 7/202 5/205 2/208 3/207 7
F-Ratio 8.133* 10.521* 25.983* 19.181* 3
* at .05 level.
Significance
The PerceivedCosts and PerceivedBenefitsvariablesare represented by the generalscales in the regres
b PerceivedCosts and PerceivedBenefits
are represented
by thespecificscales concerning
IndirectRisk PHB or
252 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR -
scales, 85 percentof thosepersonswho (18 percentto 28 percent)ofthevariance
score above the mean on the Perceived (column3).
Benefits,Perceived Barriers,and Atti- The hypothesisthat the greaterthe
tudesScales (N=73) have above average numberof "cosmopolitan"-type group
IndirectRisk PHB comparedto only 19 characteristics,thebettertheindividual's
percentof those who score low on all PHB, is supportedin thecase of Indirect
threeof thesescales (N=42). (Tables not Risk PHB but not in the case of Direct
shown). Risk PHB. Personswho are Protestants
and who scoreabove themeanon Neigh-
Social Networksand PHB borhood SES, Family SES, and Fre-
quencyof non-kin interaction (N=50) are
According to the Social Network muchmorelikelyto have above average
Model,PHB shouldbe positivelyrelated IndirectRiskPHB thanare personswith
to highSES (of boththe familyand the none of these characteristics(N=28);
neighborhood), frequentinteraction with amongconsistents,the difference is 83
non-kin,a nontraditional familystruc- percentversus10 percentand amongin-
ture,and, possibly,a Protestant religious consistents, the differenceis 70 percent
affiliation.In general,these zero-order versus29 percent.
hypotheses are supported (ornearlyso) in Controlling forage reducestherelation-
relationto IndirectRiskPHB. ButtheSo- ship betweenfamilySES and Indirect
cial Networkvariablesshow littlerela- Risk PHB to zero amonginconsistents;
tionshipto DirectRisk PHB amongcon- withinthisgroup,youngerpersonshave
sistents,and amonginconsistents, SES bothbetterPHB and a muchhigherSES
and interaction areinversely related.(col- thanolderpersonsdo. Controlling forde-
umn1, Table 3) mographicand situationalcontextvari-
A comparison ofthezero-order andmul- ables drasticallyaltersthe relationships
tivariatecoefficients (column2) suggests betweenDirectRiskPHB and theSocial
thatseveralofthezero-order relationshipsNetworkvariables;none of the relation-
are suppressed.Nevertheless,it is clear ships remainssignificant amongthe be-
that the hypothesizedrelationshipbe- haviorally consistentgroup,and onlythe
tweentheindividual's PHB andhisSocial inverserelationshipwith educationre-
Networkis fullysupportedonly in the mainssignificant amonginconsistents.
case of IndirectRisk PHB amongincon-
sistents.WhileSES, interaction, conjugal JointImpactoftheIndependent Variables
structure,andreligion are significantlyre-
latedto theDirectRiskPHB of inconsis- When examined separately, both
tents,onlythelattertwovariablesare re- social-psychological attributes oftheindi-
lated in the hypothesizeddirection. vidual and characteristics of his social
Amongthe behaviorally consistent,only milieuexerta significant impacton Indi-
SES and frequency of non-kin interaction rect Risk PHB, even when differencesin
are significantly relatedto IndirectRisk age, sex, and situational contextare held
PHB, whileSES andreligion are indepen- constant.The magnitude of the relation-
dentlyrelatedto DirectRisk PHB. With shipsbetweenDirectRiskPHB andeither
theexceptionof therelationship between the Health Belief or Social Network
familyincomeand DirectRisk PHB, all modelis somewhatsmallerandis reduced
relationships are in the expecteddirec- even further by controlling for demog-
tion. raphicdifferences.
