Toward a public health of situations:
the re-contextualization of risk
Po r uma saúd e p úb lic a d e situaç õ e s:
a re c o nte xtualizaç ão d o risc o
1 W HO Cen ter for Health Prom ot ion Resea rch a n d Dev elop m en t , Sch ool of Pu b lic Hea lt h , Un iv ersit y of Tex a s. PO Box 20186, Hou st on T X 77225, U SA.
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M ich a el W. Ross 1
Joã o Ferreira - Pin t o 1
Abst ract T h is p a p er rev iew s t h e role of sit u a t ion a l v a ria b les in h ea lt h risk b eh a v iors a n d t h e lit era t u re on t h e im p a ct of con t ex t a n d sit u a t ion in p u b lic h ea lt h . Th ree p ost u la t es for a sit u a t ion a l m od el a re p resen t ed : t h a t t h e sit u a t ion ca n a ccou n t for a d d it ion a l v a ria n ce in ex p la n a -t ion of h ea l-t h risk b eh a v iors; -t h a -t -t h e p ow er of -t h e st u a -t ion is recip roca l -t o -t h e d egree of in d iv id u a l a u t on om y; a n d t h a t t h e sit u a t ion is d efin a b le a n d m ea su ra b le. A sit u a t ion a l p resen t a -t ion m e-t h od ology is p resen -t ed for m ea su rin g si-t u a -t ion s in p u b lic h ea l-t h w i-t h p relim in a ry d a -t a on it s efficacy in t h e con t ex t of sex u al beh av ior an d in ject in g d ru g u se as HIV t ran sm ission risk s. In t erv en t i on s w h i ch m a x i m i z e t h e u se of si t u a t i on a lly- b a sed i n form a t i on a re d i scu ssed . It i s co n clu d ed t h a t si t u a t i o n a l p resen t a t i o n s m a y o f f er a d d i t i o n a l ex p la n a t o ry p ow er i n p u b li c h ealt h an d a m ean s for in t erv en in g at a sit u at ion al lev el.
Key words Risk Assessm en t ; Risk Beh av ior; Sex u ally Tran sm it t ed Diseases; Pu blic Healt h
Resumo Os a u t ores fa z em u m a rev isã o d o p a p el d a s v a riá v eis sit u a cion a is n os com p ort a m en -t os d e risco p a ra a sa ú d e, a ssim com o, d a li-t era -t u ra sob re os im p a c-t os d o con -t ex -t o e d a si-t u a çã o n a saú d e p ú blica. São ap resen t ad os t rês p ost u lad os p ara u m m od elo sit u acion al: qu e a sit u ação p ossa ex p lica r a v a riâ n cia a d icion a l n os com p ort a m en t os d e risco; q u e o p od er d a sit u a çã o seja recí p ro ca em rela çã o a o gra u d e a u t o n o m i a i n d i v i d u a l e q u e a si t u a çã o p o ssa ser d ef i n i d a e m en su ra d a . Um a m et o d o lo gi a si t u a ci o n a l é a p resen t a d a p a ra m ed i r a s si t u a çõ es n a sa ú d e p ú blica a p a rt ir d e d a d os p relim in a res sobre su a eficá cia n o con t ex t o d o com p ort a m en t o sex u a l e u so d e d roga s in jet á v eis com o fa t ores d e risco p a ra a t ra n sm issã o d o HIV. Sã o d iscu t id a s in t erv en ções q u e m a x im iz a m o u so d a in form a çã o com b a se sit u a cion a l. Con clu i se q u e a s a p resen -t a ções si-t u a cion a is p od em oferecer p od er ex p la n a -t ório a d icion a l n a sa ú d e p ú blica , a ssim com o, serv ir com o m eio p ara in t erv ir ao n ív el sit u acion al.
Th e sit u a t io n is a c r u c ia l e le m e n t in p u b lic h e a lt h : Tr ia n d is (1994:26) h a s d e sc r ib e d it a s
“on e of t h e m ost p ow erfu l p red ict ors of b eh a v -ior”. Tra d itio n a l p u b lic h e a lth m o d e ls o f in fe c-tio u s d isea se em p h a size th e in tera ctive co n tri-b u tio n tri-by exa m in in g th e tria d o f th e o rga n ism , t h e h o st , a n d t h e e n vir o n m e n t , b u t in h e a lt h p ro m o tio n a n d h e a lth e d u ca tio n re se a rch , th e en viron m en ta l a sp ects a re often con sid ered in -sofa r a s th ey en a b le, rein force, or p red isp ose to h e a lt h y o r r isky b e h a vio r s in t h e in d ivid u a l (Gre e n e t a l., 1980) b u t wit h lit t le a t t e n t io n t o a n im m ed ia te risk situ a tion . Hea lth risk ta kin g, wh eth er it b e sexu a l in tera ctio n , sm o kin g, ea t -in g, su n b a t h -in g, o r d r u g u se , is a b e h a vio r o r se q u e n ce o f b e h a vio rs wh ich o ccu rs in a t e m -p o ra lly a n d geo gra -p h ica lly (a n d o ften so cia lly) b o u n d e n vir o n m e n t . Howe ve r, t h e b u lk o f re -se a rc h in t o h e a lt h risk b e h a vio r s h a s fo c u -se d o n p e r so n a lit y a n d a t t it u d in a l ch a ra ct e r ist ics of th e in d ivid u a l, with m in im a l a tten tion to th e sit u a t io n in wh ich t h e risk is lo ca t e d . Th is fo -cu s o n th e in d ivid u a l n o t o n ly im p u tes co n tro l o f h e a lt h b e h a vio r t o t h e in d ivid u a l, b u t a lso d e va lu e s t h e im p a c t o f t h e im m e d ia t e so c ia l a n d sit u a t io n a l co n t e xt in co n t r o l o f b e h a vio r. He a lt h b e h a vio r, we a rgu e, is sh a p e d t o a sig-n ifica sig-n t e xt e sig-n t b y t h e se so cia l a sig-n d sit u a t io sig-n a l va r ia b le s – fo r e xa m p le wh e re t h e sa m e in d i-vid u a l m a y ta ke ver y d ifferen t risks in d ifferen t situ a tio n s. Given th a t o u r ta sk is to a cco u n t fo r a s m u ch o f th e va ria n ce in a h ea lth risk b eh a vio r a s p o ssib le (in m u c h t h e sa m e wa y a s a s -tro n o m ers seek to a cco u n t fo r th e h id d en d a rk m a tter in th e u n iverse), th e situ a tio n m a y p ro -vid e u s with a sign ifica n t a m o u n t o f p revio u sly u n exp la in ed va ria n ce. An u n d ersta n d in g o f th e sou rces of th is ad d ition al varian ce sh ou ld assist p u b lic h e a lt h p ro fe ssio n a ls in id e n t ifyin g n o t o n ly situ a tio n a l va ria b les wh ich a re p o ten tia lly m o d ifia b le, b u t a lso ca ll a tte n tio n to th e in te ra ctio n s b etween p erso n ra n d situ ra tio n . A situ ra -tio n a l m o d el o f h ea lth b eh a vio r is p rem ised o n th e id ea th a t p eop le a re a ffected b y th e settin gs in wh ich t h e y a ct . In t h is p a p e r, we re vie w t h e lit e ra t u re o n t h e p syc h o lo gy o f t h e sit u a t io n , m a ke som e p red iction s rega rd in g th e in flu en ce o f t h e sit u a t io n o n r isk b e h a vio r, d e sc r ib e a system o f m ea su rem en t o f situ a tio n s, a n d p re-sen t som e em p irica l d a ta d erived from th is sys-t e m . Fin a lly, we d isc u ss wa ys sys-t h is sisys-t u a sys-t io n a l p resen ta tio n to o l m a y b e u sed in p u b lic h ea lth re se a rc h . Th e re su lt in g sit u a t io n a l m o d e l a t t e m p t s t o b r in g t o ge t h e r t h e o re t ic a l a n d e m -p irica l a -p -p ro a ch e s fo r e x-p la in in g th e -p owe r o f th e con text in h ea lth b eh a vior.
