SOCIAL PSYCHOLOGY-BACKGROUND PAPER

Strategies and Their Rationalefor Changing People's Eating Habits

Godfrey M. Hochbaum

Prior to the early 1950s, research on people's health-related be­havior consisted almost entirely of sociological studies concern­ing the relationship of social class to the utilization of health ser­vices. These survey-type studies were generally of an empiricalnature and consisted primarily ofcollections ofnumerous statisti­cal data. Such research yielded much useful information in termsof assessing who engages in various kinds of health-related be­havior, what people know about health, and what kinds of pro­grams stimulate desirable health practices. The research helpedto locate the problems of undesirable health-related behaviorsbut shed little light on their nature, causes., and outlook forimprovement. For example, studies showed that people in thelower socioeconomic levels of our society tended to utilize healthservices and to engage in health-promotional and disease-pre­ventive behaviors less frequently than did people in higher socio­economic levels. However, hardly any attempt was made to in­vestigate why it was so. Anthropologists such as Paul (1) and afew others demonstrated the effects of cultural forces on healthbeliefs and behavior, mainly through evidence from foreigncultures.

Since neither socioeconomic nor cultural conditions can easilybe changed, such studies yielded few implications that mighthave been utilized in programs to improve people's health prac­tices. Thus, attempts to bring about improvements relied mostlyon guesswork which was based on the experiences of people infields such as public relations, commercial advertising, and edu­cation. The thread that ran through all of what then constitutedhealth education generally followed two assumptions. The firstwas that ignorance was the culprit in matters of health and dis­ease. Programs therefore placed heavy emphasis on creating abetter-informed public with the expectation that once peopleknew more about health and disease they would act more intel­ligently to promote the former and prevent the latter. The sec­ond assumption was that people, being naturally afraid of dis­ease and death, would respond to fear appeals. All stops werepulled to present the specter of disease in all of its terrifyingaspects.

Beginning about the middle of the 1950s, behavioral scientistsincreasingly began to apply psychological theory to the study ofhealth-related behavior. One of the first research projects of thiskind was carried out by Hochbaum (2) who, within the frame­work of Lewinian psychology, identified certain psychosocial fac­tors as being associated with the utilization of health services.On the basis of his findings, he developed with his colleagues the"Health Belief Model" (3, 4, Note 1). Despite its considerableshortcomings, this model proved to be a good predictor for avariety of health and sickness behaviors and to be useful for theplanning and evaluation of health educational programs (Note2). Its greatest significance, however, lay in the fact that it at­tempted to answer the question of why people act the way they

THE A UTHOR is Professor, Department ofHealth Education,School ofPublic Health, University ofNorth Carolina, ChapelHill, NC 27514.

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do in health matters, not just who acts how. Since then, researchon this question has proliferated and has led to various refine­ments of the Health Belief Model as well as to the emergence ofother theoretical models. An ever-growing understanding ofhuman health behavior has emerged, both in respect to the pro­motion of health and the prevention of disease, and in respect torecovery from disease, that is, patient behavior.

As such understanding grew it affected the nature of programsdesigned to generate changes in the health behavior of individ­uals as well as oflarge populations. The behaviors involved werenow considered to be merely consequences or symptoms of un­derlying psychosocial dynamics. Programs began to addressthese dynamics in a more systematic form than had been done inthe past. Thus, for example, the earlier assumption that healthbehavior was mainly a matter of health knowledge and motiva­tion gave way to a growing realization of the complexity of beliefsystems and of their interaction with social, economic, and envi­ronmental factors. Attempts were now made to identify thesefactors before planning educational strategy. In contrast, theearlier programs relied on the belief that the lay public sharedthe values, beliefs, and opinions of health professionals. Atten­tion now focused on issues such as people's subjective percep­tion of the health problems at stake, the degree to which theirlifestyles and social environments facilitated or hindered behav­ioral change, the possible clashing of health needs with otherneeds, and the influence of economic factors and of conditions intheir physical environment.

Behavioral research opened up new vistas for those concernedwith improving people's health through modification of theirhealth-related practices. The area of nutrition education, how­ever, has remained relatively, albeit not entirely, untouched bysuch developments occurring in the realms of other health-re­lated behaviors. Nutrition education research has generallyrelied on three approaches: 1) surveys of people's knowledgeand practices; 2) research on physiological factors; and 3) re­search on psychological factors carried out, by and large, undercontrolled experimental conditions. Although much has beenlearned and our understanding of people's nutrition-relatedpractices has been greatly increased by such research, it seems tohave had relatively little effect on nutrition education and on thepursuit of its avowed goal of changing the public's eating prac­tices.

One reason is undoubtedly the dearth of studies that deal withthe complexity of the behaviors involved in food selection andconsumption processes as it exists in real life. Almost all studieshave focused only on certain dimensions, such as knowledgeand attitudes, or on pronounced deviations from the norm, suchas the eating practices of the obese. Second, there has been rela­tively little utilization of the great amount of research on otherkinds of health behavior, although the factors affecting eatingpractices may, in principle, be very much the same as factorsaffecting participation in immunization, disease screening, orsmoking cessation programs. Third, most and generally the best

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research on factors affecting nutrition-related behavior, espe­cially in the psychosocial area, has been done by investigatorswho tended to be more intrigued with the advancement oftheory than with the practical aspects of producing behaviorchange. This is not meant to be a criticism of such very valuableresearch but simply a reflection that there have been relativelyfew well-designed and well-executed studies directed at evolvingand evaluating more effective programs to alter the public'seating habits for the better.