Whilesomewhatdifferent indicators of thattheinfluence
It is unlikely on PHB
the major social networkvariablesare exertedby each of the two models is
moreusefulin accounting forvariationin whollyindependent of each other.How-
the two types of PHB, a very small ever,it is possiblethattheeffectsof one
numberaccountsfora significant and- modelareentirely indirectso thattherela-
withthe exceptionof Direct Risk PHB tionshipwouldbe reducedto zero when
amongtheconsistents-moderate amount the intervening variable(s)is controlled;
 SOCIAL NETWORKS 253
TABLE 3. RELATIONSHIPS OF SOCIAL NETWORK VARIABLES TO INDIRECT AND
DIRECT RISK PREVENTIVE HEALTH BEHAVIOR (PHB),
ZERO-ORDER AND MULTIVARIATE
Consistents Inconsistents
(1) (2) (3) (1) (2) (3) (4)
Typeof PHB and Variable r Beta Beta r Beta Beta Beta
INDIRECT RISK PHB
SocioeconomicStatus
Education .37* .27*
Income .27* .14
FamilySES .40* .33* .34* .25* .26* .25*
Neighborhood SES .28* .17* .17* .14 .04
Social Interaction
FrequentKin Interaction -.03 .01 .01 .25 .18*
FrequentNon-kininteraction .27* .22* .18* .20* .32* .28*
Social Isolation -.16* -.16 -.14* 00* .23 .22*
Non-kinOnlyNetwork .13 * -.09 .03 .01
BothKin/Non-kin Network .11 * -.05 .09 -.08
(Kin OnlyNetwork) -.09 -.12
ConjugalStructure
Egalitarian .15* .02 .07 -.13
Traditional -.10 -.06 ,.19* -.26* -.21*
(Single) -.06 .10
Protestant
Religion .15* .03 .13 .17* .16*
R2 .266 .257 .198 .181
df 10/208 4/214 10/135 6/139
F-Ratio 7.548* 18.461* 3.329* 5.136*
DIRECT RISK PHB
SocioeconomicStatus
Education .03 .43* -.39*
Income -.08 -.16* .28* 19*
FamilySES .01 -.09 - .39* .43* -.45*
Neighborhood SES .17* .17* .20* -.21* -.06
Social Interaction
Frequent Kin Interaction -.03 -.18 .09 -.11
Frequent Non-kin Interaction -.05 -.05 - 19* -.21 - .14* -.15*
Social Isolation .05 -.12 .05 .06
Non-kin Only Network -.09 -.20 -.14* -.02
BothKin/Non-kinNetwork .02 .02 -.00 .08
(Kin OnlyNetwork) .03 .07
ConjugalStructure
Egalitarian .05 .04 .05 .18* .21* .20*
Traditional -.04 -.02 -.06 -.03
(Single) -.00 .01
Protestant
Religion .16* .15* .14* - .15* .15* .15* .16*
R2 .074 .067 .247 .280 .240
df 10/208 3/215 10/135 5/140 4/144
F-Ratio 1.674 5.184* 4.431* 10.884* 11.349*
* Significant
at .05 level.
254 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
alternatively, the Health Belief, Social regressionequations are presentedin
Network,and/orthe controlvariables Table 4.
mayhave bothdirectand indirecteffects Amongall respondents, appropriate Indi-
on PHB, in whichcase the relationshiprectRisk PHB is associatedwith(1) low
withPHB wouldremainsignificant when perceivedcosts/high perceivedbenefits of
controlswere introducedbut would be action,(2) positiveattitudestowardsthe
of smallermagnitude whencontrolswere providers ofservices,(3) highfamily SES,
absent. and (4) frequent interaction with non-kin.
Commonalityanalysis revealed that In addition,First-Person PIC is relatedto
boththeHealthBeliefandSocialNetwork thistypeof PHB amongthe consistents
modelshave significant uniqueeffectsas and, among inconsistents, a traditional
well as a joint impact on Indirect Risk conjugal structure and age are inversely
PHB. Amongconsistents, thesetwomod- relatedand a Protestant religiousaffilia-
els accountfor43 percentofthevariance tionis positively relatedto thisdimension
inthistypeofPHB (10.2percentuniqueto of PHB.
the Social NetworkModel, 17.3 percent Appropriate DirectRiskPHB is associ-
uniqueto the Health BeliefModel, and ated with (1) low perceivedcosts/high
15.5 percentdue to the joint or "com- perceivedbenefits ofaction,(2) olderage,
mon" effectsof these two models);the and (3) female gender. It is also relatedto
demographic and situationalvariableshad "internality" among consistents and to a
no impacton the IndirectRisk PHB of low educationalattainment and a Protes-
consistents. Amonginconsistents, theSo- tantreligiousaffiliation amonginconsis-
cial Networkand Health Belief Model tents.