Situation and environment
Reco gn itio n o f th e im p o rta n ce o f th e situ a tio n a s a d eterm in a n t o f b eh a vio r is n o t n ew. Bu rke (1962, 1965) n o t e d t h a t sit u a t io n s (in c lu d in g p h ysica l a p p a ra tu s) th em selves m a y sym b o lize a n d m o t iva t e t h e a c t io n wh ic h t a ke s p la c e with in o r a ro u n d th em , a n d th a t a ctio n s d erive t h e ir c h a ra c t e r fr o m t h e e n t ire fra m e wo r k b y wh ich we ju d ge th em . He a rgu ed th a t th e ter m “m o t ive” wa s a lin gu ist ic co n ce p t b y wh ich a n o b se r ve r e xp la in s a n d u n d e rsta n d s situ a tio n s, a n d t h a t t h e sc e n e is o n e o f t h e five ke y c o m -p o n e n t s t o b e a d d re sse d in re s-p o n se t o t h e q u e st io n a s t o wh a t is h a p p e n in g. Co t t re ll (1948) a lso su gge st e d syst e m a t ic re se a rc h o n sit u a t io n s a s a b a sis fo r u n d e rst a n d in g a ct u a l b eh a vior, a n d Price (1981) n oted th a t situ a tion -a l t h e o r y -a llows re se -a rc h e r s t o d i-a gn o se h igh risk situ a tio n s a n d o n in vestiga tio n a n d a n a ly-sis, d esign in ter ven tion s. In 1986, Ba n d u ra su g-ge st e d t h a t so c ia l c o gn it ive t h e o r y fa vo re d a con cep tion of in tera ction b a sed on tria d ic reci-p roca lity – wh ere b eh a vior, cogn itive a n d oth er p e r so n a l fa c t o r s, a n d e n vir o n m e n t a l in flu -e n c-e s o p -e ra t-e in t-e ra ctiv-e ly a s d -e t-e rm in a n ts o f ea ch oth er. He n oted th a t th e rela tive in flu en ce of th ese th ree sets of fa ctors will va ry for d iffere n t siffere t s o f a ct ivit iiffere s, in d ivid u a ls, a n d circu m -sta n ces (Ba n d u ra , 1986).
se e n a s a b e h a vio r a l e q u iva le n t t o t h e p u b lic h e a lt h t r ia d o f o r ga n ism , h o st , a n d e n vir o n -m e n t . Wh ile n o t a r gu in g t h a t la r ge r se t t in gs a n d c o n t e xt s a re n o t im p o r t a n t , in t e r m s o f m e a su re m e n t , t h is p a p e r will re st r ic t it s d is-cu ssion to th e m icro-situ a tion in wh ich risk b e-h a vio r m a y o c c u r. Howe ve r, a s En d le r in d i-ca tes, th e b ord erlin e is n ot p recise.
En d le r (1981) a lso n o t e s t h a t c o m p a re d wit h t h e p e r so n , t h e sit u a t io n h a s re c e ive d co m p a ra tive ly little a tte n tio n in p sych o lo gica l resea rch . Th e em p h a sis o n p erso n a lity wa s d e-rived from p sych om etrics, En d ler su ggests, a n d fro m t h e p re va ilin g so cia l syst e m o f 19t h ce n -tu ry lib era lism wh ich h eld th a t in d ivid u a ls a n d n o t p re va ilin g so c ia l c o n d it io n s sh a p e d t h e ir own live s. Th is so cio p o lit ica l e m p h a sis is st ill a p p a re n t in m o d e r n No r t h Am e r ic a n p u b lic h e a lt h , wh e re in t e r ve n t io n s a n d e xp la n a t io n s t e n d t o fo cu s o n t h e in d ivid u a l’s a t t it u d e s a n d b e lie fs, a lt h o u gh t h is h a s a lso b e e n c rit ic ize d a s “vict im -b la m in g” (lo ca t in g t h e ca u se o f t h e p ro b le m in t h e p e o p le wh o a re e n m e sh e d in th e p rob lem – Rya n , 1971). An em p h a sis on sit u a tio n a l fa cto rs m a y h a ve a co rre sp o n d in g so -cio p o litica l a d va n ta ge o f d e-em p h a sizin g “vic-t im - b la m in g” a n d fo c u sin g a “vic-t “vic-t e n “vic-t io n o n “vic-t h e ro le o f e n viro n m e n t a l fa ct o rs in r isk b e h a vio r. In t h e p u b lic h e a lt h c o n t e xt , St o ko ls (1992:6) a lso n o tes th a t, “Th e m ajority of h ealth p rom o-t ion p rogra m s im p lem en o-t ed in corp ora o-t e a n d com m u n ity settin gs h ave been focu sed on in d i-vid u als rath er th an en viron m en ts. Th at is, th ey h a v e b een d esign ed t o m od ify in d iv id u a ls’ h ea lt h h a b it s a n d life st yles (e.g., ex ercise a n d d iet a ry regim en s) ra t h er t h a n t o p rov id e en v i-ron m en t a l resou rces a n d in t erv en t ion s t h a t p rom ot e en h a n ced w ell b ein g a m on g occu -p an ts of an area...”.
Th e so c ia l e c o lo gy o f h e a lt h p r o m o t io n (Sto ko ls, 1992) h a s b een exten sively d iscu ssed , fo cu sin g o n th e e n viro n m e n ta l q u a litie s o f o r-ga n iza t io n a l a n d c o m m u n it y se t t in gs wh ic h a re h e a lt h p r o m o t ive. Howe ve r, St o ko ls e m p h a size s t h e b ro a d e r m a cro sit u a t io n , in clu d in g b o th so cia l en viro n m en t (cu ltu re, eco n o m -ics, p o lit ics) a n d p h ysica l e n viro n m e n t (ge o g-ra p h y, a rc h it e c t u re, a n d t e c h n o lo gy). Pa r t ic i-p a n t s in t h e se e n viro n m e n t s, h e su gge st s, ca n b e st u d ie d a t va r yin g le ve ls o f sca le a n d co m -p lexity, with loca l settin gs b ein g n ested in m ore co m p le x a n d re m o t e se t t in gs. Th e so cia l e co lo gica l a p p r o a ch t o h e a lt h p r o m o t io n , Lin d -h e im a n d Sym e (1983) a rgu e, re q u ire s e xp licit a n a lysis o f t h e in t e rp la y b e t we e n t h e e n viro n -m e n t a l re so u rce s a va ila b le in a n a re a a n d t h e h ea lth h a b its a n d life styles of th e occu p a n ts of th e a rea . Usin g Sto ko ls’ ch a ra cteriza tio n o f en
-viro n m e n t a l sca le, sit u a t io n s a re in d ivid u a l o r gro u p a ct ivit ie s o ccu rrin g a t a p a r t icu la r t im e o r p la c e . He re we fo c u s o n t h e lo we r e n d o f sc a le a n d c o m p le xit y, o n t h e risk sit u a t ion, ra t h e r o n t h e fe a t u re s o f t h e p h ysica l, so cia l, a n d cu lt u ra l e n viro n m e n t t h a t in flu e n ce t h e etiology of h ea lth a n d illn ess a n d wh ich a re th e p oin t of con vergen ce of m u ch of th e social ecol-ogy of h ealth p rom otion . Th e con cep t of risk sit-u ation (in itially u sed by Kelly et al., 1991, to d escrib e th e re la tio n sh ip sta tu s a n d H IV se ro sta t u s o f p a r t n e rs in u n sa fe se xu a l e p iso d e s) in -volves a re-con textu alization of risk b eh avior.