The one major exception is found in the area of marketing,where an abundance of research is available on the effects ofvarious kinds of advertising, the manners in which products aredisplayed in stores, and other manipulations of consumers' foodpurchasing behavior. Most of such research has served commer­cial interests more than the concerns of the health professions;and, indeed, the findings have often been used to promote prod­ucts which conflict with the demands of sound nutrition.

Despite all that is wanting in the area of research to improvethe public's nutritional status, we have gained considerable un­derstanding. Much of what we know has been reviewed in a pre­vious paper by the present author (5) and will not be repeatedhere. However, some of it has quite plausible implications forthe direction that future research and educational and othertypes of interventions might take.

THE ROLE OF PSYCHOSOCIAL AND

CULTURAL FACTORS

Perhaps the single, potentially most important issue is the recog­nition that food purchasing, preparation, and consumption be­haviors are determined far more by psychosocial, cultural, andcertain situational factors than by physiological factors. In moreprimitive organisms, nutritional intake is wholly a function oforganic needs, but such needs playa relatively minor role inhuman food consumption. What foods we select, how we pre­pare them, when we eat, and even when we feel hunger, aremostly learned behaviors.

Some of these behaviors are deeply imbedded in culturalnorms and tend to resist any but moderate modifications (l, 6).Foods that may be considered delicacies in one culture are re­jected as odious in others. Even within the United States, widevariations in food preferences can be found in geographic re­gions and religious and ethnic subcultures. These variationsshow remarkable persistence despite modern food preservationand distribution methods which make the same products avail­able virtually everywhere in the country.

Many individual nutrition-related attitudes and habits can betraced to childhood experiences. The kinds of foods eaten in thehome as a child, the way they are prepared, and the manner inwhich parents handle the child's eating behavior all leave theirimprint on an individual's later eating habits for better or forworse.

Social and cultural factors influence not only what we eat butalso when we feel the need to eat. Although the sensation ofhunger is produced by the physiological phenomenon of gastricmotility, it can also be produced merely by the awareness thatthe accustomed mealtime has arrived (7). Moreover, the subjec­tive experience of hunger can be triggered by various psychologi­cal states, such as anxiety, tension, boredom, or guilt, becausethe sensations caused by the biochemical processes accompany­ing such emotional states are easily confused with the sensationsof hunger. Such is apparently the case with obese individuals (8).Bruch (9) asserts that awareness of hunger is not "innate biologi­cal knowledge" but is learned.

Food serves to satisfy a variety of psychological as well as or­ganic needs. Various theories link eating to aggression, sexuality,

S 60 JOURNAL OF NUTRITION EDUCATION

frustration, and other psychological dynamics. Food consump­tion and dieting, especially in their more excessive forms, may becompulsive attempts to cope with pathological psychologicalproblems.

The degree to which people's food-related behaviors are in­fluenced, and very decisively influenced, by cultural, social, andpsychological forces has been stressed here because the other­wise wide recognition of these factors has had little impact onthe practice of nutrition education. Nutrition education, whethercarried out in individual face-to-face situations (as, for example,in a patient's education), in the school room, in community pro­grams, or on a national level, is still shaped by three largely in­valid assumptions:

1 that informed awareness of the health effects of nutrition isa potent motivation for people to regulate their food intake;

2 that it is lack of nutrition knowledge that prevents peoplefrom eating more rationally; and

3 that informed people will eat more rationally as long as theycan afford and have access to the proper food products.

THE ROLE OF NUTRITION KNOWLEDGEThese assumptions have led to an almost infinite number of sur­vey-type studies on what people know or do not know about nu­trition; on people's attitudes toward nutrition; and on their foodpurchasing, preparation, and consumption practices. Yet thereis ample and convincing evidence that knowledge of what consti­tutes good nutrition by itself has only limited, if any, effect onnutrition-related practices. Surveys have demonstrated over andover that increments in such knowledge in various populationgroups are not necessarily or even frequently accompanied bycommensurate improvements in the kinds of foods purchasedand consumed. This has been found to be true in almost everysituation, from attempts to achieve compliance with a dietaryregimen in patients, to school nutrition education, and to pro­grams which have broad populations as educational targets (5).