plusage accountedfor36.3percentofthe It is clearthatthedegreeofassociation
varianceinIndirect RiskPHB (8.9 percent betweenPHB andeachindividual variable
uniqueto theSocial NetworkModel,13.5 (or the directeffectof each variable)is
percentuniqueto theHealthBeliefMod- quitemodest;themagnitude ofthesignifi-
el, and 4.8 percent "common" to age and cant betas range from weak (.13) to mod-
the Social NetworkModel). erate(.35). However,thecombineddirect
About41 percentofthevariancein Di- andindirect impacton PHB ofthislimited
rect Risk PHB is accountedforby the set of variables is quite substantialwith
independent and control variablesforboth approximately 40 percentof thevariance
consistentsand inconsistents.The as- in bothtypesof PHB accountedfor.Re-
cribedcharacteristics ofage and sex have ducingthe numberof independent vari-
by far the most impacton this kindof ables from the original 23 to six or less
PHB. Amongconsistents, these two de- does not significantly reduce the R2.
mographic attributes uniquelyaccountfor
14.6percentofthevarianceinDirectRisk DISCUSSION
PHB andshareina further 12.7percent (the
HealthBeliefModeluniquelyaccountsfor Since a substantialproportionof the
another12.1 percentof thevariance,but variationin IndirectRisk PHB is ac-
the Social Networkand situationalvari- counted forby thejoint effectsof social-
ables together onlyexplainan additional psychological and social-group char-
1.2 percentof the variance).Amongin- acteristics,failureto include both in
consistents only7 percentofthevariation studiesofPHB maydistort theinterpreta-
inDirectRiskPHB is noteitheruniqueto tionofthefindings byattributing all ofthe
or sharedwiththe relativelypermanent explained variance to only one of the
characteristics ofage and sex (mostof this models. However, the failure to control
7 percentrepresents theuniqueeffectof forage and sex in manypreviousstudies
Social Network). of utilization behaviordoes notappearto
The individualvariablesthatcontinue be a serious fault, sincesex is unrelated to
to have a significant influenceon PHB Indirect Risk PHB and the impact of age
whenthe HealthBelief,Social Network in the inconsistent groupis relatively in-
and-where relevant-demographic vari- dependent of the other variables.
ables are simultaneously enteredintothe The Social NetworkModelofPHB has
 TABLE 4. SIMULTANEOUS IMPACT OF SELECTED HEALTH BELIEF, SOCIAL NETWORK A
INDIRECT AND DIRECT RISK PHB
IndirectRiskPHB
Consistents Inconsistents
Variables (1) (2) (1) (2) (1
HealthBeliefVariables
(Firstperson)
"Internality" .28* .26* .3
PositiveAttitudes/Providers .23* .21* .33* .29*
Low Barriers(overall) .14* .1
(a) To IndirectRisk PHB .12* .21*
(b) To Direct Risk PHB -.21*
High Benefits(Overall) .24*
(a) Of IndirectRisk PHB .11* .18*
(b) Of Direct Risk PHB
Social NetworkVariables
Family SES .28* .30* .15
FrequentNon-kinInteraction .19* .17* .11*
Traditional Conjugal Structure -.15* -.15*
ProtestantReligion .18* .16*
Respondent'sEducation
DemographicVariables
Age -.33* -.21* .3
Female Gender .3
R2 .418 .430 .332 .375 .3
F-Ratio 29.056* 25.548* 10.699* 9.603* 34.06
* at the.05 level.
Significant
of PHB in gener
(1) Regressionequationincludesoverallscales to measureperceivedbarriersto/benefits
of Directan
(2) Regressionequationincludesseparatescales to measureperceivedbarriersto and benefits
256 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
been less systematically developed at It shouldbe notedthatthe majorpro-
eitherthetheoretical or operationallevel portionof the variancein bothtypesof
thanis trueof the HealthBeliefModel. PHB is leftunexplainedby the indepen-
The measureused forfamilystructure in dent variablesmeasuredin this study.
thisstudyis particularly crude.Neverthe- Whileimproved andmea-
conceptualization
less, high familySES and frequentin- surement ofthedependent variableand of
teraction withnon-kin areimportant influ- the Health Belief and Social Network
ences on IndirectRisk PHB (amongin- ModelsofPHB verylikelywouldincrease
consistents, therelationship is somewhat the abilityto accountfordifferences in
obscured because these social-groupPHB, thetheoretical discrepanciesnoted
characteristics are associated with above require a more complex causal
younger age). The majortheoretical prob- modelwhichcan combinethe significant
lem is the inverserelationships between factorsin theformer twomodelsand can
DirectRiskPHB andtheSES andinterac- take intoaccountthe effectsof bothde-
tionvariables. mographiccharacteristics and behaviors
Several of the variablestheoreticallythatthe individualhas learnedand prac-
important to the HealthBeliefModel of ticedin thepast.
