1.2 Historical Context and Evolution of Behavioral and Social Sciences in Public Health

The behavioral and social sciences have profoundly shaped public health approaches over time. From early sanitation efforts to modern ecological models, our understanding of health has evolved to encompass biological, psychological, and social factors.

Key theories like the Health Belief Model and Social Cognitive Theory guide interventions today. Community-based participatory research engages local partners to address health disparities. These frameworks help public health professionals develop effective, culturally-relevant programs to improve population health.

Early Public Health Movements

Germ Theory and Sanitation Movement

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• Germ theory proposed by Louis Pasteur and Robert Koch in the late 19th century revolutionized understanding of disease causation
  • Proved that specific microorganisms (bacteria, viruses) caused specific diseases rather than miasma or bad air
  • Led to development of antiseptic techniques in surgery (Joseph Lister) and pasteurization of milk to prevent spoilage and disease
• Sanitation movement emerged in response to poor living conditions in rapidly industrializing cities of Europe and North America
  • Focused on improving water quality, sewage disposal, food safety, and general cleanliness to prevent disease outbreaks (cholera, typhoid)
  • Key figures included Edwin Chadwick in England who advocated for separating sewage from drinking water and cleaning up slums
  • In U.S., Lemuel Shattuck's 1850 Report of the Sanitary Commission of Massachusetts was influential in promoting sanitary reforms

Social Reform and Public Health

• Social reformers in late 19th/early 20th centuries recognized link between poverty, poor living and working conditions, and ill health
  • Settlement house movement established community centers in poor urban areas to provide social services, education, and healthcare (Jane Addams' Hull House in Chicago)
  • Progressive Era reformers advocated for child labor laws, minimum wage, housing regulations to improve health of working class
• Public health nursing emerged as a specialty to provide home-based care and health education to poor families
  • Lillian Wald founded Henry Street Settlement in NYC in 1893, which became a model for public health nursing services
• Social reform efforts laid groundwork for understanding social determinants of health and importance of addressing root causes of disease and health disparities

Evolution of Health Models

Biomedical Model

• Dominant model of disease in Western medicine since 19th century
  • Views disease as a deviation from normal biological functioning caused by specific pathogens or abnormalities in genes or physiology
  • Focuses on diagnosing and treating individual patients' physical ailments
  • Relies heavily on medical technology (diagnostic tests, drugs, surgery) to identify and fix biological problems
• Critiques of biomedical model emerged in late 20th century
  • Reductionist approach that neglects psychological, social, and environmental influences on health
  • Defines health narrowly as absence of disease rather than positive well-being
  • Patient is a passive recipient of expert medical care rather than an active participant in their own health

Biopsychosocial Model

• Proposed by George Engel in 1977 as an alternative to biomedical model
  • Recognizes that biological, psychological, and social factors all play a significant role in human health and illness
  • Biological factors include genes, physiology, neurochemistry
  • Psychological factors include cognition, emotion, behavior
  • Social factors include family, community, culture, socioeconomic status
• Encourages a more holistic and patient-centered approach to healthcare
  • Considers the patient's subjective experience of illness and its meaning and impact on their life
  • Emphasizes importance of doctor-patient relationship and communication
  • May incorporate mental health care, social services, and health promotion alongside traditional medical treatment

Ecological Models of Health

• Ecological models view health as a product of multiple levels of influence, from individual to societal
  • Intrapersonal level: individual characteristics (knowledge, attitudes, skills)
  • Interpersonal level: social relationships and networks (family, friends, peers)
  • Organizational level: rules, regulations, policies, and informal structures (schools, workplaces, churches)
  • Community level: relationships between organizations, cultural norms, mass media
  • Public policy level: local, state, and national laws and policies
• Implication is that health promotion efforts need to target multiple levels simultaneously to be effective
  • Example: smoking cessation programs should include individual counseling (intrapersonal), peer support groups (interpersonal), workplace smoking bans (organizational), anti-smoking media campaigns (community), and higher tobacco taxes (policy)
• Social ecological model (Bronfenbrenner) and Precede-Proceed model (Green & Kreuter) are examples of ecological planning models used in public health

Behavioral and Social Science Theories

Health Belief Model

• Developed in 1950s by U.S. Public Health Service to explain low participation in disease prevention and screening programs
• Proposes that a person's likelihood of engaging in a health behavior depends on their perceptions of:
  • Susceptibility to the health problem
  • Severity of the health problem
  • Benefits of the preventive action
  • Barriers to taking action
  • Cues to action that trigger behavior (media campaign, advice from others)
  • Self-efficacy (confidence in one's ability to perform the behavior)
• Widely used to design health education messages and programs
  • Example: promoting flu vaccination by emphasizing high risk of flu (perceived susceptibility), seriousness of flu complications (perceived severity), effectiveness of vaccine (perceived benefits), addressing concerns about side effects or cost (perceived barriers), offering reminders and convenient vaccine clinics (cues to action)
• Limitations: does not directly address social influences on behavior, assumes rational decision-making

Social Cognitive Theory

• Developed by Albert Bandura, emphasizes reciprocal interaction between individual, environment, and behavior
• Key constructs include:
  • Observational learning: learning new behaviors by observing others' actions and their consequences (positive or negative reinforcement)
  • Outcome expectations: anticipated consequences of a behavior, which can be physical, social, or self-evaluative
  • Self-efficacy: person's confidence in their ability to perform a behavior, affected by past experiences, social modeling, verbal persuasion, and emotional arousal
• Has been applied to wide range of health behaviors, including physical activity, nutrition, and substance use prevention
  • Example: mass media campaigns featuring admired celebrities (social modeling) to promote healthy eating (observational learning), emphasizing benefits like improved energy and appearance (positive outcome expectations)
• Recognizes importance of environmental influences and social support on individual behavior change

Community-Based Participatory Research

• Approach to research that involves equitable partnership between academic researchers and community members in all phases of the research process
  • Community members help define the research questions, design the study, collect and interpret data, and disseminate findings
  • Aims to combine knowledge and action to achieve social change to improve health and eliminate disparities
• Principles include:
  • Building on community strengths and resources
  • Fostering co-learning and capacity building among all partners
  • Balancing research and action for mutual benefit of all partners
  • Focusing on local relevance of public health problems and ecological perspectives
  • Involving a long-term process and commitment to sustainability
• Example: Healthy African American Families project in Los Angeles, a coalition of community organizations, health agencies, and university researchers working to improve health in the African American community
  • Used CBPR approach to assess health needs and assets, develop and test family health education program, and advocate for policy changes
  • Documented improvements in participants' self-efficacy, health behaviors, and health outcomes, as well as increased community capacity and trust in research
• Challenges include power imbalances, conflicting priorities, time demands, and need for flexibility and cultural competence