Elsevier

Social Science & Medicine

Volume 80, March 2013, Pages 47-56
Social Science & Medicine

Habit, custom, and power: A multi-level theory of population health

https://doi.org/10.1016/j.socscimed.2012.12.029Get rights and content

Abstract

In multi-level theory, individual behavior flows from cognitive habits, either directly through social referencing, rules of thumb, or automatic behaviors; or indirectly through the shaping of rationality itself by framing or heuristics. Although behavior does not arise from individually rational optimization, it generally appears to be rational, because the cognitive habits that guide behavior evolve toward optimality. However, power imbalances shaped by particular social, political, and economic structures can distort this evolution, leading to individual behavior that fails to maximize individual or social well-being. Replacing the dominant rational-choice paradigm with a multi-level theoretical paradigm involving habit, custom, and power will enable public health to engage in rigorous new areas of research.

Highlights

► A new theoretical framework is offered to explain how the many elements included in existing conceptual models function. ► Patterns of behavior can be better explained by cognitive habits, than by rational choice theory. ► When cognitive habits are widely shared within a society, they take on a social ontology as custom. ► Custom evolves toward optimality through a process of natural selection. ► Social, economic, and political power exerts selective pressure for custom to evolve toward the interests of power.

Introduction

Thoughtful introspection suggests that we are thoughtfully introspective. Science says otherwise. An abundance of carefully conducted research now demonstrates that we are imperfect optimizers, slapdash rationalists. The past 20 years have seen an explosion of research in neuroscience, psychology, marketing, and behavioral economics, all of which suggests that our minds are more efficient than rational (Rice & Unruh, 2009). Where the rational choice model claims that behavior is the aggregation of individual decisions, each a thoughtfully deliberative weighing of pros and cons, newer research shows that behavior is not reducible to individual decisions, that decisions have momentum, and that behavior is the accretion of patterns, not the aggregation of choices.

But if we are not careful and deliberative, if instead we are predictably irrational, profoundly influenced by default options, framing, and heuristics, how are we able to make good decisions at all? How is it that, despite it all, most of our decisions are rational, or at least rational-seeming? If we are such bad decision-makers, why aren't we in worse shape? This question has tremendous implications for public health (Ubel, 2009).

This paper lays out an alternative paradigm for human decision-making, a paradigm that acknowledges its debt to rational choice, but is not indentured to it. This alternative paradigm locates the genesis of thought and action in cognitive habits: clusters of cognitions that are triggered as a group by a single cue—much as a musician plays a scale, not a set of individual notes. These cognitive habits evolve over time in response to selective pressure, and can be distorted by powerful individuals or groups (cigarette manufacturers, soda marketers, specialty physicians) who have a vested interest in influencing behavior. This paradigm insists on rigorous integration of research on individual choices with scientific disciplines that model the elements of choice in its neuroscientific underpinnings as well as in its social, economic, and legal contexts. This alternative paradigm is called multi-level theory. It stands in sharp distinction to the pervasive paradigm of rational choice theory.

Multi-level theory is an effort to bring theoretical thinking in the public health upstream (McKinlay, 1975; Pearce, 1996). Upstream from obesity lie diet and physical activity, but upstream from these issues are territories as yet uncharted by public health, contested, and which must be hard-fought: the realm of choice theory and, farther still, social theory. A map of this region is essential, along with a strategic understanding of how this terrain is controlled. Without aggressive intellectual inroads into these areas, public health risks being swept away in the downstream effluvium of forces it cannot apprehend (Krieger, 2011; Mooney, 2009; Pearce, 1996).

Section snippets

Cognitive habits

Suppose that God had given you the task of designing a decision-making machine for his new creature, Adam. You might start by giving Adam some likes and dislikes and a calculation engine that tells Adam to choose the option corresponding most closely to his preferences. His behavior is the collection of these choices, with no correlation among choices other than that implied by Adam's stable preferences. Fig. 1 presents the rational-choice theoretical model.