The necessity exists for people to be knowledgeable about cer­tain aspects of sound nutrition in order to be able to make ra­tional decisions, but such knowledge functions as a tool only ifand when people are ready to make changes. Knowledge is not,by itself, the instigator of change. From research in other health­related behaviors it appears that there has to be an emotional"readiness" on the part of a person to shift from a present to adifferent kind of behavior in order for factual knowledge to beaccepted (2-4, Note 1). Facts are used to justify and rationalizethe decision to change rather than to stimulate it. In the absenceof such readiness, facts are either disregarded or altered to ra­tionalize the present behavior. Since even the most objectivescientific data are open to subjective interpretation, people areprone to interpret such data to support what they wish them tomean. A classic example is those smokers who are not ready togive up cigarettes and who, when told that 20 percent of smokerswith their daily consumption of cigarettes will fall victim totobacco-linked diseases, may convince themselves that the oddsare that they will be among the 80 percent who survive. Toomuch information, especially complex information, may be con­fusing to those who are not able to process it in their minds. Insuch cases, concern over possible health consequences andknowledge about how to prevent these (that is, what actionsmay be required) may be insufficient to produce the desirable be­havior. Too much additional information on the more scientificaspects may even have a detrimental effect.

Research has not yet provided any guidelines to help nutritioneducators match an optimally effective type and quantity of fac­tual information with a specific target population. Educatorsmust rely largely on whatever skills, instinct, and experiencethey happen to possess.

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THE ROLE OF MOTIVATIONEarlier a reference was made to emotional "readiness" for chang­ing to a new behavior, a concept derived from the Health BeliefModel. As adapted to nutrition-related behavior, one can postu­late that such readiness exists when a person feels motivated toachieve or obtain something strongly desired or to preventsomething feared from happening, and when the individual per­ceives that the new behavior will lead to the desired result.

Nutrition education has been based by and large on the beliefthat the achievement of optimal health and the prevention of dis­ease are strong and widely shared motivations. Therefore, theprinciple thrust has been to convince the public that proper nu­trition will satisfy these motivations. That belief is by all appear­ances justified, and this thrust has had considerable impact.Both, however, have serious limitations embodied in the actionsof millions of people who aspire to health and are aware of thelink of well-balanced meals to health, but who still persist in un­desirable nutritional practices.

Health is an abstract concept. Health professionals operation­alize it as the absence of pathological conditions, the capacityfor optimal functioning, or sometimes as the state of well-being.But most laypersons consider health to be the means to achieveand enjoy the other things that happen to be important to them.Being free from pain and disability and prolonging life are only apart, albeit an important part, of health. Laypersons are likelyto engage in particular behaviors if they see these as contributingto their personal goals, regardless of whether the behaviors arelabeled by health professionals as healthful or not, or evenwhether or not they are labeled as detrimental to health. Only asmall minority of the American public adopt health-promotingpractices merely because of their health-promoting quality.

The same is surely true for nutrition behavior. There are, ofcourse, people who recognize the abstract concept of health as avalue to be achieved for its own sake and who will rationally anddeliberately adopt dietary habits conducive to its achievement.The only educational problem presented by such people is one ofensuring that they are properly informed as to the kinds of nu­tritional practices likely to contribute to their health. Programsthat appeal to health outcomes and stress the information-givingdimension of nutrition education are most likely to be successfulwith these people. Such people clearly represent, however, onlya rather small minority of the population. If we place credence inthe results of various surveys, there is a much larger group whoalso are guided more or less by health concerns in their food pur­chases. However, as Zetterberg (Note 3) has pointed out, theseare "verbal norms," that is, normative statements which peoplehave learned are socially acceptable and laudable in their socie­ties. They verbalize these statements without being guided bythem in their daily conduct although they may have internalizedand believe in such norms.

To value health and to purchase and prepare foods with theireffects on health in mind, are verbal norms in our society largelybecause of concerted efforts to make the public conscious of theimportance of nutrition. Poorly structured questionnaires andnaively phrased questions, characteristic of many surveys thisauthor has seen, tend to elicit such verbal norms rather than val­id responses. Many years ago, in connection with a project unre­lated to nutrition, the present author interviewed a sample ofpeople exiting a supermarket. Although a sizeable percentage ofthem extolled the health values of the very staples they hadbought, only a handful could identify how or why these particu­lar staples were related to a healthful diet. Since the results ofsurveys are often used to plan educational programs and evennational strategies, better methodologies are needed to provideus with more valid data on the role that health-related percep-

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tions of food play in the actual nutrition-related behaviors of thepublic.

A parallel case in point is that of joggers and golfers who mayproclaim (and honestly believe) that they engage in these sponsfor health reasons. However, very plausible arguments can beadvanced that the real motives are more in the nature of the en­joyment of the particular activity, its social aspects, the yieldingto what is in essence a social movement, the pride in accomplish­ment and in excelling, the thrill of testing one's stamina, and thelike. In a study of men over forty who were recruited into alengthy project to examine the effects of regular exercise on therisks of heart disease, Heinzelmann and Bagley (10) have pro­vided interesting evidence for these arguments. Although all par­ticipants in the study volunteered for the project out of a wish tobenefit medically, many dropped out. The difference betweenthose who dropped out and those who persisted to the end wasthat the latter enjoyed the physical activities for their own sakesand/or enjoyed the social aspects of the participation. The in­itial health-motivation had receded as a significant stimulus forcontinuation in the project.

There is ample reason to assume that what is true for much ofhealth-related behavior in general is also true for nutrition-re­lated behavior specifically. As remarked earlier, the great major­ity of people are guided in their food selections by considerationstotally unrelated to health: by their own and by their family'staste preferences, by costs, by convenience, by the lures of ad­vertising and store displays, and so forth. They may be influ­enced to a moderate degree by some broad and vague notionabout what is supposed to be healthful, such as consuming freshvegetables or using polyunsaturated fats, but even these notionsare not the primary factor determining what they buy.

