Negative health behavior: a personal responsibility or not?
Subject: Chronic diseases (Risk factors)
Chronic diseases (Reports)
Public health (Reports)
Author: Licina, Derek
Pub Date: 10/01/2012
Publication: Name: U.S. Army Medical Department Journal Publisher: U.S. Army Medical Department Center & School Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 U.S. Army Medical Department Center & School ISSN: 1524-0436
Issue: Date: Oct-Dec, 2012
Product: Product Code: 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs
Accession Number: 309980589
Full Text: According to the World Health Organization, chronic diseases with preventable risk factors have surpassed infectious diseases as the major cause of morbidity and mortality worldwide. (1) Five of these diseases--cardiovascular diseases, diabetes, obesity, cancer, and respiratory diseases--kill more than 33 million people a year and account for over 46% of the global burden of disease. Out of this 33 million, 12 million people die as a result of heart attack and/or stroke each year. Furthermore, over one billion adults in both developing and developed countries worldwide are overweight, with 300 million clinically obese. (1) The deaths of an additional 5.4 million people annually are attributable to tobacco-related illnesses. (2)

Within the United States, 7 of 10 Americans die each year as a result of chronic diseases. (3) Commensurate with international statistics of both developed and developing countries, heart disease, cancer, and stroke make up more than 50% of all deaths annually. (4) These 3 diseases in conjunction with diabetes and arthritis are the most prevalent, costly, and preventable in the United States. Further exacerbating the current rate of US mortality is a growing obese population where one in every 3 adults living here is clinically obese. (5) Additionally, the most recent empirical study by the Centers for Disease Control and Prevention using 2000-2004 US data estimated 443,000 individuals die each year, (6) including 3,000 adult nonsmoker deaths as a result of exposure to secondhand smoke. (7) Beyond the human toll, the report found the economic impact of smoking-attributable health care costs to be approximately $96 billion, which did not include the estimated productivity losses of $97 billion--collectively $193 billion annually. (6)

There are multiple factors leading to this increase in chronic diseases. One of the primary causes is the epidemiologic transition of developing countries driven by 3 major determinants: ecobiologic; socioeconomic, political, and cultural; and medical and public health interventions. (8) One example of these components is the migration of rural agrarian populations to more urban-based communities as a result of industrialization and economic development. This dramatic increase in chronic diseases is creating a double burden of disease as these countries and individuals continue to struggle with the impact of infectious diseases. (9) As individuals move between these environments, behaviors are modified which could have a deleterious effect on those unaccustomed or without social and community networks to address new risk factors. Negative changes in dietary habits, reduced physical activity, and an increase in tobacco product use and alcohol consumption are the primary driving factors of this rapid increase of chronic diseases worldwide, including the United States.

In an effort to mitigate the rapid growth of these diseases and their associated costs, nations are looking at ways to address the root causes of these risk factors and associated behaviors. Simultaneously, they are determining how existing health care systems could be modified to meet the growing demand due to these chronic diseases. As a result, the debate surrounding personal and social responsibility in relation to health behavior and negative outcomes has intensified. Different philosophies have emerged, as well as methods to establish a role for responsibility in healthcare and develop appropriate intervention strategies to minimize unhealthy behaviors. Both are discussed as they identify the roles that individuals and societies play in addressing this growing health burden of global proportions.


A US survey conducted in July 2006 found that 53% of Americans thought it would be fair to ask people with unhealthy lifestyles to pay higher insurance premiums than those with healthy lifestyles. (10) In the United Kingdom, a June 2010 poll found 35% of the population surveyed believed higher taxes on alcohol, cigarettes, and unhealthy food would be the best way to reduce their National Health Service spending. (11) Both of these national surveys indicate that their respective populations see a role for individual responsibility in negative health behavior as it relates to health insurance. However, much controversy revolves around individual rights to make independent choices and whether states or healthcare systems have the right to intervene by demanding personal responsibility for health. (12)

Some Americans use car insurance as a proxy when discussing health insurance and the role of individual responsibility. For example, individuals must pass a driver's license test to gain the right to drive, which requires some type of minimum insurance coverage. If over time individual failures such as speeding tickets or traffic accidents accumulate, penalties in the form of higher deductibles or the potential of being dropped by an insurance company occur. Similarly, the idea that individuals must show a minimum level of preventive services conducted before using a warranty for larger vehicle repairs could be applied to health insurance. (13) Most notably, Dr C. Everett Koop, a former US Surgeon General, stated "the plain fact is that we Americans do a better job of preventive maintenance on our cars than on ourselves" while noting car insurance does not cover preventive maintenance for vehicles. (14) Both of these examples highlight the perceived need for individuals to be accountable in reducing and eliminating their negative health risks while investing in preventive services such as health promotion activities and vaccination programs. Others argue against the auto insurance comparison, stating that individuals can simply avoid speeding by deciding to do so which does not adversely impact their individual costs. (15) Simply deciding to lose weight, stop smoking, or reduce cholesterol is not enough, as there are numerous individual and societal barriers. Those include a lack of fitness center availability, poor smoking cessation program access, and a paucity of healthy food options coupled with unfortunate human genetics. (15)

