A Framework for Prevention: Changing Health-Damaging
To Health-Generating Life Patterns
NANCY MILIO, PHD, RN
Abstract: A set of propositions is offered to pro-
vide a frame of reference for proposed strategies to im-
prove healthful behavior by placing personal choice-
making in the context of societal option-setting.
The health status of populations at a given point in
time is seen as a result of customary personal choice-
making. These choices in turn are limited by both the
perceived and actual options available to individuals,
depending on their personal and their community's re-
sources, from which to make choices. Most people,
most of the time will make the easiest choices, i.e.,
will do the things, develop the patterns or life-styles,
which seem to cost them less and/or from which they
It is a paradox that health professionals, in their efforts
to improve people's health-related practices, seem to expect
more of the ordinary consumer than they do of themselves.
Almost all patient and consumer health education assumes,
explicitly or implicitly, that if people know what is most
healthful, they will do it.
Perhaps the most obvious test of this assumption is to
look at health professionals themselves. If knowing what is
health-generating were directly related to doing, then surely
we in the health field would be among the most robust in the
nation, slim, agile, nonsmoking, temperate eaters of com-
plementary protein, low fat and cholesterol, low-sucrose,
and nonrefined carbohydrate foods, avoiders of drugging lev-
els of alcohol and other artificial mood-changers, evenly
paced in our daily patterns. This picture is obviously non-
existent. Nor do we expect it to exist. Most will recognize
that it is not much more likely for a physician earning
$85,000 a year to change his life pattern than for a $6,000 a
year hospital aide to do so. However, the potential for life-
style change, the array of options available to these two indi-
viduals, may differ considerably.
The point is that most human beings, professional or
Dr. Milio is Associate in Nursing, Simmons College, and Direc-
tor, Alternatives in Health Care, 255 Massachusetts Avenue, No.
1010, Boston, MA 021 15. Address reprint requests to her at the
above address. This paper, based on concepts presented by the au-
thor in the Sybil Palmer Bellos Memorial Lecture at Yale University
School of Nursing, April 9, 1975, was submitted to the Journal on
October 8, 1975, revised and accepted for publication January 16,
1976.
AJPH May, 1976, Vol. 66, No. 5
will gain more of what they value in tangible and/or in-
tangible terms.
The range of options available to them, and the
ease with which they may choose certain ones over
others, is typically set by organizations, public and pri-
vate, formal and informal. The more powerful the orga-
nization, i.e., the more effective it is in carrying out its
policies, the more it affects the options available to oth-
er organizations and populations, whether or not these
effects are immediately perceived by individuals in
their day-by-day choicemaking. Implications for
health education strategies are noted. (Am. J. Public
Health 66:435-439, 1976)
nonprofessional, provider or consumer, make the easiest
choices available to them most of the time, and not necessari-
ly because of what they know is most healthful. Thus, if it is
agreed that health-promoting life patterns are a good thing,
then the focus for changing behavior should be on the prob-
lem of how to make health-generating choices more easy,
and how to make health-damaging choices more difficult.
A Time for Change
There is increasing national and even international inter-
est in the problems of "primary prevention" of disease,
"health education," "life-style changes," etc. This is occur-
ring, in part, because of studies which indicate the historic
and contemporary limitations of medical care for improving
the health of populations. Those limits include the narrowing
impact that traditional, microbe and infestation-oriented pre-
ventive programs can have on the modern profile of chronic
and degenerative illness and violent deaths.'"8
A more immediate impetus for serious attention to ill-
ness prevention is the uncontrolled rising costs of personal
health services. This derives from the capital- and energy-
intensive nature of the inpatient facilities and technology
which dominate health care organization, and is aggravated
by inflation in the national economy. As greater shares of
health care financing come from governmental sources,
more concerted efforts will be made to control costs. One
such major effort is to find ways to prevent major disease en-
tities, principally chronic illnesses and accidents.
Two recent developments are focused on this issue. One
435
MILIO
is the National Health Education and Promotion Bill which
requires health education in delivery systems and sets up
mechanisms for nationwide development, testing, and dis-
semination of methods to promote health-generating behav-
ior. Another important event was the National Conference
on Preventive Medicine. Studies cited above, the 1300 pages
of Senate health education hearings, and many Conference
Task Force papers thoroughly review the "state-of-the-art"
of disease prevention, and document the limitations of con-
temporary health services. These will not be reiterated
here.9' 10
Recommendations from these sources concerning what
needs to be done cover a broad spectrum. Some groups rec-
ommend educational programs in the elementary schools, in
adult education classes, in health services settings using
small group techniques; or for the general public, using the
media and other advertising and mass communications meth-
ods. Others emphasize federal policy changes not directly re-
lated to personal health services or to conventional educa-
tion-information-persuasion methods, such as placing a high
tax on cigarettes, the funds to be used in the research and
treatment of lung disease.
