Many of these [behavioral] theories end up blaming the victim for their own circumstances. “What, you can’t plan? What, you can’t reason?” You know. “You can’t think? You can’t believe? You don’t have knowledge? …” We need to make explicit the assumptions that guide these theories and the limitations that underlie the theories
Study Key Informant 3
Over the past decade, the importance of social context to understanding health behavior and decision-making has been increasingly recognized in public health research (Emmons 2000
; Frohlich, Corin, & Potvin 2001
; McKinlay 1995
; Perry, Thompson, and Fowkes 2002
; Revenson & Pranikoff 2005
; Sorensen et al. 2003
; Susser & Susser 1996
; Williams 1995
). Two streams of research have addressed the role of social context in health behavior: social psychological models and social ecological models. This article contributes to the emerging public health literature by suggesting a third approach to social context. Social context as used and theorized in the social science disciplines of anthropology and sociology, should be integrated with emerging social cognitive and ecological models for a more complete understanding of health behavior. We show how and why social context broadly conceived offers significant opportunities for deeper understanding of behavior as well as dynamics that likely figure importantly in health disparities.
In most social psychological theories of health behavior, social context has been consistently relegated to a relatively minor influence on individual behavior and health outcomes. While behavioral science seeks to understand, explain, and often change human behavior through the adoption of healthier lifestyles, behaviors, and attitudes, the theories employed have an individual, cognitive focus, largely abstracted from social context (Frohlich et al., 2001
; Singer & Weeks, 1996
; Williams, 1995
). Based in these theories, much prevention research places emphasis on cognitive and motivational variables including how individuals interpret behavioral information, how they value that information, and how capable they feel to use the information (Bandura, 1984
; Krumeich, Weijts, Reddy, & Meijer-Weitz, 2001
; Singer & Weeks, 1996
). Social, organizational, historical, political, and cultural influences upon individual behavior are, at best, relegated to the position of background variables, acknowledged only insofar as they affect beliefs that are theorized to be a dominant influence. Importantly, when they are acknowledged, these organizational, political, and so on, associations are mainly framed as unidirectional, the individual being the recipient or object of unchanging external forces.
Over the past decade, several critiques of behavioral models have attempted to move the focus of health promotion research and practice beyond the realm of individual behavior by demonstrating the inextricable ways that context, in a variety of forms, is integral to health and health behavior outcomes. These efforts have generated social ecological models incorporating social context (Berkman & Glass, 2000
; Emmons, 2000
; Krieger, 2005
; Kreiger & Davey Smith, 2001
; Stockols, 1992
); conceptualizing social context as both modifying conditions and mediating mechanisms (Sorensen et al. 2003
); and re-defining social contexts as risk regulatorsi
(Glass & McAtee 2006
). As one critic summarized,
“There has been a gradual shift away from explaining health related behavior simply in terms of ‘health beliefs’ (i.e., health belief models etc.) toward attempting to understand the lay person’s actions in terms of their own logic, knowledge and beliefs which are grounded in the context of people’s daily lives”
This article elaborates a theoretical approach to “social context” that draws on the social sciences of anthropology and sociology to understand the multiple dimensions of social and cultural phenomena in daily life as they relate to the health behavior of underservedii
women. We define social context as the sociocultural forces that shape people’s day-to-day experiences and that directly and indirectly affect health and behavior (Pasick & Burke, 2008
). These forces include historical, political, legal structures and processes (e.g. colonialism and migration), organizations and institutions (e.g. schools, clinics, and community), and individual and personal trajectories (e.g. family, interpersonal relationships). Notably, these forces are co-constituitive, meaning they are formed in relation to and by each other and often influence people in ways of which they are not consciously aware. In the following, we explain the theoretical basis for this definition of social context, and detail how it is always situationally dependent.
The theoretical approach we propose here evolved from a combination of social science literature and our findings from an inductive, qualitative study of the appropriateness of several behavioral theory constructs for understanding the practice of getting a mammogram among US Filipina and Latina women. Elsewhere we detail problems with the use of health behavior theory in the study of mammography screening in underserved populations (Pasick & Burke 2008
). In this volume, we focus on describing the study – “Behavioral Constructs and Culture in Cancer Screening
” (R01 CA81816, Pasick, Principal Investigator), known as the “3C’s” project – and its findings in detail. Four other articles in this volume detail study methods and findings: (a) the study overview, methods, and major findings (Pasick, Burke, et al., 2009); accompanied by in-depth analyses of three major domains of social context that emerged from our data – (b) social capital (Burke et al.2009); c) transculturation/transmigration (Joseph, Burke, Tuason, Barker, & Pasick, 2009); and (d) relational culture (Pasick, Barker, et al., 2009). These other reports examine the implications of our theoretical perspective on social context for specific behavioral theory constructs. In other words, our 3C’s study explores a more contextualized approach to health behavior (specifically, use of mammography), and draws conclusions about the validity of traditional behavioral constructs from this perspective.
The purpose of the present article is to set the stage for those articles by: (a) introducing readers to the social science theory behind our data analyses, and (b) contrasting it with dominant forms of analysis in health behavior research (health behavior theory and SE models). In the sections that follow, our data in the form of exemplary quotes serve as brief examples that illustrate various aspects of the concept of social context. We discuss some assumptions made by social psychological theories, assumptions that limit the theory’s value with regard to behavior in the context of diverse ethnic and underserved individuals and groups. Next, we examine more closely social cognitive theory (SCT) and SE models which represent important advances that embed the individual in the context of her social and physical environments. We then address the theoretical influences behind our conceptualization of the relationship between the individual and social context, highlighting key ideas in social science theory such as individual agency and rational action. We conclude with a discussion of the implications of our conceptualization of social context for health promotion and practice.