As health reform is implemented in the United States, some maintain that since it is for the population, they must "become full participants and assume much greater responsibility for their actions if health benefits are to be maintained at an affordable cost." (13) Directly associated with cost is the issue of poor compliance by the individual patient which is commonly cited by physicians as an impediment to positive health outcomes. (13) Encouraging individuals to assume responsibility for completing preventive screening tests, obtaining proper vaccinations, and taking prescribed medications by either incurring penalties or obtaining a cost savings are options available. It is perceived that responsible patients and communities support physicians by acting responsibly, which could have a direct impact on overall cost-effectiveness of the health care system. (13)

However, others acknowledge reasons may exist outside of individual control which directly and indirectly impact patient compliance with medical recommendations and their ability to keep individual appointments. Some of these factors include poor physician-patient communication, adverse side effects of medication, limited access to modes of transportation and child care, rigid work schedules, language barriers, and other cultural barriers. (16-18) Additionally, it is argued that in order to encourage personal responsibility, more fundamental social and structural issues must be addressed. (19)


The terms "lifestyle" and "health behavior" automatically imply individual culpability rather than considering the role social and physical environments may have in reinforcing individual negative behavior. (20) Dr Koop acknowledged that American health problems are due more to society, "especially the shameful prevalence of poverty in this rich country," than from problems with the healthcare system. (14) Some posit that poverty is the single biggest factor underlying adverse health outcomes which worsen when poverty intensifies. (21) Within the United States, Medicaid is the program which supports the medical needs of the impoverished and has been the recent target of state efforts to address individual responsibility by imposing paternalistic health requirements, such as those in West Virginia. Enforcing individual responsibility will not necessarily improve the impoverished individual's health coverage, access, or independence, (19) but will more likely further exacerbate unhealthy behaviors and an already poor health status. This is highlighted today by the situation in which individuals living in poverty experience a higher rate of HIV/AIDS and are the least likely to have access to both the healthcare and treatment so desperately needed, even 25 years after the disease was first recognized. (22)

To address this issue from a social inequalities perspective, studies indicate a higher prevalence of unhealthy behaviors among lower socioeconomic status individuals, which correlates directly to an overall worse health status among this group. (23-25) Stringhini et al (26) examined the British Whitehall II cohort established in 1985 which included 10,308 civil servants stratified by socioeconomic status, and assessed 4 risk factors (smoking, alcohol consumption, diet, and physical activity) over 4 periods of time from 1985 to 2004 and found those within the lowest socioeconomic status had a 1.6 times higher risk of death due to preventable diseases than those in the highest socioeconomic status. (26) However, do these individual decisions to participate in unhealthy behaviors alone result in the negative health outcomes in a form of causal responsibility?

Buyx argues that there are problems with the theory of causal responsibility. (12) In order to hold an individual accountable for their behaviors, a direct link must be identified and other external factors completely eliminated. She states the reality of most conditions which are cited as preventable (eg, diabetes, high blood pressure, some cancers) are multifactoral and influenced by individual behavior and environmental, societal, and even genetic components. Therefore, holding individuals responsible for a condition without one single causal factor is a "great challenge." (12) Her thoughts are similar to those of Daniels who rejects the concept of enforcing individual accountability through costs associated with risky lifestyle choices. (27) Daniels claims measuring causal contribution is practically unfeasible.

Further confounding the issue is the theory of freedom of health behavior. In order to show direct attribution for accountability purposes, individuals would have to exhibit complete control over the negative behavior and choose it freely. Buyx highlights the problem with the theory by stating many unhealthy behaviors are actually socially accepted norms. (12) In Stinghini's study of the British Whitehall II cohort, her group found a higher prevalence rate of smoking, unhealthy diet, and low levels of physical activity among participants in the lower socioeconomic status which directly correlated to higher rates of mortality. (26) This would imply social acceptance of the unhealthy behaviors among the lower SES, thereby removing complete freedom of individual control. As a result, one would have to eliminate these externalities to define what level of responsibility the individual should bear. Buyx does not use this argument to remove personal responsibility from the debate, rather to inform the substance of the deliberation. She acknowledges the need to appropriately manage scarce health resources and the role that personal responsibility has in leading to better health. (12)