PHB provedto have no impactwhenthe A causal model to account more
effectsoftheotherindependent variables adequatelyfor differences observed in
weretakenintoaccount.Mostimportant,adults' PHB is diagrammed in Figure1.
theidea thatperceptions of vulnerabilitySome of the proposedcausal paths are
serve as motivationfor action was not fairlywell documented, whileothersare
supported; neither does saliencyappearto speculativeat thispoint.Path(1) suggests
be a precondition fortheoperationofthe thatchildhoodand currentSES are re-
social-psychological motivations specified lated (Blau and Duncan, 1967),religious
in theHealthBeliefModel.The failureof affiliation is notlikelyto change,and par-
the perceivedvulnerability and the sa- entalconjugaland extrafamilial relation-
liencyvariablesto exertan independent shipsmayserveas a pattern forthechild.
impacton PHB is not due to eithercol- Path(2): childrenfromhighSES families
linearitybetweenthemor withthe other are more "internal"(Battleand Rotter,
social-psychological variables.Of minor 1963) and high SES childrenhave less
importance is the factthatThird-Persontraumaticdental visits (Kriesbergand
PIC and SES arepositively relatedso that Treiman,1960) which should resultin
controlling forSES reducesthe relation- morepositiveattitudes towardsproviders
shipbetweenThird-Person PIC and PHB of care. Path (3): highSES childrengo
to zero. earlierandmorefrequently forpreventive
Althoughboth the Health Belief and checkupsof all kinds(Bice et al., 1972);
Social NetworkModelsare partiallysup- very littleis known about early PHB
portedin regardto IndirectRisk PHB, socializationbut it is possiblethatmore
neitheraccountsformuchofthevariation "cosmopolitan" families stress "Indi-
in Direct Risk PHB. Thus, attemptsto rect" rather than "Direct Risk" be-
changethe individual'sPHB by altering haviors.
eitherhis personalattributes or his social Differencesin earlysex roletraining
may
milieuare likelyto have a biggerpayoff makeboys morelikelyto feeltheyexert
when directedtowardimproving"indi- controloverevents(4) ormayrewardgirls
rect"typesofbehaviors.However,there forengaging inDirectRiskPHB (5); older
was relativelylittlevariationin Direct cohorts may feel they have relatively
RiskPHB as measuredinthisstudy(most morepersonalcontrolover lifethando
respondents havinghighscores) so that younger cohorts(6) andverylikelydidnot
thestrongest relationshipswouldshowup develop a habitof engagingin Indirect
as statistically Furtherrefine- Risk PHB early in life, since manyof
significant.
mentofthemeasuresforDirectRiskPHB the-sebehaviorshave onlyrecentlybeen
may uncover relationshipswith non- recommended (7). Comparedto theother
demographicvariables if, indeed, they HealthBeliefvariables,PIC and attitudes
exist. towardsprovidersappear morelikelyto
 SOCIAL NETWORKS 257
Childhood Characteristics Adult Characteristics Behavior

Social Network (1) Social Network

Characteristics -?- - - Characteristics

\ \ Il

(3)\\ (2)\ _ ( 7

Social Sca 7
Psychological (8) Psychological I
Attributes ---- Attributes

(4) 116
Se (9) PHB

(5) / II 1I(13)-
~~~~~~~~~~(11) /

/ / ~~~~~~~~Situational
Context | , 15) /
(6) Si/t:(7) : (1
/ s~~~~~~~~~~~~~~(12)
/(4)

Cohort E

FIGURE 1. PROPOSED MODEL OF PHB

be formedin childhoodand to persistin view the barriersto PHB as high.The

theabsenceofratherextremeadultexpe- presentstudy-as well as mostprevious
riences(8). Manyofthehabitslearnedin studies-was focusedon therelationships
childhoodwill persist(9) regardlessof corresponding to paths(16) and (17).