Even when people have a fairly strong health orientation,conflicting motives may often and easily interfere with adherenceto its principles. The wish to be considered a good host or host­ess may prevent the preparation of, and social amenities mayprevent a guest from selecting, foods that are believed to be de­sirable from a health point of view. The desire to join and be ac­cepted by one's peers may impose on the most conscientiousperson the need to eat at places where nutritious foods are notoffered. The immense popularity of "fast-food restaurants"reflects less a disregard for sound nutrition than the pervasive­ness of a culture and lifestyle that put heavy emphasis on timeand convenience.

To complicate matters even further, food and its consumptionhave special psychological significance and social symbolism. Areview of the various theories that link foods, eating activities,and digestive processes to oral aggression, sexuality, insecurity,poor self-image, arrested ego-development, and various person­ality traits and psychological dynamics is outside the scope ofthis paper. Similarly beyond this paper's scope is a review of theconsiderable range of social symbolism associated in our ownand in other cultures with all aspects of nutrition , such as obesitysignifying beauty, sexual attraction, power, wealth, even health,in several cultures and in some subcultures of this country; thesocial esteem accorded the gourmet cook; the host's or hostess'need to provide sumptuous meals, the culturally determinedelaborate rituals accompanying meals in social settings, and soforth.

Food has always universally been considered the staff of lifeand has frequently been invested with magical powers. TheGreek gods were given eternal life by nectar and ambrosia. In­numerable legends have arisen in which food plays divine ordemoniac roles. Such beliefs and superstitions are hardly moremystical than those prevalent in our society today: one needonly to think of the blind faith with which millions of people

JOURNAL OF NUTRITION EDUCATION S 61

consume vast quantities of vitamins, take in iron supplements,or restrict themselves to "natural foods," trusting that thesepractices will assure them youth, attractiveness, and immunityagainst disease. These are often individuals who are intellec­tually well enough aware that they receive all the nutrients andminerals they need from their normal daily meals (II).

THEORIES OF NUTRITION BEHAVIOR

The social, psychological, and cultural dynamics which deter­mine what, when, and how people eat are as complex and variedas those that determine all of human behavior. No single theorycan encompass what we call nutrition behavior. What theoriesare set forth to explain such behavior are invariably more gen­eral theories of human behavior applied or adapted to specificphenomena of nutrition behavior. As such, they can be very use­ful for a better understanding of certain aspects of this behavior,of its manifestations under certain conditions or in certain popu­lations, and of some of the vast array of factors and forces thatmay shape it.

Thus, anthropological studies have cast light on the role ofcultural and subcultural forces (I, 8, Note 4). References to bothnormal and pathological eating behaviors abound in the psycho­analytic literature. Various social psychological theories, e.g.,theories of cognitive dissonance, attribution, locus of control,risk-taking, and others, can readily be applied to nutrition be­havior. All of these, however, help explain only limited dimen­sions of such behavior. Moreover, while most of them are moreor less useful in attempts to change the food consumption pat­terns of individuals or small face-to-face groups, only very fewhave practical implications of value to programs addressed tolarge populations.

This pertains particularly to theories concerned with whatmight be called nonnormative nutrition behavior, which has,not surprisingly, stimulated the interest of behavioral scientistsmore than the mundane daily eating practices of the public atlarge. Typical of research on such nonnormative nutrition be­havior is the wide range of studies on the eating habits of theobese (7, 12-15) and more recently in the area of anorexia ner­vosa.

Another problem is that, except for some cultural theories,most theories of nutrition behavior deal predominantlY withvariables which operate and manifest themselves differently fromindividual to individual. They may provide excellent guides fordiagnosing factors that determine a particular individual's eatinghabits and for formulating appropriate steps to help modifythese habits. In essence, they are tools, most appropriate anduseful when dealing with individuals or small groups of individ­uals in what might be called "clinical" settings, such as onewould encounter in weight-reducing programs; in working withchronically ill patients who are on special nutritional regimens;or in the contacts between practicing nutritionists or dieticiansand individual clients and their families.

Although training in such theories is introduced increasinglyin the professional preparation of patient educators and nutri­tionists, the great majority of professionals are virtually unac­quainted with these theories and are therefore unable to utilizethem effectively in practice. Partly because of this, such theorieshave remained largely a tool of behavioral scientists and of a rel­atively few number of professionals working mainly in clinicalsettings. This situation is caused in part by the lack of researchon the development of methods and techniques which wouldutilize implications of these theories to train professionals wholack background and indepth understanding of the theories.

But the main goal of nutrition education is not to modify thenutritional practices of select individuals and small groups.

S 62 JOURNAL OF NUTRITtON EDUCATION

Rather, it is to change certain nutritional practices which pre­dominate among large population groups such as ethnic minori­ties, school children of a certain age, or the American public atlarge. And here, the idiosyncratic nature of all but a few of ex­tant theories renders them of little value to the planning of edu­cational strategies and programs.