With this rational machine, Adam can

Evolution

If you are looking for a vegetable whose preparation tries your patience, look no further than the fava. It must be shelled twice, and the bitter inner skin is difficult to remove. Tricks abound for making the process easier, but even with boiling in salt water and plunging into a cold bath, shelling favas is no one's idea of a good time. One San Francisco food writer, lamenting the substantial work it takes to get a quarter-cup of usable beans concludes, “you are so sick of them you'd rather

Power

If, as William Foege has written, “the philosophy of public health is social justice” (Foege, 1987), then the analysis of population health must be the study of power. Indeed, to ignore power would be to ignore the most important determinant of population health—it would be possible, but it would be theoretically impoverished, ad hoc, and boring. As many in public health have argued, rigorous analyses of power are possible (Mooney, 2009; Solar & Irwin, 2010).

Just as neuroscience and psychology

True interests

The invocation of the capacity of power to distort cognitive habits raises the issue of discerning true interests. If a child prefers soda to milk, how can it be determined that this is a choice arising from a distorted set of cognitive habits rather than from his own natural cognitive habits?

To begin, it should be emphasized that “true interests” apply only at a certain level of abstraction. It is reasonable to assert that true interests prioritize health over ill-health, but it would be

Multi-level theory and rational choice theory: a tale of two paradigms

This conceptual apparatus allows our causal maps to be more accurate. There are two frames for decision-making, equally valid, but unequally applicable. The rational-choice model says that we are vassals of fixed preferences, in homage to which we weigh the costs and benefits of each option in our choice set. The habit-custom-power multi-level frame recognizes that our choices and the preferences behind them are profoundly influenced by cognitive habits, which have an ontological existence at a

Conclusion

Conceptual models abound in public health, but conceptual models and theory serve different purposes. While a conceptual model taxonomizes the factors involved in a health outcome, a theory proposes a specific causal mechanism for how these factors work. This distinction is that between nouns and verbs. We in public health have better luck communicating with each and others when we are careful and conscientious in our use of verbs. We now have a good sense of what upstream factors influence

Acknowledgments

The author is grateful to Tom Rice and Dan Bromley for many fruitful discussions, and to the feedback of the Department of Health Policy and Management Seminar at UCLA. Any infelicities are those of the author's alone.

References (75)

  • A. Bandura

    Toward a psychology of human agency

    Perspectives on Psychological Science

    (2006)
  • A.J. Barnes et al.

    One fish, two fish, red fish, blue fish: effects of price frames, brand names, and choice set size on medicare part D insurance plan decisions

    Medical Care Research and Review

    (2012)
  • T.D. Barnes et al.

    Activity of striatal neurons reflects dynamic encoding and recoding of procedural memories

    Nature

    (2005)
  • R.F. Baumeister et al.

    Ego depletion: a resource model of volition, self-regulation, and controlled processing

    Social Cognition

    (2000)
  • J. Beaulac et al.

    A systematic review of food deserts, 1966–2007

    Preventing Chronic Disease

    (2009)
  • D. Blane et al.

    Social class differences in years of potential life lost: size, trends, and principal causes

    British Medical Journal

    (1990)
  • P. Bourdieu

    The logic of practice

    (1992)
  • S.L. Bray

    Power rules

    Columbia Law Review

    (2010)
  • S. Brickman

    Fava beans: Roasting pods simplifies preparation

    (2011)
  • D.W. Bromley

    Sufficient reason: Volitional pragmatism and the meaning of economic institutions

    (2006)
  • D. Cohen et al.

    Eating as an automatic behavior

    Preventing Chronic Disease

    (2008)
  • L. Cosmides et al.

    Better than rational: evolutionary psychology and the invisible hand

    The American Economic Review

    (1994)
  • D.M. Cutler et al.

    Why have Americans become more obese?