currentsocial psychologicalor social The assumption thatthe effectsof sex
group properties(e.g., Kriesbergand and age on PHB takeplace in childhood
Treiman[1960]foundthatthebestpredic- andaffect currentPHB via thepersistence
torof adultdentalbehaviorwas whether ofhabitslearnedearlieris a usefulheuris-
thefirstdentalvisitcamebeforeage six). ticdeviceforunderstanding thesourceof
It makes no sense to thinkof present behavioralinconsistency as wellas forac-
social-psychologicalcharacteristics(at countingfor differences in Direct Risk
least nottheones includedin theHealth PHB. None of the independent variables
BeliefModel) as "causes" of Social Net- measuredin the studywas able to ac-
workproperties, butthereverseis plausi- count for consistencyversus inconsis-
ble (10)-e.g., highpresentSES mayin- tencyper se. However, ifwe compare the
crease PIC, highereducationor frequent extremecategoriesamongboththe con-
non-kininteraction may add to or alter sistentsand inconsistents(and ignorethe
viewson therelativeefficacyofparticular intermediatecategoryin each group),it
actions.Paths (11) through(15) referto becomes clear thatbehavioralinconsis-
Direct Risk PHB only: Age (indepen- tencyis due to specificcombinations of
dentlyofcohort)maydirectly on the one hand,
affectPHB social characteristics,
if thereexistsan age-relatedincreasein withcohortand/orgender,on the other
via reduceddemands hand. Persons who consistentlyand
cautionor indirectly
engageinbothtypesofPHB
on one's timeand energy.The situational appropriately
contextmayindirectly influencePHB in tend to have high SES, interactfre-
anotherway-the extremely busypeople quently,have positiveattitudestowards
inoursampletendtofeeltheylackcontrol providers andtendto be older,femaleand
overtheirlives,rankhealthrelativelylow "internal."Conversely,those who con-
amongtheirconcerns(low saliency),and sistently do poorlyon bothtypesof PHB
258 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR
have just the opposite set of char- highand/or thecostsarelow(positiveatti-
acteristics;this particulargroup comes tudestowardproviders can be considered
closest to beingthe ideal-typical "paro- a low-costfactor),and (b) belonging to a
chial" social groupin that almosttwo- socialnetwork characterizedbyhighSES
thirdsare blue-collarworkers,over half andfrequent interaction betweennon-kin;
are non-Protestants, and two-thirds ofthe theserelationships are somewhatstronger
marriedpeople have "traditional"con- amongpersonswhoare behaviorally con-
jugalrelations(two-thirds ofthewivesare sistentthantheyare amongtheinconsis-
not employed).Withinthe behaviorally tent.In contrast,appropriate DirectRisk
inconsistent category,personswho eng- PHB is mainlyassociatedwitholderage
age ingood Indirectand poorDirectRisk and femalegender.
PHB combinethe social characteristics A model of PHB was suggested
associatedwithgood IndirectRisk PHB which-if futureresearchsupportsthe
and the demographicand psychological hypotheses-wouldhelp to accountfor
characteristics associatedwithpoor Di- both the Direct/Indirect dimensionof
rect Risk PHB: these people have high PHB andfordifferences inbehavioralpat-
SES, interact frequentlywithnon-kin, and terns. Longitudinalresearchemploying
have positiveattitudestowardproviders, morerefined conceptualization and meas-
and at the same time,theytend to be urementof thetypeof PHB labelledDi-
young,male and relatively"external." rectRiskhereand oftheSocial Network
Conversely, personswhohave poorIndi- variableswouldbe ideal. Cross-sectional
rectRisk PHB and excellentDirectRisk research on familycharacteristics and
PHB are sociallyisolated,have low SES the PHB and health related social-
and negativeattitudestowardproviders, psychological ofthechildwould
attributes
but are older,morelikelyto be female, also be veryuseful.