NUTRITION EDUCATION FOR THE PUBLIC

Partly for lack of any integrated theory that might provide aconceptual and operational framework, community and, evenmore so, national nutrition education programs have been forcedto rely mainly on conventional empiricism. If there is any guid­ing theoretical orientation, it is, as remarked earlier, one that isbased on two assumptions: I) that people can be motivated togive up present nutritional habits and adopt new ones by alert­ing them to the potential health risks of the former and by prom­ising beneficial health consequences from the latter; and 2) thatthe dissemination of nutrition knowledge is the backbone of anyeducational program.

Both assumptions are undeniably valid for some people insome circumstances and, in practice, have had considerable im­pact. However, their acceptance as being universally valid or asbeing valid for even a majority of people has handicapped thenation's efforts to improve public nutrition beyond a somewhatless than moderate degree.

Based on the preceding discussion of various theories and re­search in the areas of nutrition and other health-related behav­iors, one can draw a number of implications for more effectivenutrition education. Some of these should be treated merely ashypotheses that call for testing through research in the real-lifesettings of our community.

We have seen that people do seem to value health and thatsome adopt select practices or even a lifestyle commensuratewith what they believe will assure lasting health. In the vast ma­jority of cases, however, the long-range goals of assuring lastinghealth and long life have little effect on their daily living prac­tices. These daily practices are more influenced by demandsmade by psychosocial, cultural, economic, and environmentalpressures in their homes and workplaces, and in line with theirindividual, non-health-related aspirations, interests, wishes,fears, and goals. The utilization of whatever already stronglyinfluences their daily conduct would seem more promising thanan appeal to an apparently relatively unimportant "healthmotivation. "

For example, widely held popular views equate healthful, nu­tritious diets with insipidity, costliness, and inconvenience of ac­cess and preparation. But we know that taste, cheapness, andconvenience are among the prime motivators of people's foodselections. Since there is no reason why a nutritious diet couldnot offer these advantages, at least within certain unavoidablelimits, these need to be stressed as motivational factors morethan potential health effects. One need only think of the numer­ous popular diet books which become best sellers by promisingassured, pleasant, and painless weight reductions without theneed to sacrifice what most people are loath to sacrifice. In con­trast, most books and pamphlets authored by professional nutri­tionists are in title, nature of publicity, and content appealing to(and are likely to be bought and used by) only those potentialreaders who happen to be already concerned with a healthfuldiet. The question is not one of sacrificing truth for the sake ofpopularity but of shifting emphasis from those attributes ofsound nutrition that are weak motivators to those that arestrong.

A related issue concerns influencing people to eliminate or re­duce the ingestion of possibly hazardous food substances such as

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saccharin, sugar, salt, and many others. Here the educationalappeal is directed largely to fear of heart disease, cancer, andother diseases. At first glance, such an appeal appears powerfulsince fear of disease and death is a strong and nearly universalmotivating force. Indeed, fear of disease has been widely used toentice people to engage in preventive health actions. However,as is the case with all emotional appeals, the effects are notalways predictable, and the results may frequently be the oppo­site of the intended results.

The public is bombarded almost daily by reports of newthreats to health and safety. The result is that the public appearsto be increasingly adapting to these threats, which robs thewarnings of some of their potential impact (15). Only the mostintensely felt threats are apt to retain their impact. Inasmuch asthey pertain to the nutrition area, threats are apparently not per­ceived to be of great magnitude by the majority of people for anumber of reasons. For one, the mass media report scientificfindings before these are verified and/or before their implica­tions are tested. A good illustration is the saccharin affair. Con­cern over the possible carcinogenic nature of saccharin led towarnings based only on questionable evidence derived from ex­periments with animals. A drive to curtail saccharin's availabil­ity to consumers was even launched. To the layperson and evento some scientists and professionals, the evidence was and per­haps still is insufficient to justify such radical steps. Reactionsranged from ridicule and disregard to the spread of skepticismtoward reported findings of other carcinogenic food substances,ingredients, and additives.

Another reason for the waning effectiveness of such "fear ap­proaches" is the steadily burgeoning abundance of substancesthat are declared or suspected as causes of disease. A popular at­titude is emerging that anything and everything can cause dis­ease, so that one is generally helpless to defend oneself againstthese hazards.

In addition, uncertainty surrounds both the danger of hazard­ous substances and the benefits obtained by avoiding these. Epi­demiologically and statistically, such danger may be established.However, individuals do not usually regulate their eating prac­tices on the basis of this kind of evidence. Rather, they do it onthe basis of subjective perceptions of the likelihood that theythemselves will be affected (2). Such subjective perceptions areinfluenced by factors other than or in addition to scientific evi­dence. The ultimate effects of ingestion of hazardous or even ofmerely unhealthful foods are vague and far removed in time,while the benefits of such foods, if they are the kind a personlikes, are concrete and in the present, to wit, the enjoyment of adelicious meal. Thus the benefits outweigh the possible dangersas the individual may see it. In such a case, any further emphasison possible risks is not very promising unless avoidance of therisks can be linked to immediate benefits. For example, educa­tional programs that stress taste, convenience, cost, and the ad­vantage of safe and healthful foods while at the same time refer­ring to the possible risk of eating less safe and healthful foods aremore likely to be persuasive than programs that rely only onthreat-appeals.