    Journal of Economic Perspectives

    (2003)
  • R.M. Dawson

    The shacklean nature of commons's reasonable value

    Journal of Post Keynesian Economics

    (1994)
  • T.M. Desrochers et al.

    Optimal habits can develop spontaneously through sensitivity to local cost

    Proceedings of the National Academy of Sciences

    (2010)
  • R.A. Deyo et al.

    The messenger under attack: an occupational hazard for health researchers

    The New England Journal of Medicine

    (1997)
  • R.A. Easterlin et al.

    The happiness-income paradox revisited

    Proceedings of the National Academy of Sciences

    (2010)
  • P. Farmer

    On suffering and structural violence: a view from below

    Daedalus

    (1996)
  • P. Farmer

    Pathologies of power: rethinking health and human rights

    American Journal of Public Health

    (1999)
  • R. Ferraro et al.

    The power of strangers: the effect of incidental consumer brand encounters on brand choice

    Journal of Consumer Research

    (2009)
  • E.A. Finkelstein et al.

    The fattening of America: How the economy makes us fat, if it matters, and what to do about it

    (2008)
  • W.H. Foege

    Public health: moving from debt to legacy

    American Journal of Public Health

    (1987)
  • K.R. Fontaine et al.

    Obesity and health-related quality of life

    Obesity Reviews

    (2001)
  • B.S. Frey et al.

    What can economists learn from happiness research?

    Journal of Economic Literature

    (2002)
  • S. Galea et al.

    Estimated deaths attributable to social factors in the United States

    American Journal of Public Health

    (2011)
  • J. Galtung

    Violence, peace, and peace research

    Journal of Peace Research

    (1969)
  • Graybiel, A. (2008a). Our habitual lives: how the brain makes and breaks habits. Vanderbilt Prize in Biomedical Science...
  • Cited by (36)

    • Combining econometric analysis and simulation modeling to evaluate Population-Based health policies for chronic disease prevention and control

      2021, Preventive Medicine Reports
      Citation Excerpt :

      As the epidemic of chronic diseases continues to grow unabated around the world, there is an urgent need for public health leaders, health care providers, and policymakers to make evidence-based decisions to reduce the burden of chronic disease and improve population health. A new paradigm in chronic disease prevention and management has evolved, whereby individual-level approaches are complemented with population-level and policy changes to mitigate the burden (Zimmerman, 2013). While methods for formal evaluation of these broad changes are community-based randomized controlled trials, these designs are costly and often not feasible to implement in conjunction with policy advances.

    • Public health and the economy could be served by reallocating medical expenditures to social programs

      2017, SSM - Population Health
      Citation Excerpt :

      Perhaps if these costs were better understood in these human terms, it would be less commonplace for policy-makers to shrug off the nearly trillion dollars in wasteful spending every year. The levels of healthcare spending by states and the US are a result of specific policy choices (Zimmerman, 2013). They reflect decisions not to negotiate over the price of pharmaceuticals, to avoid price transparency, and to prohibit the use of cost-effectiveness analyses in health priority setting.

    • Designing and Undertaking a Health Economics Study of Digital Health Interventions

      2016, American Journal of Preventive Medicine
      Citation Excerpt :

      To illustrate what a complex economic evaluation might look like, consider Zhang and colleagues,15 who used an agent-based model of social network interactions to examine the effect of different policy instruments in changing dietary behaviors (Figure 1). Based on a multilevel theory of population health that encompasses habitual behaviors,16 behaviors are influenced by standard economic incentives, such as price, but also affected by cognitive habits that are subject to social norms. The model simulated potential policy impacts (e.g., taxation) and could be extended by incorporating data from natural experiments and health administrative records, to examine influences on health, well-being, and costs to the healthcare system.

    • Social Determinants of Health

      2023, Chronic Illness Care: Principles and Practice, Second Edition
    • Investigating Employment Quality for Population Health and Health Equity: A Perspective of Power

      2022, International Journal of Environmental Research and Public Health
    View all citing articles on Scopus
    View full text