What follows here is a preliminary effort to place in con-
text, as an interrelated set of working hypotheses, the well-
founded but seemingly divergent recommendations of nu-
merous groups actively concerned with the problem of en-
hancing health-promoting life patterns and/or discouraging
health-damaging habits.
A Set of Propositions
1. The health status ofpopulations is the result of depri-
vation andlor excess of critical health-sustaining resources.
Health-sustaining resources include the seminal ones (e.g.,
food) or the synergistic ones (e.g., basic education, health
services). In any population those subgroups which are de-
prived of sufficient and safe food, water, shelter, and envi-
ronment have great vulnerability to acute, infectious disease
processes. The poor in Third and Fourth World countries are
the most stark examples. The population subgroups which
are affluent have disease resulting from too much food (e.g.,
obesity and hypertension) of the highest cost varieties (e.g.,
meat, concentrated sucrose, refined carbohydrates, and
fats); alcoholic, caffeinated and other drinks, and other dan-
gerous relaxants (e.g., drugs, smoking, passive use of lei-
sure); too rapid transportation and communication-often re-
sulting in accidents and in stressful work overloads dealt
with in sedentary posture. Excessive environmental pollu-
tion arises from the production-consumption patterns of this
affluent way of life. Affluent urban Americans are the best
example.
Somewhere between the very poor and the affluent are
the population subgroups, having a low-income but living in
a relatively affluent or "advanced" society. Low-income
Americans are not only more vulnerable to acute disease
relative to their affluent counterparts, but also sustain more
of the chronic degenerative illnesses and accidents which are
integral to the affluence of the wider society. The cigarettes,
436
sucrose, cars, pollutants, and tensions are readily available
to the poor, while at the same time they are deprived of the
level of protection afforded by the quality of food, shelter,
and environment which sustain the more affluent. The poor
not only succumb more readily to virtually all disease proc-
esses, they also possess fewer options for getting the damage
repaired or contained through the medical care system.
These socioeconomic realities thus form the basis for the typ-
ical life-style or behavior patterns which result in the varying
illness profiles of different population subgroups.' -16
2. Behavior patterns ofpopulations are a result of habit-
ual selection from limited choices, and these habits of choice
are related to: (a) actual and perceived options available; (b)
beliefs and expectations developed and refined over time by
socialization, formal learning, and immediate experience.
Ordinary, "average," day-to-day behavior stems from
daily choices that are relatively set and no longer con-
sciously made. These choices have been limited by what is
actually available to groups of people and what they perceive
to be available or possible. Their knowledge of the possible
and their perceptions are influenced by what they have
learned in the past, informally and non-verbally as well as
formally, and by what they experience.17
Applied to consumers, this is a point at which new
health information and knowledge may influence individual
choice-making under certain conditions.
3. Organizational behavior (decisions or policy-choices
made by governmentallnongovernmental, nationallnon-na-
tional; non-profit/for-profit, formallnon-formal organiza-
tions) sets the range of options available to individuals for
their personal choice-making. Organizational decisions di-
rectly affect the options available to people and/or their
awareness of those options and/or the ease with which they
may make daily, habitual, selections.'7" 8
For example, federal policy decisions concerning tax-
ation, business subsidies, tax incentives, and import-export
restrictions affect whether and how much of such items as
cigarettes and palatable soy protein will be available, how
widely distributed and advertised, and at what price. These
decisions set the array of options available to various eco-
nomic and geographic populations concerning the ease with
which they may or may not choose such items.
As another example, combinations of policy choices by
such organizations as city government and public and pri-
vate housing, transportation, and banking firms concerning
land use set the range of options available to population sub-
groups concerning where they may or must live and work,
and the means and speed of their transportation (therefore
how physically active they may be, how fatiguing or com-
pact their day, how clean their air). Such policies also deter-
mine which of the available array of options are the easier.
National governmental decisions concerning the politi-
cal economy in a country such as China stand in marked con-
trast to those in the U.S.A. The result in China has produced
forms of social organization such as rural communes and ur-
ban neighborhood and industrial-worker networks which fa-
cilitate collective decision-making within organizations. Col-
lective or small-group decision-making can then become a
mechanism by which participants can develop new options
AJPH May, 1976, Vol. 66, No. 5

for themselves as well as be supported in the reinforcement
of the new choices which they make, concerning community
and personal health care among other things.'9 -22
4. The choice-making of individuals at a given point in
time concerning potentially health-promoting or health-
damaging selections is affected by their effort to maximize
valued resources. Choice is therefore related to the type and
amount of:
(a) their personal resources: their awareness, knowl-
edge, beliefs and skills; those of family, friends, and of oth-
er primary (small, face-to-face) groups; available money
and time; convenience concerning distance, travel, trans-
portation; the urgency of other priorities; and
(b) societal (community and national) resources: the
availability of health-sustaining services and resources in
terms of cost, distance or location, type, comprehensive-
ness, program outreach components (e.g., food, housing,
income maintenance, environmental protection, health
services); alternatives to formal services; penalties or loss-
es incurred, or rewares given, for selection or failure to se-
lect given options.