Risk situations
Th e risk sit u a t ion is a c o n st r u c t wh ic h d e -scrib es th e situ a tio n in wh ich risk b eh a vio r o c-cu rs, a n d wh ich m a y eith er in itia te o r p ro m o te risk b eh a vior. For exa m p le, a risk situ a tion m a y in clu d e d ru g u se, p eer p ressu re, u n fa m ilia r en -viro n m en t, la ck o f co n d o m s, m o n ey, a n d lo n e-lin ess or a rou sa l, a ll of wh ich m a y m a ke u n sa fe se xu a l b e h a vio r wit h a n u n kn o wn p a r t n e r m o re likely. Go ld (1993) ca lls th ese “typ es of oc-casion”– referrin g to fa cto rs in th e life o f a n in -d ivi-d u a l wh ich ca n va r y ove r a re la t ive ly sh o r t p eriod of tim e. Som e of th e la ck of u n d ersta n d -in g o f r isk b e h a vio r m a y b e re la t e d t o t h e fa ct th a t it is u n situ a ted in ter m s of tim e, p la ce, a n d a ffe c t . Fo r t h is re a so n , a c r it ic a l in c id e n t a p -p r o a c h , wh ic h a sks a b o u t t h e la st t im e a r isk b eh a vior occu rred , a n d its tim e, p la ce, a n d oth -e r a cco m p a n im -e n t s, m a y p rovid -e u s-e fu l clu -e s a s to th e in flu e n ce o f th e situ a tio n (Ro ss e t a l., 1993).
1993; Go ld e t a l., 1994). A sit u a t io n a l m o d e l o f h e a lt h b e h a vio r se e ks t o sit u a t e t h o se c o gn i-tion s in a con text wh ich a llows for som e gen er-a t io n er-a n d m e er-a su re m e n t o f t h e h e er-a t er-a s we ll er-a s th e co gn itio n s by situ a tin g th e co gn itio n s in a s re a list ic a c o n t e xt a s p o ssib le : “in t h e h e a t o f th e m om en t”.
Individualistic versus community approaches
No rth Am erica n a n d Eu ro p ea n p sych o lo gy h a s ten d ed to co n cen tra te o n th e in d ivid u a l a s u n -sit u a t e d : Ma r t ín -Ba ró (1994) a rgu e s t h a t in d ivid u a ls a re p resen ted a s b ereft of th eir com m u -n it y, p o lit ic a l h ist o r y, so c ia l st r u c t u re s, a -n d a d ia lectic of in terp erson a l rela tion s. He su ggests th a t a fo cu s o n th e so cia l a s well a s th e p erso n -a l ro o t o f p ro b lem s -a n d -a n -a lysis o f b eh -a vio r in th e ligh t o f so cia l a s well a s p erso n a l m ea n in gs sh o u ld o ccu r, a n d a rgu e s t h a t t h e n e e d t o u n d ersta n d th e co n text o f th e in d ivid u a l go es b e -yo n d th e p sych o lo gica l co n te xt to th e p h ysica l a n d h isto rica l, in so fa r a s th ese ca n b e sep a ra te d . Ma rc u s & Kit a ya m a (1991), in a c o m p rte -h e n sive re vie w o f c u lt u ra l c o n c e p t io n s o f t -h e se lf a n d o t h e r s, p re se n t su b st a n t ia l e vid e n c e t h a t t h e No r t h Am e r ic a n a n d We st e r n Eu ro -p e a n in d e -p e n d e n t vie w o f t h e se lf c o n t r a st s m a rke d ly wit h t h e in t e rd e p e n d e n t vie w in m o st o t h e r p a r t s o f t h e wo r ld . Th e y n o t e t h a t t h e We st e r n n o t io n o f t h e se lf a s a n e n t it y d e -ta ch ed fro m co n text is sim p ly n o t a n a d eq u a te d e sc r ip t io n o f se lfh o o d : in n o n - We st e r n c u l-tu res, self is viewed a s in terd ep en d en t with th e su rro u n d in g co n te xt. Sto ko ls (1992) a lso n o te s t h a t t h e m a jo r it y o f h e a lt h p r o m o t io n p r o -gra m s in No rth Am e rica h a ve b e e n fo cu se d o n in d ivid u a ls ra th er th a n en viron m en ts a n d h a ve b e e n d e sign e d t o m o d ify in d ivid u a ls’ h e a lt h h a b it s a n d life st yle s. In d e e d , Ka ka r (1990) a rgu e s t h a t in t h e In d ia n co n t e xt , b e h a vio r ca n -n o t b e ea sily co m p reh e-n d ed o u tsid e o f th e sit-u a tio n , a n d th a t th e tellin g o f a sto ry to exp la in a n a ct io n is t o lo ca t e a n y e xp la n a t io n wit h in a sp e c ific c o n t e xt – a n d a re a so n wh y a b st ra c t io n s o f b e h a vio ra l m o t ive s in in d ivid u a l co n t e xt s a re n o t e a sily u n d e r st o o d . Th is a b st ra c t io n o f m o t ive s, st r ip p e d o f c o n t e xt a n d su r -ro u n d in g d isco u rse, m a y b e o n e o f th e rea so n s t h a t h e a lt h p ro m o t io n in t e r ve n t io n s b a se d o n in d ivid u a listic con cep ts of b eh a vior ch a n ge a re se e n a s a lie n in n o n -No r t h Am e r ica n se t t in gs. Re se a rc h wh ic h in ve st iga t e s t h e d isc o u r se s su r ro u n d in g h e a lt h risk sit u a t io n s is o n e wa y o f u n d e r st a n d in g t h e m o d e ls o f b e h a vio r ch a n ge wh ich in tera ct in a p a rticu la r settin g.
We a rgu e t h a t t h e co n ce p t o f t h e sit u a t io n is m ore u sefu l in a p p roa ch es in wh ich th e com m u n it y ra t h e r t h a n t h e in d ivid u a l is e m p h a size d . Th e p owe r o f th e co n te xt is p ro b a b ly in -versely co rrela ted with th e d egree o f in d ivid u a l se lf- e ffic a c y, wh e re t h e m o re se lf- e ffic a c io u s th e p e rso n , th e le ss th e co n te xt will d e te rm in e b e h a vio r. In a se t t in g wh e re t h e co m m u n it y is em p h a sized m ore th a n th e in d ivid u a l, self-effi-ca cy will sim ila r ly b e a t t e n u a t e d , p a r t icu la r ly wh e n o t h e rs a re p re se n t in t h e sit u a t io n , ove r a n d a b ove t h e in flu e n ce o f p e e r n o r m s. Th e re is a lso a p o t e n t ia l re cip ro cit y b e t we e n p e rso n a n d e n viro n m e n t : Fre ire (1971) n o t e s t h a t h is co n cep t o f con scien tiz ação(critica l co n scio u s-n e ss) le a d s s-n o t o s-n ly t o p e r so s-n a l a s-n d so c ia l t ra n sfo rm a t io n , b u t t h a t p e rso n s ch a n ge t h e ir re la t io n s wit h t h e su r r o u n d in g e n vir o n m e n t (in clu d in g o t h e r p e o p le ) (Ma r t ín - Ba ró , 1994). Th is in t e rre la t io n sh ip wit h e n viro n m e n t illu s-t ra s-t e s s-t h e p o ssib le c o n s-t in u u m b e s-t w e e n in d i-vid u a list ic a n d co m m u n it y-b a se d a p p ro a ch e s wh e re t h e c o m m u n it y m a y fo r m p a r t o f t h e co n text a n d situ a tio n . Wh ere th e a gen cy o f th e in d ivid u a l is st re n gt h e n e d , t h e im p a c t o f t h e c o n t e xt , in c lu d in g c o m m u n it y, is like ly t o b e le sse n e d (o r m o d ifie d ) (Ba n d u ra , 1986). It fo l-lows t h a t sit u a t io n a l a n a lyse s a re like ly t o b e m o re u se fu l t o e xp la in a gre a t e r a m o u n t o f va ria n ce in h ea lth b eh a viors wh ere th ere is less fo c u s o n t h e in d ivid u a l a s a n in d e p e n d e n t a gen t. Su ch h yp o th eses rega rd in g th e rela tio n sh ip s b etween situ a tio n a l va ria b les, selfeffica -cy, a n d extern a l locu s of con trol a re em p irica lly testa b le.
