The most common use of the term "predisposing factors" in the field of public health has been in the context of L. W. Green's PRECEDE-PROCEED model of community health promotion planning and evaluation. Years of research have shown that literally hundreds of factors have the potential to influence a given health-related behavior—either by encouraging the behavior to occur or by inhibiting it from occurring. Green's original PRECEDE model of health education planning and evaluation and the more recent PRECEDE-PROCEED model group these factors into three types: predisposing, reinforcing, and enabling factors. "Predisposing factors" are defined in these models as factors that exert their effects prior to a behavior occurring, by increasing or decreasing a person or population's motivation to undertake that particular behavior.
The term "predisposing characteristics" had initially been used in two other health-related models. J. M. Stycos employed the term in a model to predict couples' use of family planning methods. In this model, the term referred to the converging motivations of husbands and wives in making family planning decisions. R. M. Andersen then used the term in the 1960s in his behavioral model of families' use of health services. Andersen's model has been used widely in the health administration and health services research fields to explain utilization of health services. His original model postulated that people's use of health services was a function of their predisposition to use the services, the resources that enabled or impeded their use of the services, and their need for care. Predisposing characteristics were seen to include demographic factors (age and gender), social structure (education, occupation, ethnicity, and other factors measuring status in the community, as well as coping and the health of the physical environment), and health beliefs (attitudes, values, and knowledge that might influence perceptions of need and use of health services). In Andersen's behavioral model, therefore, the term "predisposing characteristics" refers broadly to everything that might predispose a person to need and use a particular service.
The initial version of the PRECEDE model adapted the concept of predisposing characteristics from Andersen and Stycos to concentrate on motivational factors subject to change through direct communication or education—that is, factors that predispose individuals or populations to want to change their behavior. The predisposing factors of importance for health education operate primarily in the psychological realm. They include people's knowledge, attitudes, beliefs, values, self-efficacy, behavioral intentions, and existing skills. All of these can be seen as targets for change in health promotion or other public health interventions. This emphasis on factors that appeal to people's motives for behavioral change has been maintained throughout the various refinements of PRECEDE and its elaboration into the full PRECEDE-PROCEED model.
As shown in Figure 1, predisposing factors that can function as targets for change in public health programs interact with each other. For example, awareness leads to cognitive learning, which, in turn, produces knowledge. Cognitive learning also amasses as experience, which generates beliefs. A change in any of these will affect the others because of the human drive for consistency. The impact of these factors, however, on behavioral change often depends on their support from enabling and reinforcing factors.
TYPES OF PREDISPOSING FACTORS
Awareness and Knowledge. Knowledge is usually a necessary but not always a sufficient cause of individual or collective behavior change. In other words, at least some awareness of a particular health or quality-of-life need and of some behavior that can be taken to address that need must exist before that behavior will occur. Usually, however, the behavior will not occur without a strong enough cue to trigger motivation to act on that knowledge and possibly also without enabling factors such as new skills or resources.
Beliefs. Beliefs are convictions that something is real or true. Statements of belief about health include such comments as "I don't believe that exercising daily will make me feel any better." The most widely used model for explaining and predicting how health beliefs relate to behavior is the health belief model. In brief, this model posits that the likelihood of taking a recommended health action is dependent on one's beliefs about the severity of the disease or health problem in question, one's susceptibility to it, and the benefits of and barriers to taking the health action—plus some kind of cue to action.
Figure 1
A potent motivator related to beliefs is fear. Fear combines an element of belief with an element of anxiety. The anxiety results from beliefs about the severity of the health threat and one's susceptibility to it, along with a feeling of hopelessness or helplessness to do anything about the threat. Such a combination can lead to a flight response, leading the person to deny that the threat is real. Health educators, therefore, usually avoid arousing fear unless they can also suggest a course of action that can be taken immediately to ease the fear.
Values. Values are the moral and ethical propositions people use to justify their actions. They determine whether people consider various health related behaviors to be right or wrong. Similar values tend to be held by people who share generation, geography, history, or ethnicity. Values are considered to be more entrenched and thus less open to change than beliefs or attitudes. Of interest is the fact that people often hold conflicting values. For example, a teenage male may place a high value on living a long life; at the same time, he may engage in risky driving activities, such as speeding and driving without a seat belt, because he values the sense of power and freedom he gains through such activities. Health promotion programs often seek to help people see the conflicts in their values or between their values and their behavior.
Attitudes. Attitudes are relatively constant feelings directed toward something or someone that always contain an evaluative dimension. Attitudes can always be categorized as positive or negative. For example, a woman may feel that being over-weight is unacceptable, and a young teenager may feel that taking illicit drugs is a bad thing to do. Attitudes are distinct from values in that they are directed toward specific persons, objects, or actions and are based on one or more values. They differ from beliefs in that they always include some evaluation of the person, object or action.
Self-Efficacy and Cognitive Learning Theory. Learning why particular behaviors are harmful or helpful as well as learning to modify one's behavior are prerequisites for being able to undertake or maintain behaviors that are conducive to health. Social cognitive theory (SCT) postulates a number of principles by which learning is acquired and maintained. Health education and behavioral change programs based on cognitive learning theory help a person to bring the performance of a particular behavior under his or her self-control. The most important requirement for self-regulating one's behavior is seen to be self-efficacy—that is, the person's perception of how successful he or she can be in performing a particular behavior. Self-efficacy plays a particularly important role with addictive or compulsive behaviors that are associated with a high degree of relapse, such as weight loss and smoking cessation.
Behavioral Intention. Behavioral intention is a concept fundamental to the theory of reasoned action (and the closely related theory of planned behavior), which proposes that the performance of a particular health behavior is a direct result of whether or not one intends to perform the behavior. It further assumes that all other variables that influence behavior do so through affecting one's behavioral intention. If it is to adequately predict behavior, measurement of intention must correspond as closely as possible to the measurement of behavior in terms of context, time, and outcome.
Existing Skills. If a person does not possess certain skills that are necessary for completion of a specific health behavior, then acquiring those skills would fall under the category of enabling factors. If, however, a person comes to a situation already equipped with the skills needed to successfully perform the behavior, then those skills may predispose that person to behave in a particular fashion and thus are considered predisposing factors. For example, if a teenager attended a program that taught a method of refusing illicit drugs offered by members of a peer group and has been able to refuse them on a previous occasion, then that teenager is considered to have skills that may predispose him or her to refusing drugs on a future occasion. This example reveals how existing skills may be closely related to one's behavioral intention (whether one intends to take drugs on a future occasion) and self-efficacy (regarding one's abilities to refuse drugs).
Predisposing Factors That Are Not Amenable to Change. The PRECEDE-PROCEED model views other factors such as genetic, sociodemographic, and personality characteristics as also playing a role in predisposing to health-related behavior. However, because most of these are not amenable to change through health education, they are treated as a special subcategory of predisposing factors. Some of them can be used to subdivide a population to provide focus for health education and to extend the educational component of health promotion programs to include policy and organizational changes. For example, eating nutritious breakfasts may be less prevalent among children from certain low-income immigrant families. School-based breakfast programs in inner-city schools could include nutrition education pamphlets designed for children to take home to their parents, using language and illustrations that would be especially appealing to the respective immigrant groups. Food purchasing policies might also use the information about factors predisposing the eating behavior of these immigrant groups to include selected ethnic foods in the school-based breakfast program.
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