All of these resources implicitly or explicitly limit or
widen the array of options available to individuals for retain-
ing or altering health-related habitual choices, and determine
the ease with which new, possibly more healthful choices
may be made. Any change in pattern would involve some ef-
fort or cost and some actual and/or perceived gain.
An example might be the $85,000 a year physician and
the $6,000 a year aide, both of whom have mild hypertension
and each of whom would benefit by a more healthful life
style. Given that both are made aware of what shifts in be-
havior would be most likely to have health-enhancing ef-
fects, it is quite apparent that the physician has a potentially
greater opportunity to adopt a more health-promoting pat-
tern of daily choices because of his personal resources.
The physician may conceivably slow the pace of his life
by choosing to live closer to his work in the urban medical
center in a quiet townhouse. He may take more frequent va-
cations as a means to relax and thereby diminish the need for
cigarettes, alcoholic drinks, or other drugs. He would have
no serious financial problem in obtaining palatable meals
within caloric-cholesterol-sodium limits in restaurants or spe-
cially prepared for him alone. Medical center fringe benefits
would allow him ample sick leave, medical insurance, pen-
sion, and other supportive resources.
The aide earning $6,000, typically a woman, possibly
with adolescent children, has fewer options for making new
choices. There is virtually no chance for her to find even a
low-paying job in a less hectic environment. Without rapid
transit, moving the household to a less congested area is out
of the question, even if such housing were available. To
work fewer hours is not an option since her husband is spo-
radically employed at best. Besides, taking too much time
off may risk her job security. There is little extra time or mon-
ey to change the family's customary diet, and food and ciga-
rettes are two of the very few options left for relaxation and
pleasure. Neither friends nor family, though willing, have
enough resources to share to make a difference. The medical
AJPH May, 1976, Vol. 66, No. 5
FRAMEWORK FOR PREVENTION
clinic which diagnosed her condition has no consistent meth-
ods to intervene and offer help in her home situation.
For either individual, the physician or the aide, the per-
sonal and societal resources will not determine whether or
not they will alter their life patterns. But those resources will
make the likelihood that each one can change-given an ini-
tial moderate willingness to do so-either more or less a pos-
sibility. This is because of the array of options before them,
and because some of those options, health-promoting or
health-damaging in their net effects, are easier to choose
than others.
5. Social change may be thought of as changes in pat-
terns of behavior resulting from shifts in the choice-making
of significant numbers of people within a population.
In order then for life-style patterns to alter among indi-
viduals in numbers sufficient to affect the incidence of major
diseases, new, health-promoting options must be available,
and more readily so than health-damaging options, i.e., in
such a way as to be less costly in dollar and other costs.
People also must be aware of the new options and of what
they can gain from selecting them relative to their former
choices.
6. Health education, as the process of teaching and
learning health-supporting information can have little signifi-
cantly extensive impact on behavior patterns, that is, on per-
sonal choice-making of groups of people, without the easy
availability of new, or newly-perceived alternative health-
promoting options for investing personal resources.
Typically, what has been regarded as health education
has focused on providing consumers with information or
knowledge in order to make them aware of the costs and ben-
efits to their health to be derived from particular behaviors.
The relative lack of other options from which to choose new
behavior patterns has not been dealt with realistically, partic-
ularly for outcast groups, such as rural and lower income. It
is not enough to make people knowledgeable about health-
promoting choices. The other side of the coin is to provide
ready access to health-promoting options.'0023-25
The strategy of making health-promoting options easier
is implicit in the small group approach to behavior change,
e.g. weight-reduction, cessation of smoking or alcohol con-
sumption. By becoming an integral part of a group which ap-
proves of certain choices, individuals can more easily make
such choices. Thus by choosing low calorie foods they gain
the short term reward of group approval and avoid its dis-
approval, as well as gaining the longer term reward of weight
reduction. The reward is apparently greater than in the typi-
cal individual counseling method, making the group ap-
proach the more successful.'0
However, the small group approach is limited for sev-
eral reasons. It is costly to individuals in both time and mon-
ey, and would be very costly to the delivery system were it
applied extensively enough to impact on the behavior of
large populations. Its benefits, measured in terms of impact
on groups of people, are not very efficient. This approach
has successfully reached just over an estimated 2 per cent of
all smokers; further, as another common example, up to 4
out of 5 members of weight control groups may drop out.
There is also some question as to whether the changes in be-
437
MILIO
havior that do occur are large enough to be clinically signifi-
cant.26-28
In one report, a mass media approach was combined
with small group techniques for clinically high-risk groups.