Psychological research on the situation
p h ysica l ch a ra cteristics of th e p erson s p resen t) a n d t h e p erceivede n viro n m e n t (wh ich will in -clu d e th e a p p lica tio n o f th e so cio cu ltu ra l ru les fo r p re scr ib e d b e h a vio r in t h a t se t t in g). Sit u a -t io n s, h e n o -t e s, fo r m o u r p e rce p -t io n s a n d n orm s, an d give feed b ack. In th is last sen se, th e situ ation p rovid es wh at Rotter (1955) h as called
“rein forcem en t valu e”a n d wh a t Skin n e r (1938) re fe rs t o a s “resp on d en t s”(d ire ct re sp o n se s t o stim u li), alth ou gh wh at Skin n er refers to as “op -era n t s”(re a ct io n s in d e p e n d e n t o f o b se r va b le stim u li) m a y in fa ct b e sh a p ed b y th e situ a tio n a s we ll. It is a c e n t ra l a r gu m e n t o f t h is p a p e r th a t b eh a vio r ta kes p la ce in , a n d exists in re la -t io n -t o, si-t u a -t io n s, a n d -t h a -t -t h e si-t u a -t io n a n d its a sso cia ted rein fo rcers will a cco u n t fo r a sig-n ifica sig-n t a m ou sig-n t of th e va ria sig-n ce of th e b eh a vior o c c u r r in g in it . Ma gn u sso n (1981b ) su gge st s t h a t in c o r p o ra t in g t h e sit u a t io n in t h e e q u a -t io n m a ke s fo r m o re re a lis-t ic a n d fu n c -t io n a l m o d els fo r co gn itive b eh a vio r – a n d sp ecifica lly, t h a t c o n sid e r in g t h e p e r so n a n d t h e sit u a -t io n a n d -t h e ir in -t e ra c-t io n will le a d -t o a b e -t -t e r u n d ersta n d in g o f b eh a vio r. Tra it m o d els o f b e -h a vio r, fo cu sed o n t-h e in d ivid u a l, exa m in e stab le crosssitu a tion a l m od els, wh ile socia l m od -e ls, wh ich fo cu s o n t h -e so cia l d -e t -e r m in a n t s o f b eh a vior, exa m in e th e effects of d ifferen t socia l sit u a t io n s ove r t h e sa m e in d ivid u a l. Th e re is a m p le e vid e n c e fo r t h e c h a n gin g o f b e h a vio r b y c h a n gin g t h e e n vir o n m e n t in wh ic h it o c cu rs (e.g., Sh erif et a l., 1961). Ma gn u sso n co m -p a re s t h e in d ivid u a l a n d t h e sit u a t io n d ist in ct io n ct o figu re gro u n d re la ct io n sh ip s in p e rce p -tu a l p sych o lo gy, wh ere th e in tera ctio n is a crit-ic a l c o m p o n e n t : t h e p e rc e p t io n c a n o n ly b e u n d erstood in term s of b oth com p on en ts.
Th e situ a tion , su ggests Ma gn u sson (1981b ), ca n b e d e fin e d in t e rm s o f t h e stim u li(wh a t is th ere) a n d th e even ts(wh a t h a p p en s th ere). Situ a tio n s ca n fSitu rth er b e d efin ed in term s o f gen -e ra lit y (wh a t h a p p -e n s in a cla ssr o o m ) v-e r su s sp ecificity (wh a t h a p p en s in th is sp ecific cla ss-ro o m a t t h is p a r t ic u la r t im e ). To u n d e r st a n d th e p owe r o f th e situ a tio n , Ma gn u sso n a rgu e s, wh a t is im p o r t a n t is wh a t is ce n t ra l t o t h e a c -t o r, a n d -t h a -t wh a -t is p e r ip h e ra l is ir re le va n -t . Th e p e rce ive d co n t e xt , t h e n , m a y b e d iffe re n t in con ten t a n d in em p h a sis from th e a ctu a l en -viro n m e n t wh e n vie we d t h r o u gh t h e filt e r o f t h e a c t o r. Th e re is a lso t h e d yn a m ic c o m p o n e n t , wh e re t h e re c ip ro c a l in t e ra c t io n s b e -t we e n a c -t o r s a n d si-t u a -t io n s will im p a c -t b o -t h p erson a n d situ a tion . Th e ch a ra cteristics of sit-u a t io n s ca n , ssit-u gge st s Ma gn sit-u sso n (1981b ), b e d e fin e d in t e r m s o f so m e n in e d im e n sio n s . Th e se m a y b e gr o u p e d in t o t h e b r o a d ca t e -go r ie s o f st r u ct u re, co n t e n t , a n d se t t in g. Th e
stru ctu ra l ch a ra cteristics in clu d e th e co m p lex-it y o f t h e slex-it u a t io n , lex-it s c la r lex-it y (wh a t va r ia b le s a re ove r t o r cove r t ), t h e st re n gt h o f t h e se va r ia b le s, ia n d t h e d e gre e o f p ro m o t io n ve rsu s re -st r ict io n (fo r e xa m p le , t h e ra n ge o f b e h a vio r s p erm itted , su ch a s in a p r ison or h osp ita l, com p a re d wit h a le ss re st r ict ive se t t in g). Th e co n -te n t ch a ra c-te ristics in clu d e so cio cu ltu ra l va ri-a b le s su c h ri-a s t h e t ri-a sks, p ro b le m s, d e m ri-a n d s, a n d go a ls in th e im m ed ia te situ a tio n ; th e ru les a n d / o r r it u a ls a sso c ia t e d wit h t h e sit u a t io n ; a n d th e ro les wh ich a re a scrib ed o r a d o p ted by t h e a ct o r s in t h e se t t in g. Fin a lly, t h e re a re t h e se t t in g ch a ra ct e r ist ics, wh ich will in clu d e t h e p h ysica l se t t in g a n d t h e o t h e r p e rso n s (if a n y) p resen t.