The point is that the general thrust of nutrition educationshould lean less toward emphasis on the unhealthy and hazard­ous aspect of the undesirable and more toward emphasis on thepleasant, advantageous, and attractive aspects of desirable foodpurchasing and preparation (16). Expectations of immediate,concrete, assured rewards have been shown to lead to the ac­tions which are believed to bring such rewards. Where rewardsare forthcoming, they tend to reinforce actions. This basic prin­ciple from psychology has not received its deserved attention innutrition education.

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EDUCATIONAL AND SITUATIONAL FACTORS

As mentioned earlier, much of the more rigorous research onpeople's nutrition-behavior has been conducted with attemptsto control "extraneous" factors. This is the proper approach forresearch aimed at extending our knowledge of several variablesrelevant to the behavior. Much of the research that has ad­dressed nutrition-related behavior in real life and under uncon­trolled conditions has focused on such specific dimensions of thebehavior as studies of food-purchasing behavior, food prefer­ences, or compliance with prescribed dietary regimens. In re­search, too, certain variables are usually singled out as being ofinterest, while the others are either disregarded or considered"extraneous. "

Without neglecting further research along these lines, there isa need for another approach - one that relatively few scientificand well-designed studies have taken. Such an approach wouldstart out with the behaviors under scrutiny and systematicallytrace back as many of the factors that contribute to the emer­gence of such behaviors as possible. In other words, all antece­dents to the behavior would be considered as independent vari­ables which themselves are linked together by interdependence.Thus, cultural, psychosocial, economic, situational, and otherfactors would be treated as of equal importance, none of them as"extraneous"; and several diverse theories might be called uponto help with the various dimensions of the behavior under study.

One such variable is perceived and real accessibility to desir­able food supplies. By accessibility is meant the availability andease of obtaining food, costs involved, convenience of storageand preparation, and so on. Negative aspects in any of these var­iables are, in essence "barriers" to desirable nutritional prac­tices. The importance of such barriers has received much atten­tion in respect to patients' adherence to nutritional and othermedical regimens (Note 4) as well as to the nutritional practicesof select population groups (17). Even adequate nutritionalknowledge and strong motivations to translate such knowledgeinto practice can falter in the face of strong barriers.

It seems imperative that educational efforts be linked to effortswhich make the desired behavior easier and remove or weakenexisting barriers (16, Note 5). For example, if restaurants incor­porated into their menus special diet selections such as sugar­free or low sodium foods, those people on such diets would beable to eat out more often; and the temptation to deviate fromtheir diets would be minimized. Similarly, difficulty in decipher­ing the often confusing, and for most people uninterpretable, in­formation on the labels offood items presents a real and discour­aging barrier to the people who try to follow the dictates ofsound nutrition.

In general, the terminology, language, presentation of infor­mation, and organization of content of the professional tend tobe quite different from those to which consumers are accus­tomed. The greater the discrepancy, the less likely it is that con­sumers will understand, follow, and utilize the information pre­sented (18). To remove such potential barriers as much as isfeasible, nutrition information should be tailored to variouspopulation groups rather than be presented in standardizedform as in current nutrition education. At the present we lackenough reliable information, however, on the mundane ways inwhich various subgroups think about foods and meals in the nat­ural course of their daily lives. Such information would help usto adapt educational material to the consumers' habits.

SCHOOL NUTRITION EDUCATION

Children have been singled out as the potentially most promis­ing target for effective intervention not only because they are

JOURNAL OF NUTRITION EDUCATION S 63

presumed to be more flexible in respect to acquiring new knowl­edge, attitudes, and behaviors than adults but also because theyrepresent a convenient captive audience.

That children do absorb much nutrition-related knowledge inthe better school nutrition programs has been amply demon­strated. There is even documentation that at least some, thoughfar fewer than desired, behavioral changes occur, such asreduced consumption of sweets and carbonated drinks and in­creased consumption of wholesome foods and drinks. The ques­tions of the long-term effects of such education, of the persist­ence of the newly acquired habits over the following years, andof the assessment for successes and failures in these respects stillawait answers. What scanty evidence is available is very disap­pointing. The long-term impact of school nutrition educationseems small, indeed.

This is not surprising when one considers that the influence ofexposure in the classroom is far outweighed by influences thatimpinge upon children outside the classroom, both while theyare still going to school and in later years.

Any education, whether school education or adult and com­munity education, does not and cannot influence behavior di­rectly but only brings changes in knowledge, attitude, and emo­tional factors within the individual. which may then make theperson opt for certain kinds of behavior. Whether these behav­iors actually occur or not, and in what form they occur, dependson a host of other conditions on which educational processeshave little or no influence, for example, cost, accessibility, andsocial pressure. In a sense, education can do little more thancreate cognitive and affective conditions within individuals thatare favorable to the adoption and maintenance of desirable nu­tritional habits and hope that these will assert themselves behav­iorally against present and future counter-influences.