and are relatively "internal". Research has concentratedalmost
If thecausal processesoutlinedin Fig- on thecharacteristics
entirely oftheindi-
ure1 arecorrect,onewouldexpecttofind vidualorhissocialmilieuandhasvirtually
bothconsistentand inconsistent patterns ignoredtheincentives anddisincentives to
of adultPHB. The following (simplified)engagein PHB thatare providedby the
examplewillillustrate this:two individu- healthcare systemand the largersocial
als are bothraisedin a "cosmopolitan" structure. For example,mosthealthinsur-
familyand are currently in "cosmopoli- anceplansdo notpayforpreventive services
tan" socialmilieusbutMs. A (old cohort) andsomephysicians maynotbe willingto
has (and had in childhood) consistently give preventive care even to those who
appropriatePHB while Mr. B (young can affordit (one respondent reporteda
cohort)engagesin good Indirectbutpoor veryhumiliating experiencethatoccurred
Direct Risk PHB; if the presentsocial whenher doctorfoundout she was not
milieus of these two individualswere sickbut"only" wanteda checkup);these
"parochial," thenMs. A would be ex- kindsof factorsmustbe exploredbefore
pected to have good Direct and inter- we can hope to have an adequateunder-
mediateIndirectRisk PHB as an adult, standing ofwhysomepeopledo andsome
whileMr. B wouldhave poor Directand do notengagein preventive action.
intermediate IndirectRisk PHB, etc. Finally,inviewofthemoneyandeffort
beingdevotedto understanding PHB, it
would be worthwhile to investigate just
CONCLUSION
which among the many recommended
What accounts for the observeddif- healthbehaviorsactuallyaffecthealth-
ferencesin PHB? It appearsthatthean- particularly, just how dependent is health
swerto thisgeneralquestiondependson on
status what theindividualhimself does
whichtypeof PHB attention is focused or does notdo inthecontextofa polluted
on. Appropriate IndirectRiskPHB is re- environment? Ifthegoalis to improvethe
lated to (a) the perceptionsthatone has healthstatusof the U.S. population,are
somecontroloverone's healthstatusand effortsdirectedtoward changingindi-
thatthebenefitsof preventive actionare vidual preventivehealth behavior the
 SOCIAL NETWORKS 259
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EXPLAINING PAIN AND ENJOYMENT

IN CHILDBIRTH*
KATHLEEN L. NORR CAROLYN R. BLOCK ALLAN CHARLES
of Chicago
Loyola University Commission
IllinoisLaw Enforcement MichaelReese Hosptal
SUZANNE MEYERING ELLEN MEYERS
Indiana University and of Chicago
Loyola University

260-275
ofHealthandSocial Behavior1977,Vol. 18(September):
Journal

Thereare twoseparatebutrelateddimensions ofwomen'sbirthexperiences: painand enjoy-

ment.A causallyorderedmodelofmedical,psychological, andsocialfactorsexplainsoverhalf
thevariancein enjoyment and abouta thirdofthevarianceinpain. Medicalfactorssuchas
lengthof labor,complications, of delivery
and difficulty independent
are relatively of social
factors,and theirimpactsonpainand enjoyment are small.Womenwithhighersocialstatus,
attitudestowardsex roles,and greatermaritalclosenessare morelikelyto
less traditional
tohavetheirhusband'shelpduringlaborand delivery,
prepareforchildbirth, and tohaveless
pain and moreenjoyment duringbirth.Social supportduringlabor is a criticalfactorin
improving birth
experiences. theavailability
Increasing ofpreparationclassesandencouraging
greatersupportfromrelatives birthcouldimprove
during birthexperiencesformanywomen.

Sociologistsand anthropologistshave The waywomenexperiencebirthinthe

been fascinatedwith the customs and
ceremoniesassociatedwithbirth,espe-
societies.Yet few
ciallyin preindustrial
researchershave askedhowwomenactu-
ally experiencechildbirthor what ac-
countsfortheirdifferentexperiences.
* We wouldliketo thankJamesL. Norrforhis
We
analysis,criticalreviewsand encouragement.
wouldalso liketo thanktwoanonymous reviewers maternal deaths, and subsequent ill
fortheirhelpfulcomments.
UnitedStates is considerablyinfluenced
by the dramaticchanges in the social
organizationof birth over the last
seventy-fiveyears.Priorto thetwentieth
century,most birthsoccurredat home.
Women deliveredin the comfortand
of theirown surroundings-
familiarity
and highratesofinfant
suffered mortality,
care.
health,partlydue to poorobstetrical