However, as En d ler & Magn u sson (1976) an d Magn u sson (1981b ) also n ote, th e p erceived en -viro n m e n t is im p o r t a n t (a p o in t wh ich will b e re t u r n e d t o in t h e d iscu ssio n o n e licit a t io n o f sit u a t io n a l va r ia b le s). Sin c e t h e in d ivid u a l is a ct ive in p e rce ivin g a n d a t t e n d in g, wh a t is se -le c t e d , c o n st r u e d , a n d e va lu a t e d is c r it ic a l t o t h e m e a su re m e n t o f sit u a t io n a l c o r re la t e s o f b e h a vio r. Th e p e rce p t io n o f sit u a t io n will d e-p e n d o n t h e st r u c t u re a n d c o n t e n t a s we ll a s t h e in d ivid u a l va r ia b le s su c h a s t h e a ffe c t ive t o n e in t h e sit u a t io n , t h e c o p in g st r a t e gie s o f t h e in d ivid u a l, a n d t h e skills o f t h e in d ivid u a l. Th e re will b e b o t h co m m o n a n d u n iq u e sit u a-t io n p e rc e p a-t io n , c o r re sp o n d in g a-t o a-t h e sh a re d so c ia l a n d c u lt u r a l u n d e r st a n d in gs a s c o m -p a re d wit h t h e -p riva t e wo rld o f t h e in d ivid u a l. Sit u a t io n p e rc e p t io n , h owe ve r, is a p e r so n a l ch a ra cteristic a s m u ch a s it is a settin g ch a ra c-teristic: Ma gn u sson & Sta ttin (1978) rep ort th a t d ifferen ces in p ercep tion will d iffer in rega rd to im p o r t a n t ch a ra ct e rist ics su ch a s a ge, ge n d e r, a n d cu ltu re. In a stu d y exa m in in g a n xiety rea c-tio n s to th ree d ifferen t situ a c-tio n s (fo r exa m p le, in t h e wo o d s a t n igh t , a lo n e a t h o m e , a lo n e in th e wood s a t n igh t), th ey fou n d th a t th e level of a n xie t y re a ct io n d e m o n st ra t e d st r ikin g cro ssc u lt u ra l d iffe re n ssc e s fo r t h e se sp e ssc ifissc sit u a -tion s.
x-im it y, crowd in g, o r ie n t a t io n , co lo r, fu r n it u re, d eco ra tio n , a n d eq u ip m en t), a n d th e co n cep ts u se d , wh ich h e re fe rs t o (Brown e ll e t a l., 1986) a s sa lie n ce d im e n sio n s. Su ch sa lie n ce d im e n -sio n s in clu d e t h e p e rso n a l co n st r u ct s u se d b y th e p a rticip a n ts to a ssess th e situ a tion , eq u iva -le n t t o Ma gn u sso n’s p e rc e ive d sit u a t io n d im e n sio n s. Wh ile Ar gyle’s t a xo n o im y e im p h a -size s t h e so c ia l a sp e c t s o f t h e sit u a t io n , t h e sim ila rity with th e elem en ts n o ted by Ma gn u s-so n is st r ikin g. Ar gyle a ls-so su gge st s t h a t t wo fu r t h e r c r it ica l va r ia b le s in t h e a sse ssm e n t o f sit u a t io n s a re wh e t h e r t h e y a r e co m p le x o r sim p le , o r wh e t h e r t h e y a r e fa m ilia r o r u n fa -m ilia r.
Th e q u e st io n o f so cia l b e h a vio r in a sit u a -tio n is a lso with o u t q u e s-tio n critica l a n d th e re is a n exten sive litera tu re p erta in in g to it, b u t it will n o t b e d e a lt wit h in t h is p a p e r. Ma n y h e a lt h b e h a vio r s (e a t in g, d r in kin g, sm o kin g, su n b a th in g, se a t-b e lt we a rin g) m a y ta ke p la ce in a n a socia l con text, a n d for th is rea son , socia l b e h a vio r in t h e sit u a t io n will b e se t a sid e a l-t h o u gh n o l-t d isco u n l-t e d a s a fu rl-t h e r sign ifica n l-t sou rce of va ria n ce in risk b eh a viors.
The situation in public health
Th e sign ifica n ce o f t h e sit u a t io n ca n b e illu st ra st e d b y p o sin g a p r o b le m . Ist is n o st u n co m -m o n fo r risk b e h a vio rs t o va r y fro -m co n t e xt t o c o n t e xt : t h a t is, t h e p e r so n m a y e n ga ge in a risky b e h a vio r in o n e co n te xt a n d n o t a n o th e r. Assu m in g t h a t a t t it u d e s a n d b e lie fs a re re la -t ive ly c o n s-t a n -t in -t h e in d ivid u a l, wh y will -t h e p e rso n e n ga ge in r isk a t o n e t im e in o n e p la ce a n d n o t a t a n o t h e r t im e in a n o t h e r p la c e ? A su b st a n t ia l a m o u n t o f t h e va r ia n ce in r isk b e -h a vio r m a y b e e xp la in e d b y c o n t e xt – o t -h e r s p re se n t , c o n t e xt u a l c u e s a n d p re ssu re s, d r u g u se, a ffects en gen d ere d b y th e co n text a n d th e re ce n t p a st. A stu d y o f th e co n te xt m a y illu m i-n a t e so m e o f t h e im m e d ia t e c o i-n c o m it a i-n t s o f th e risk b eh a vior.
Re se a rch in to h e a lth p ro m o tio n h a s e xa m -in e d t h e t a xo n o m y o f h e a lt h b e h a vio r- re la t e d situ a tio n s. An a lyzin g clu ster a n a lysis stu d ies o f a d d ic t ive b e h a vio r s, Cu m m in gs e t a l. (1980) d ist in gu ish e d t h re e gro u p in gs o f ch a ra ct e r is-t ics: a ffe cis-t , p a r is-t icu la rly n e ga is-t ive a ffe cis-t ; so cia l situ a tio n , i.e., p resen ce o f o th ers; a n d p h ysica l cra vin g (wit h d ra wa l sym p t o m s). Th e se ca n b e co n ce p t u a lize d a s in d ivid u a l, sit u a t io n a l, a n d p h ysio lo gica l clu sters. Velicer et a l. (1990) eva l-u a t e d a n l-u m b e r o f m e a sl-u re m e n t m o d e ls fo r sm o kin g re la p se sit u a t io n s a n d a lso d e r ive d th re e d im e n sio n s o f situ a tio n s: p o sitive / so cia l
sit u a t io n s, in wh ich a ll it e m s d e scrib e d h a p p y a ffect a n d rela xin g with frien d s; n ega tive/ a ffec-t ive iffec-t e m s, im p lyin g iso la ffec-t io n a n d sffec-t re ss; a n d h a b it/ a d d ictive item s, reflectin g cra vin gs a sso-c ia t e d wit h p h ysisso-c a l o r p sysso-c h o lo gisso-c a l n e e d st a t e s. Ve lice r e t a l. n o t e t h e im p o r t a n ce o f in -terp retin g th ese d a ta with in a sta ges o f ch a n ge m od el, wh ere d ifferen t d im en sion s ap p ly at d if-fe ren t sta ges o f sm o kin g cessa tio n (essen tia lly, a situ ation by stage m od el). After cessation , th e h a b it/ a d d ictio n d im en sio n is th e m o st sa lien t; t h is is fo llowe d b y t h e p o sit ive / so cia l a s t h e m ost salien t, an d th en th e n egative/ affective d i-m en sio n a s a n “excu se” to rela p se. Th e in tera c-tion of stages of ch a n ge with th e situ a tio n is a n im p o r t a n t p o in t wh ich n e e d s t o b e t a ke n in t o a c c o u n t in d e t e r m in in g t h e im p a c t o f sit u a -tion a l va ria b les.