EVALUATING NUTRITION EDUCATION

In evaluating the effectiveness of nutrition education in school orany other setting, we therefore need to consider three dimen­sions: I) the cognitive and affective changes produced, 2) the im­mediate behavioral changes, and 3) the long-term behavioraleffects. Only the first of these appears to be a completely validcriterion of educational effectiveness. Evaluation of the othertwo requires data on present and future conditions and eventsthat may either reinforce or counteract the educational impact.

This is analogous to much of preventive medicine which ad­dresses itself to risk factors. For example, the public is urged tofollow certain dietary recommendations-to engage in physicalexercise or abstain from smoking to reduce risk factors in rela­tion to cardiovascular disease. Reduction in such risk factorslessens the probability of the occurence of cardiovascular diseasebut does not rule it out because the disease can also be caused byfactors other than these particular risk factors.

One can say that ignorance, misconception, indifference, andother cognitive and affective factors are risk factors which reducethe probability that a person will adopt sound nutritional habits.Education that removes or reduces these risk factors increasesthe probability that a person will adopt sound habits, but eventhe most effective education does not and cannot assure it. Thereare other risk factors, among them the influence of other per­sons, certain characteristics of a person's lifestyle, economicstatus, or occupational conditions, which are little, if at all, re­sponsive to educational processes. A "nutrition program," incontrast to only a "nutrition education program," must attemptto reduce these additional risk factors as well or must at least at­tempt to create conditions that will help individuals cope withthem.

S 64 JOURNAL OF NUTRITION EDUCATION

The foregoing suggests the need for research aimed at the dis­covery and identification of risk factors in the lives of school-agechildren as well as of adults. The present author is unaware ofany studies aimed at the kind of systematic mapping out of riskfactors that could provide a sound basis for planning broad edu­cational and other intervention strategies and for freshly ap­proaching the perplexing problem of how to evaluate immediateand lasting educational effectiveness. To speak of the latter interms of risk reduction would make it possible to differentiatebetween the contribution of educational processes as distinctfrom the effects of other factors.

ADOPTION AND MAINTENANCE OF NEW BEHAVIOR

Common to all attempts to change long-standing habits is theproblem of maintaining over time a new habit pattern once it hasbeen adopted. The enormous number of smokers who have re­linquished their cigarettes, perhaps several times, only to returnto the habit is matched by the number of people who modifytheir food intake for the better, yield to temptation, and returnto their earlier eating habits.

As is the case for smoking, nutritional behavior change iseasy. It is the maintenance of the new behavior that is threatenedby conditions and events, whether these are of the nature of anirrepressible yearning for certain foods; their sight and smell;their linkage with certain events, such as between watching tele­vision and snacking; seductive persuasion by friends; or whathave you.

A better understanding is needed of what events occur in thelives of persons after adoption of new nutritional practices totrigger recalcitrancy - events which one might consider to be"risk factors" in respect to recalicitrancy. While events mayvary among individuals, some of these events are likely to becharacteristic of certain types of people, certain populationgroups, or even a large segment of the public. Here again, re­search to identify risk factors could provide a basis for educa­tional and other intervention strategies that will empower con­sumers to anticipate and withstand or cope with conditions andevents that threaten continued adherence to an adopted nutri­tion style.

CONCLUSION

The present paper does not claim to cover theories, research,and educational aspects relating to nutrition behavior to anycomprehensive extent. It is meant primarily to stimulate interestin and discussion of certain issues which have not received asmuch concerted theoretical, research, and/or program attentionas they need if we wish to have a more decisive and lasting im­pact on the public's nutrition-related practices.

One of the main conclusions to be drawn is that nutrition edu­cation, no matter how effective, will have little impact by itself;neither laws and regulations nor changes in food production,processing, and distribution will individually have much impact.Any profound, population-wide, and lasting changes in the foodculture of the public will come only over a protracted period oftime and only if all of these approaches are coordinated in ageneral and comprehensive strategy. In other words, educationmay prepare people for the adoption of more desirable nutri­tional practices; laws and regulations may promote or assure ac­cessibility of the appropriate food supplies; financial aid maybring these within the reach of the poor; meals-on-wheels orother programs may offer hot meals to those who cannot obtainthem otherwise; and new technologies may produce morehealthful, tastier, and more conveniently prepared foods - but

VOLUME 13 NUMBER 1 SUPPLEMENT 1981

none of these alone will affect any but a small segment of thepopulation.

To use an analogy once more, daily baths did not become aprevalent popular habit until technology provided hot watersupply in homes, and even then it took a spreading concernabout the hygienic and aesthetic benefits of daily baths to estab­lish them as a deeply ingrained behavioral pattern. Thus thehabit was a result of technological advances combined with edu­cational stress on personal hygiene and aesthetic values.

Many theories deal directly with nutrition-related behaviorand have significant implications (Note I). Research on people'sfood-related behaviors abounds, though much of it is merely de­scriptive, carried out under controlled conditions, or addressedonly to specific situations, people, or problems. More research isneeded in the context of people's daily lives in all the complexityand sometimes seeming irregularity and unpredictability of theirfood-related practices to discover common and recurrent ele­ments which may generate new theories. These, in turn, mayyield practical and promising new approaches to influence thepublic's nutrition behavior. Moreover, such behavior takesplace and is deeply embedded in the community and is thereforestrongly influenced by community factors and dynamics. Poten­tially fruitful research might use the community as its arena andnot necessariy address only individuals or select groups or set­tings.