There was an increase in knowledge and change in attitudes
concerning health-relevant choice-making, but relatively
little change in actual behavior. Change included a lessening,
but not cessation of smoking, and a drop in the number of
eggs eaten-a change which also occurred in the non-experi-
mental population apparently related to the economic situ-
ation of the communities involved.29 Choice-making regard-
ing physical activity and exercise was unchanged.
This non-change is understandable in terms of the ear-
lier discussion about gains and losses of resources. Activity
patterns reflect daily concentrations of work, job, leisure,
housing location, available transportation, family responsi-
bilities, etc. As such, they are integral to both family and
community choice-making. Even a strong desire by an indi-
vidual to alter and increase his or her physical activity would
require a sustained effort if the readily available options in
the family-home, job-community favor time-consuming and
sedentary or light activities. Under these conditions, a burst
of effort at increased exercise is likely to subside and accom-
modate again to customary, more readily-taken options for
less physically exerting activity patterns of household and
community.30
The small group approach seems somewhat more effi-
cient when applied to patients, especially those who are seri-
ously ill.9 31 This again is understandable. III people have rel-
atively more to gain by making choices which will diminish
their symptoms and restore their ability to live more pain-
lessly and with less effort.
As awareness of the limitations of traditional health edu-
cation grows, a contemporary concept is developing which
includes, along with information and motivation, change-
making in the living environment, conceivably to the broad-
ening of healthful options for personal choice-making.32
There is also evidence of more comprehensive and planned
approaches to health education, with increasing emphasis on
cost-effectiveness and the evaluation of results, including the
measurement of changes in behavior and health stat-
us. 9' 33-37
Summary
These hypotheses provide a framework in which health
status of populations at a given point in time is viewed as the
outcome of customary personal choice-making. These
choices in turn are limited by the actual and perceived op-
tions available to individuals, which reflect their personal
and their community's resources. Most people, most of the
time will make the easiest choices, that is, will develop the
patterns of behavior or life-styles which seem to cost them
less and/or from which they will gain more of what they val-
ue in tangible and/or intangible terms.
The range of options available to populations, and the
ease with which they may choose certain ones over others, is
typically set by organizations, public and private, non-profit
438
and for-profit, formal and informal. This is done through the
organizations' capacity to determine policy choices which af-
fect the allocation and distribution of various kinds of
amounts of goods and services and their price, direct or in-
direct, to the user. The more powerful the organization, that
is, the more effective it is in carrying out its policies, the
more it affects the options available to other organizations
and populations, whether or not these effects are immediate-
ly perceived by individuals in their day-by-day choice-mak-
ing.
Implicit in this view of organizational decision-making
and individual choice-making as they affect health-relevant
patterns is the notion of a pyramid of decisions. The deci-
sions taken at the "higher", more powerful organizational
levels, set the range of options available at lower levels. This
may be seen in the ways in which both federal government or
multinational and large scale corporation policies concerning
food, energy, transportation, or antipollution enforcement ul-
timately affect not only the policy-choices of public and pri-
vate bodies at state and local levels, but also the individual in
his and her daily choices about diet, residence, exercise and
pace of life. ' 8
Implications
Given this framework, strategies for encouraging
health-promoting choices may also be put in perspective.
Their minimal aim, for example, might be to broaden the
range of options available to people and to make health-
promoting choices easier and/or to diminish health-damaging
options by making them more difficult to choose. For the
most widespread impact, the focus might be on national-lev-
el policy-making which would in turn change the range of op-
tions for the largest number of people, i.e., the national popu-
lation. Selected populations, those most vulnerable to ill
health because of the limited healthful options available to
them, might also receive special attention.
This frame of reference can also help assess or project
the relative effectiveness of various efforts at behavior
change. For example, a local effort at conveying more knowl-
edge about healthful diets is not likely to result in changes of
eating patterns unless it is accompanied by a combination of
healthful, low cost, readily available foods-changes which
require effort beyond the individual or small group methods,
and extend to the community public and private organiza-
tional structure.
The question may be raised that this perspective sug-
gests a manipulation of behavior, a constraint on freedom.
Quite the contrary, since as this discussion shows, current
policy and allocative decisions clearly constrain personal
choice-making, even if not so perceived by many people.
This framework rather suggests strategies which will en-
hance the freedom to choose, making it readily possible for
individuals and groups who now have difficult options to
create healthful lifestyles. Those who wish to pursue health-
damaging patterns would still be able to do so.
These are working hypotheses, not yet sufficiently re-
fined to be fully testable. Hopefully, passage of an adequate
AJPH May, 1976, Vol. 66, No. 5

National Health Education and Promotion Act will make
possible the development and testing of such models in order
to help health professionals and consumers focus effectively
on the prevention of disease rather than on its repair or con-
tainment.
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