So cia l lea r n in g th eo r y (Ba n d u ra , 1986) re c-ogn izes th e in tera ction s of b eh a vior, p erson a li-t y, a n d e n vir o n m e n li-t in li-t r ia d ic re c ip r o c a lili-t y. Howe ve r, Ba n d u ra (1986:26) a r gu e s t h a t fr o m t h e p e r sp e c t ive o f t r ia d ic re c ip r o c a lit y, “t h e com m on p ra ct ice of sea rch in g for t h e u lt im a t e en viron m en tal cau se of beh avior is an id le exer-cise”, b e ca u se t h e sa m e e ve n t ca n b e e it h e r a n e n viro n m e n t a l st im u lu s, a re sp o n se, o r a n e n -viro n m e n t a l re in fo rc e r. Wh ile t h is is t r u e if a c o m p le t e d e c o n st r u c t io n o f t h e b e h a vio r a l c o m p o n e n t s o f t h e sit u a t io n is so u gh t , Ba n d u ra a lso n o tes th a t p h ysica l va ria b les a n d sit -u a t io n a l c o n st ra in t s m a y in fl-u e n c e b e h a vio r. Th e p resen t m o d el seeks to b r in g th e situ a tio n in t o in t e lle c t u a l sa lie n c e a s a c o n t r ib u t o r t o va r ia n ce o n h e a lt h b e h a vio r ra t h e r t h a n t o e st a b lish u lst im a st e c a u se . Esse n st ia lly, st h e sist u a -t io n a l m o d e l a s d e sc r ib e d in -t h is p a p e r h a s t h re e p o st u la t e s: fir st , t h a t t h e sit u a t io n c o n trib u te s to th e va ria n ce o f e xp la n a tio n o f p u b -lic h ea lth risk b eh a vio rs; seco n d , th a t th e p ow-e r o f t h ow-e sit u a t io n m a y va r y in vow-e rsow-e ly wit h t h ow-e d e gree o f in d ivid u a l a u to n o m y a n d selfeffica -cy in th e situ a tio n ; a n d th ird , th a t th e situ a tio n is d efin a b le a n d m ea su ra b le.
M easurement of the situation
Eke h a m m a r (1973) fo u n d t wo b ip o la r sit u a t io n a l d im e n sio n s a cro ss sit u a t io n s: p o sit ive n ega tive a n d a ctivep a ssive, p lu s a u n ip ola r so -c ia l fa -c t o r, wh i-c h is sim ila r t o t h e fin d in gs o f Velicer et a l. (1990) in term s o f th eir d im en sio n d e scrip t io n s. Howe ve r, t h e ce n t ra l q u e st io n is n o t so m u ch t h e cla ssifica t io n o f sit u a t io n s a s it is t h e sit u a t io n a l va r ia b le s wh ich sh a p e b e h a vio r. Th e d im e n sio n s d e r ive d in t h e t a xo -n o m ic re se a rc h a re ge -n e ra l i-n -n a t u re a -n d d o n o t e a sily t ra n sla t e in t o sp e c ific sit u a t io n a l va r ia b le s. En d le r (1981) h a s n o t e d t h e n e e d t o in vestiga te rea llife situ a tion s ra th er th a n la b o -ra t o r y o n e s, e m p h a sizin g t h e im p o r t a n c e o f t h e n e e d t o p r ovid e a s re a list ic a sit u a t io n a s p ossib le for a ssessm en t.
Desp ite criticism of h ea lth b eh a vior m od els fo r e m p h a sizin g in d ivid u a l o ve r sit u a t io n a l m o d e ls, h e a lt h p syc h o lo gy h a s a lso p r ovid e d vign e t t e m e t h o d o lo gie s fo r e xa m in in g t h e in -flu e n c e o f sit u a t io n o n b e h a vio r. Wh ile vi-gn ettes a re o n e p o ssib ility fo r stu d yin g co n tex-t u a l a n tex-t e c e d e n tex-t s, tex-t h e n e e d tex-t o va r y o n ly a fe w p a ra m e t e r s a t a t im e m a y re st r ic t t h e ir e ffe c -t ive n e ss. McKe ga n e y e -t a l. (1995) lo o ke d a -t vi-gn e t t e s in o ve r 500 in je c t in g d r u g u se r s in wh ich so cia l d ist a n ce fro m t h e in je ct in g p a r t -n er wa s va ried , a -n d fo u -n d th a t co -n textu a l va ri-a b le s in c lu d in g so c iri-a l d ist ri-a n c e , ge n d e r, ri-a n d t im e in je c t in g b u t n o t a ge sign ific a n t ly in flu -en ced th e t-en d -en cy to sh are eq u ip m -en t. Th e vign ettes were sim p le a n d con ta in ed a b r ief situ -a t io n in wh ich o n ly so ci-a l d ist -a n ce w-a s v-a r ie d (th e oth er p erson in th e in teraction b ein g a sex-u al p artn er, a close acq sex-u ain tan ce, or a stran ger). In a m o re co m p le x p re se n t a t io n , Dijke r e t a l. (1997), lo o kin g a t d e t e r m in a n t s o f fe a r o f p e o p le wit h AID S, u se d vign e t t e s wh e r e a d e scrip tio n o f th e in d ivid u a l to b e ra ted wa s p ro -vid e d in a b o o kle t (wit h a n u m b e r o f e xp e r i-m e n t a l p a ra i-m e t e r s va r yin g ra n d o i-m ly in t h e b o o kle t s), a lo n g wit h a d e t a ile d p ict u re o f t h e room in wh ich th e in tera ction wa s to ta ke p la ce a n d th e p rovision (in th e p ictu re) of a gla ss wa ll b etween th e scen e a n d th e room of th e in d ivid u a l t o b e ra t e d , t o e n a b le t h e (im a gin e d ) o p -p o rtu n ity to sta re a t th is in d ivid u a l. Th is stu d y h e lp e d p a r t ic ip a n t s t o m o re vivid ly im a gin e t h e p h ysic a l a n d a ffe c t ive c o n d it io n s u n d e r wh ic h in t e ra c t io n wit h t h e t a r ge t in d ivid u a l wo u ld t a ke p la c e . Th e u se o f vign e t t e s t o a p -p ro a ch re a lism a t t e m -p t s t o sit u a t e a n d “h e a t” th e cogn itive p rocess.
A seco n d a rea o f th eo retica l im p o rta n ce fo r situ a tio n a l m e a su re m e n t is its o p p o rtu n ity fo r a sse ssin g t h e ro le o f a ffe c t in sit u a t io n a l o u t -com es. An ecd ota l rep orts of risk situ a tion s su g-gest th a t wh ile cogn ition s a re im p orta n t in ou
t-c o m e , t h e y a re ove r r id d e n b y a ffe t-c t s in so m e in st a n c e s, fo r e xa m p le se xu a l b e h a vio r s. Af-fects a ct to “h ea t” th e co gn itio n s o r to overrid e t h e m , a n d u n like c o gn it io n s, wh ic h a re re la -t ive ly s-t a b le, a ffe c -t s a re u su a lly -t ra n sie n -t a n d situ a tio n a lly elicited . In o rd er to d eterm in e th e im p a c t o f a ffe c t s, e m o t io n s n e e d t o b e m e a -su re d , a n d t h e ir m e a -su re m e n t is t o a la rge e x-t e n x-t d e p e n d e n x-t o n b e in g a b le x-t o e licix-t x-t h e m in sit u a t io n s wh ic h a re a s re a list ic a s p o ssib le . Th e c o m p u t e r ize d sit u a t io n a l p re se n t a t io n m e t h o d d e scr ib e d h e re a d d s a cle a rly sit u a t e d in te ra ctio n , a n a lo go u s to vign e tte m e th o d o lo -gy wit h e n h a n c e d sit u a t io n a l c u e s su c h a s in th e stu d y b y Dijker, Koom en , a n d Kok.