A last point may be worth considering. Nutrition science hasmade tremendous advances in recent years but is still plagued bymany gaps in knowledge. The field is still in a state of flux, sothat yesterday's tested and asserted facts are modified or even re­jected today, and today's assured facts may have to be modifiedor rejected tomorrow. This is, of course, the case with all sci­ences. But some potentially disturbing implications arise whentoday's scientific conclusions lead to programs designed to per­suade or even coerce people to change their lifestyle.

Both ethical and practical questions must be raised. When arewe sure enough of findings to intervene in their name in people'slives? How much persuasion, pressure, or coercion are we justi­fied to use to induce people to sacrifice practices they enjoy andto adopt practices which may prove in the light of future scien­tific findings to bring few benefits or even to be detrimental totheir health (l9)?

Concern with such questions was recently echoed by Philip L.White, Director of the Department of Foods and Nutrition ofthe American Medical Association:

American concern about correct nutrition and physicalfitness may be exaggerated.... Too much is being prom­ised in the name of nutrition, and too much politicking isbeing done in the name of nutrition. It's no wonder thathardly anyone believes anybody anymore. (20)

Although this issue is not strictly within the realm of either sci­entific theory or research, it is highly and disturbingly relevant tonutrition education and one which should be of concern to allengaged in nutrition education. D

VOLUME 13 NUMBER I SUPPLEMENT 1981

NOTES

1 Hochbaum, G. M. Behavior in response to health threats. Unpub­lished paper presented at the Annual Meeting of the American Psy­chological Association, 1960.

2 For more detailed exposition of the complete Health Belief Model,see (3).

3 Zetterberg, H. Personal communication to author, 1951.4 Hatch, 1., and G. M. Hochbaum. Implications of social change for

dietary patterns of black Americans. Unpublished presentation atthe Annual Meeting of the American Public Health Association,New Orleans, 1974.

5 Caron, H. An evaluation of the booklet Planning low sodium meals.Unpublished report, 1955.

LITERATURE CITED

Paul, B., ed. Health, culture and community. New York: RussellSage Foundation, 1955.

2 Hochbaum, G. M. Participation in medical screening programs: Apsychosocial study. U.S. Public Health Service Publication. Wash­ington, D.C.: Government Printing Office, 1953 (2d ed. 1970).

3 Becker, M. H., ed. The Health Belief Model and pw,onal healthbehavior. Health Education Monographs 2(4):328-508, 1974.

4 Rosenstock, I. M., and G. M. Hochbaum. Determinants of healthbehavior. In White House Conference on Children and Youth.Washington, D.C.: Government Printing Office, 1960.

5 Hochbaum, G. M. Nutrition behavior and education. In Nutrition,lipids, and coronary heart disease, R. Levy et aI., eds. New York:Raven Press 1979, pp. 365-90.

6 Montague, M. F. A. Nature, nurture and nutrition. AmericanJournal of Clinical Nutrition 5:237-44, 1957.

7 Schachter, S., and L. Gross. Manipulated time and eating behav­ior. Journal of Personality and Social Psychology 10(2):98-106,1968.

8 Bruch, H. Transformation of oral impulses in eating disorders: Aconceptual approach. Psychiatric Quarterly 35:458-81, 1961.

9 Bruch, H. Hunger and instinct. Journal of Nervous and MentalDiseases 149(2):91-114, 1969.

10 Heinzelmann, F., and R. W. Bagley. Responses to physical activityprograms and their effect on health behavior. Public Health Re­ports 85:905-911,1970.

11 National Analysts, Inc. A study of health practices and opinions.Washington, D.C.: Government Printing Office, 1973.

12 Schachter, S., R. Goldman, and A. Gordan. Effects of fear, fooddeprivation and obesity on eating. Journal of Personality andSocial Psychology 10(2):91-97, 1968.

13 Schachter, S. Obesity and eating. Science 161:751-56, 1968.14 Stuart, R. B., and B. Davis. Slim chance in afat world: Behavioral

control of obesity. Champaign, Ill.: Illinois Research Press, 1972.15 Hochbaum, G. M. An alternate approach to health education.

Health Values 3(4):197-201,1979.16 Hochbaum, G. M. Patient counselling vs. patient teaching. Clinical

Nursing 2(2): 1-8, 1980.17 Goldsmith, F. J., and G. M. Hochbaum. Changing people's behav­

ior toward the environment. Public Health Reports 90:231-34,1975.

18 Janis, I. L., and J. Rodin. Attribution, control, and decision mak­ing: Social psychology and health care. In Health psychology­Handbook, G. C. Stone et aI., eds. San Francisco: Jossey-BassPublishers, 1979, pp. 487-521.

19 Hochbaum, G. M. Ethical dilemmas in health education. HealthEducation 11(2):4-6, 1980.

20 White, P. L. Remarks at a meeting of the National Food ProcessorsAssociation, as reported in Institute of Nutrition News 10(3):2,1980.

JOURNAL OF NUTRITION EDUCATION S 65