Anyone participating in the debate over individual versus societal responsibility for unhealthy behaviors can see merit to both arguments. Harlad Schmidt brings these 2 perspectives together in his concept of health responsibility as coresponsibility. (28) First mentioned in Article 1 from Book V of the German Social Security Code, "coresponsibility" was bestowed upon citizens to lead healthy lifestyles and take an active role in prevention, treatment, and rehabilitation to avoid sickness and disability. (29) Schmidt's concept acknowledges health is affected by both individual behavior and factors beyond their immediate control, therefore, it is neither exclusively an individual nor social responsibility. He cites this as necessary to assess the causal factors, both prospective and retrospective, that result in the particular health state as well as determining attribution of praise or blame with associated positive or negative outcomes. (28) The concept of health responsibility as coresponsibility is found in the ecological model of social behavior which targets health behaviors through multifaceted approaches in order to generate positive health outcomes. Although explicitly defined by Schmidt after the ecological model was developed, coresponsibility is evident in the construct.


An early framework which incorporated individual and environmental determinants in assessing behavior was proposed by Brofenbrenner. (30) The significance of this framework and other ecological models is their premise that individual behavior is affected by the social environment, and, in a symbiotic relationship, the individual can in turn affect the social environment. Leveraging the original work done by Brofenbrenner and other ecological model pioneers, McLeroy et al (20) developed an ecological model for health promotion with patterned behavior as the outcome of concern as determined by the following 5 factors (20):

1. Intrapersonal factors

2. Interpersonal process and primary groups

3. Institution factors

4. Community factors

5. Public policy

The unhealthy behavior of smoking which results in a significant number of chronic diseases and high rate of mortality mentioned earlier in this article will be used to illuminate each of these factors and set precedence in determining where intervention could occur and where responsibility should reside.

Intrapersonal factors are the characteristics of the individual which are the target of intervention. It is assumed that the individual has control over his or her behavior and therefore should have both the responsibility and ability to make the necessary behavioral change. Smoking interventions such as educational programs through peer counseling or media campaigns can assist individuals in changing their knowledge, attitudes, and beliefs to bring about a positive health behavior change.

The second factor of interpersonal process and primary groups focuses around external influences of health related behaviors. Both positive and negative social norms are exuded by human networks which impact individuals within and outside of the groups. (20) These networks also provide resources such as information and emotional support which could be leveraged to assist in modifying unhealthy individual behavior. (31) Therefore, interventions focused on these factors seek to modify group influences which could encourage and facilitate positive health behaviors of individuals. One example would be changing the acceptable norm of smoking within a network based on consistent messaging and modeling by the group against the toxic habit.

Third, institution factors, also referred to as organizational factors, are another level of environmental determinants that impact individual health behavior. Since individuals spend one-third to one-half of their lives in organizational settings ranging from school to the workplace, the role organizations can and do play in health related behaviors cannot be underestimated. (20) In an effort to assuage the adverse impact smoking has on productivity and increased costs associated with medical support, organizations began to modify their cultural norms to discourage tobacco use. Examples include the enforcement of smoking bans and/or restrictions at the worksite and encouraging (with encentives) employee enrollment in smoking cessation programs. Although the impact of eliminating individual unhealthy behavior through these interventions is an outcome of this effort, a change in organizational culture which institutionalizes positive health behaviors is the objective.

According to McLeroy et al, the fourth factor of community has 3 meanings (20):

1. Community refers to mediating structures such as families, friendship networks, and neighborhoods.

2. Community includes relationships among organizations in a defined area.

3. Community is defined in geographical and political terms

Each of these definitions defines communities as relationships and the role they perform in supporting individuals. In the case of smoking cessation programs, a disadvantaged community may not have the resources necessary to effectively implement the required intervention program. Therefore, strategies within this factor will focus on linking communities without resources to other community agencies such as regional health departments to close the requirement gap.

The final factor in this ecological model for health promotion is public policy. Through the use of public policy interventions, national laws mandating the protection of society are enforced and other strategies to address health risks associated with diseases are developed. Laws derived as a result of public policy banning smoking in public facilities and increasing taxes on tobacco products highlight the role individual responsibility has in protecting the welfare of society. As a result, this ecological model reinforces the concept of coresponsibility in health by focusing interventions on 5 separate and overlapping factors from the individual to society and external environment.

This discussion concludes with the situation in the United States, where 443,000 individuals die each year as a result of smoking and $193 billion is spent for smoking-related healthcare costs. (6) What percentage of this economic burden should individuals carry as a result of unhealthy behavioral choices? As much of this disease burden is carried by the disenfranchised, what can they actually afford? Since individuals and their environments influence and impact health behavior, governments should develop intervention solutions impacting both. The ecological model for health promotion, in concert with the theory of coresponsibility, provides an actionable framework to address unhealthy risk behaviors in a multifaceted approach. The United States and its citizens cannot afford anything less.


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MAJ Derek Licina, MS, USA

MAJ Licina is pursuing a DrPH degree at the George

Washington University, Washington, DC.
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.