Utility of a computer-based situational presentation method to assess predictors of HIV-risk situation response
Wh a t is la ckin g in a n a ttem p t to d eterm in e th e co n trib u tio n o f th e situ a tio n to th e va ria n ce in r isk b e h a vio r s is a n a p p r o p r ia t e m e t h o d fo r m ea su rin g situ a tio n s. Devisin g a m eth o d o lo gy to overcom e th e p rob lem of a lterin g a situ a tion b y in t e r ve n in g in it h a s le d t o a n u m b e r o f in -n ova t ive a p p ro a ch e s t o d a t a co lle ct io -n . Th e se h a ve in clu d e d o b se r va t io n o f a sit u a t io n fro m ou tsid e it with ou t th e kn owled ge of th e p a rtici-p a n ts (wh ich ra ises eth ica l q u estio n s) a n d rtici-p a r-t ic ip a n r-t o b se r va r-t io n . Re c a ll o f a sir-t u a r-t io n b y t h e p a rt icip a n t s is fra u gh t wit h t h e d ifficu lt ie s o f re t ro sp e ct ive d ist o r t io n a n d o f ra t io n a liza -t io n s a n d ju s-t ific a -t io n s. We d e sc r ib e h e re a c o m p u t e r- b a se d m e t h o d o lo gy o f sit u a t io n a l p resen ta tio n (SITPRES) wh ich a p p ea rs to h a ve so m e a d va n ta ges over th ese two a p p ro a ch es in m e a su r in g t h e sit u a t io n a l c o n t r ib u t io n t o h ea lth risk in m ea su rin g th e situ a tio n a l co n tri-b u t io n t o h e a lt h r isk tri-b e h a vio r, a lt h o u gh it in tu rn in trod u ces p rob lem s of its own .
cter-ist ics a re re p re se n t e d b y se ve n b a rs wh ich ca n ra n d o m ly va r y, t h u s wit h e a c h va r ia t io n p re -sen tin g a n oth er scen a r io for ra tin g.
In a t e st o f t h is a p p r o a c h (Ke la h e r e t a l., 1994) su b jects were exp o sed to 20 h yp o th etica l situ a tio n s wh ich a re d efin ed by seven en viro n -m e n t a l va r ia b le s o n scre e n (t h e Figu re 1 illu s-t ra s-t e s a s-t yp ica l scre e n fo r a sse ssin g p re d ics-t o rs o f e q u ip m e n t sh a rin g b y in je ctin g d ru g u se rs). Fo r a ssessin g p red icto rs o f co n d o m u se a m o n g h o m o se xu a l m e n , we u se d t h e fo llowin g e n vi-ron m en ta l va ria b les:
• Attra ctiven ess of p a rtn er • Degree of in toxica tion • Ava ila b ility of con d om s • How stron gly you wa n t a n a l sex • How m u ch p a rtn er is a ttra cted to you • In sisten ce of p a rtn er on u sin g a con d om • Am ou n t of tim e a va ila b le
Th e se va ria b le s a re gra p h ica lly m a n ip u la t -e d b y in c r-e a sin g o r d -e c r-e a sin g t h -e l-e n gt h o f t h e ir re p re se n t a t io n o n a b a r gr a p h , a n d m a n ip u la t io n s a re m a d e ra n d o m ly (fr o m a ra n -d o m n u m b e r s ge n e ra t o r wit h in t h e p ro gra m ) fro m o n e t r ia l t o t h e n e xt o n a se ve n - p o in t sca le. On ly th e h igh est a n d lowest va lu es on th e sca le a re a ssign ed lexica l la b els (“a little” a n d “a lo t”). Th e se e n viro n m e n t a l va r ia b le s we re d e r ive d fro m p ilo t in t e r vie ws a n d fr o m t h e re -se a rc h lit e ra t u re p r io r t o d e ve lo p m e n t o f t h e p ro gra m . Two e xa m p le s a re p re se n t e d t o t h e su b je c t fir st a n d d e m o n st r a t e d b y t h e re
-se a rc h e r t o e xp la in t o su b je c t s h o w SITPRES works.
Ra t in g o f re sp o n se va r ia b le s in c lu d e d : 1) self-rep o rted p ro b a b ility o f co n d o m u se fo r rece p tive a n a l se x (o r sh a rin g n e e d le s fo r th e in -jectin g d ru g exa m p le); 2) freq u en cy th a t a ctu a l exp erien ce m a tch ed th e h yp oth etica l situ a tion ; 3) if so, t im e e la p se d sin ce a n e xp e r ie n ce like t h e h yp o t h e t ica l sit u a t io n ; a n d 4) sa t isfa ct io n wit h t h e d e cisio n , a ga in u sin g a se ve n - p o in t sca le. Fo r t h e h o m o se xu a l sa m p le (n = 79), we a cco u n t e d fo r 34% o f t h e va r ia n ce in sa fe t y o f se x (Ke la h e r e t a l., 1994), d e fin e d b y a ttra ctio n to p a rtn er, d esire fo r a n a l sex, a n d p ercep tio n s of attractiven ess to p artn er (am on gst th ose list-ed ab ove).
In a d d itio n , o th er m ea su rem en t sca les m a y a lso b e p resen ted o n screen fo llowin g th e situ a t io n a l p re se n t a t io n t o p e r m it p e r so n sit u a t io n in t e ra c t io n a p p r o a c h e s t o p re d ic t in g re -sp on se. In ou r exp erien ce, su b jects from a wid e ra n ge o f e d u ca t io n a l b a ckgr o u n d s a re a b le t o u se t h is syst e m , a n d it h a s a ch ie ve d co n sid e r a b ly grea ter a ccep ta b ility th a n p a p er a n d p en -cil m e a su re s. In a d d it io n , it h a s n o ve lt y va lu e a n d wa s re la t ive ly e a sy t o a d m in ist e r in b a r s , ga y b a t h h o u se s, a n d c lin ic s a s we ll a s o n t h e stre e t u sin g a co lo r la p to p co m p u te r (p ro gra m a va ila b le fro m th e a u th o r o n receip t o f b la n k 3 1/ 4 in ch flo p p y d isk). An a lysis by lin ea r regres-sio n o r ca n o n ica l co r re la t io n , a s a p p r o p r ia t e, u sin g sta n d a rd sta tistica l p a cka ges, is rela tively sim p le a s d a t a a re wr it t e n d ire ct ly t o a flo p p y d isk.
Wh ile t h is p r o gra m h a s t h e a d va n t a ge s o f a llowin g p recise p resen ta tio n o f th e situ a tio n’s p a ra m eters, ra n d om iza tion of situ a tion a l p a ra -m e t e r s t o p e r -m it -m u lt iva r ia t e a n a lysis o f t h e in d ep en d en t p red ictors’ con trib u tion , a n d p re-c ise m e a su re m e n t o f re sp o n se , it h a s se ve ra l d isa d va n ta ges. First, th e situ a tio n is o n ly a s re-a list ic re-a s t h e p re-a rre-a m e t e r s p re se n t e d re-a n d o b vi-o u sly ca n n vi-o t en cvi-o m p a ss a ll th e en virvi-o n m en ta l va r ia b le s p re se n t . To a lim it e d e xt e n t , t h is ca n b e ove rco m e b y in st r u ct io n s t o “im a gin e o n e -se lf in t h is sit u a t io n” (a lt h o u gh t h e a d d it io n a l cu e s p rovid e d b y im a gin a t io n a re t h e m se lve s id io p a t h ic a n d t h u s a so u rc e o f u n c o n t r o lle d va ria n ce). Secon d , th e situ a tion is on e of “cold” co gn it io n wit h o u t t h e va r ia b le s o f (in t h e t wo exa m p les p resen ted h ere) sexu a l o r d ru g-rela t-e d a ro u sa l (a lt h o u gh co llt-e ct in g d a t a o n sit t-e in ga y b a t h h o u se s a n d b a r s, o r in d r u g c lin ic s, m a y h a ve p rovid e d so m e re a lism ). Th e re is lit-tle p ro sp e ct o f in tro d u cin g a situ a tio n o f “h o t” co gn itio n with o u t th e a d d itio n o f er o tic m ed ia a n d d r u g a d m in ist ra t io n , a lt h o u gh t h is is ce r-t a in ly a p o ssib le d e ve lo p m e n r-t . Howe ve r, d e
ci-Fig ura 1
Examp le o f c o mp ute r-g e ne rate d sc e nario .
Situation 10 A little A lot
Effe c t o f alc o ho l and d rug s
Attrac tive ne ss o f p artne r
Attrac tive ne ss to p artne r
Availab ility o f c o nd o ms
Ho w stro ng ly anal se x is d e sire d
Partne r’s insiste nc e o n c o nd o m use
Ho w muc h time is availab le
Would you have anal sex and be the receptive partner?
(p re ss a numb e r fro m 0 to 7)
De finite ly Unlike ly De finite ly
wo uld no t to wo uld
sio n sa tisfa ctio n m a y p rovid e a m ea su re o f th e ga p b etween “h o t” a n d “co ld” co gn itio n . Th ird , th e situ a tion will b e a ccu ra tely ra ted on ly in so fa r a s it a ccu ra t e ly re p re se n t s a re a l life sit u a -tio n , a n d it is p o ssib le, given ra n d o m iza -tio n o f variab les, th at u n likely com b in ation s m ay arise. To so m e exten t th is ca n b e m ea su red by a skin g t h e su b je c t t h e e xt e n t t o wh ic h t h e sit u a t io n re p re se n t s a sit u a t io n in wh ic h t h e su b je c t s h a ve a ct u a lly fo u n d t h e m se lve s. Howe ve r, t h e co m p u t e r scre e n -b a se d m e t h o d o lo gy a lso h a s th e a d d itio n a l a d va n ta ge s o f b e in g sim ila r to a vid eo ga m e a n d a p p ea rin g m ore a n on ym ou s to th e resp o n d en ts sin ce d a ta a re written d irectly to d isk.
It is p ossible, u sin g a trian gu lation of m eth od-o lod-o gies su ch a s 1) re trod-o sp ective reca ll tod-o a ssess t h e co gn it ive p ro ce sse s u t ilize d in a p a rt icu la r situ a tio n ; 2) p a rticip a n t o r n o n p a rticip a n t o b -se r va t io n ; a n d 3) a sit u a t io n a l p re -se n t a t io n syst e m a s d e sc r ib e d h e re, t o ga in a p ic t u re o f t h e sit u a t io n a l a n d p e r so n a l va r ia b le s wh ic h m a y p re d ict re sp o n se. Ou r d a t a wit h in je ct in g d r u g u se r s a n d u sin g SITPRES h a ve p rovid e d very sim ila r fin d in gs to a n th rop ologica l stu d ies of sim ila r situ a tion s: with n= 84, we a ccou n ted fo r 88% o f th e va ria n ce in sa fe ty o f ch o ice (Ke -la h er & Ross, 1999). Th e va ria b les were: • How m u ch you’re h a n gin g ou t for a h it • How a va ila b le th e d ru g is
• How we ll yo u kn ow th e p e o p le yo u ’re sh a r-in g with
• How often you’ve sh a red with th ese p eop le • How a va ila b le b lea ch is to clea n n eed les • Priva cy of p la ce wh ere you h it u p • How h igh / ston ed / d ru n k you a re
Th e p r o b a b ilit y o f sh a r in g in c re a se d a s clea n n eed le a va ila b ility d ecrea sed , cra vin g in crea sed , a n d level o f p revio u s sh a rin g with p o -ten tia l p a rtn ers in crea sed .
Th e se d a t a fr o m t wo d iffe re n t sa m p le s a t risk of HIV in fection in d ica te th a t SITPRES p r o-vid es a u sefu l m eth od ology to con tr ib u te to th e u n d e r st a n d in g o f sit u a t io n a l d e t e r m in a n t s o f H IV-re la t e d risk b e h a vio rs, a n d m a y gu id e t h e c o n t e n t o f b o t h p o lic y a n d e d u c a t io n a l p r o -gra m s a s well a s p rovid e eva lu a tio n o f th eir ef-fectiven ess. It m a y a lso b e u sefu l to o th er a rea s o f p u b lic h e a lt h , su ch a s sit u a t io n s in wh ich p e o p le ove re a t o r e a t in a p p r o p r ia t e fo o d s; e x-cessive su n exp osu re; sm okin g or u se of sm oke-less tob acco; alcoh ol an d d ru g u se; u se of in fec-t io n c o n fec-t r o l p r o c e d u re s; d o m e sfec-t ic vio le n c e ; u se o f se a t b e lt s o r o ccu p a t io n a l sa fe t y e q u ip -m e n t; a n d a d h e re n ce to -m e d ica tio n re gi-m e n s, to id en tify b u t a few.
Domains and their elicitation in situational presentations
Th e d o m a in s c h o se n fo r p re se n t a t io n in SIT-PRES sh o u ld p refera b ly b e em p irica lly d erived , eith er fro m p revio u s stu d ies o r fro m a p relim i-n a ry q u a lita tive ii-n vestiga tioi-n . Id ea lly, th ere will b e a d e q u a t e q u a lit a t ive st u d ie s d e r ive d fro m o b se r va t io n , in t e r vie ws, o r fo c u s gr o u p s t o c o n fir m t h e m a in fa c t o r s p e rc e ive d t o in flu -e n c-e th -e h -e a lth b -e h a vio r o f in t-e r-e st in th -e giv-en situ a tio n . If n o t, th giv-en th e in itia l sta ge o f th e re se a rch sh o u ld b e th e e licita tio n o f th e se fa c-t o r s. In so m e c a se s, c-t h e va r ia b le n o c-t e lic ic-t e d m a y b e h yp o t h e size d t o h a ve a su b t le im p a c t o n t h e h e a lt h b e h a vio r a lt h o u gh n o t a t a co n -scio u s level, a n d th ere is n o rea so n wh y su ch a va ria b le sh ou ld n ot b e in clu d ed if p reviou s em -p ir ic a l o r a n e c d o t a l e vid e n c e im -p lic a t e s it . Howe ve r, e licit a t io n o f fa ct o rs fro m t h e p o p u -la tio n o n wh ich th e SITPRES a p p ro a ch is go in g to b e tried is a d visa b le.
Th e “crit ica l in cid en t ”a p p r o a c h (Bro o k-fie ld , 1990; Ro ss e t a l., 1993) is a se co n d u se fu l wa y of elicitin g m aterial for d esign in g SITPRES. Bro o kfield (1990) d escrib es a “critical in cid en t”
a s a sit u a t io n o r e ve n t t h a t is vivid ly re m e m -b e re d o r th a t h o ld s sp e cia l sign ifica n ce fo r th e n a rra t o r. Th e u se o f a p a r t icu la r e ve n t , fo r e xa m p le t h e lxa st t im e xa h e xa lt h r isk b e h xa vio r o c -c u r re d , n o t o n ly p rovid e s a n a n -c h o r fo r m o re a ccu ra te m em ory, b u t a lso for reca ll of th e situ -a t io n in wh ic h t h e b e h -a vio r w-a s e m b e d d e d . Fo r e xa m p le, Le o n a rd & Ro ss (1997) lo o ke d a t th e la st a ct of sexu a l in tercou rse in 400 resp on -d en ts to a street ou trea ch stu -d y, a n -d n ote-d th a t a cts o f u n sa fe se x we re like ly to b e va gin a l se x, a cco m p a n ie d b y a lco h o l, m a r iju a n a , o r o t h e r d ru gs, to ta ke p la ce with n ew p a rtn ers, in a h o-te l o r m o o-te l in a p a rticu la r city b lo ck, b e twe e n 8 a n d 11 PM (o r a t lu n ch tim e ), th u s p rovid in g im p o rta n t clu es to b o th th e d esign o f in terven -t io n a n d sc re e n in g p r o gra m s a n d -t h e c o n -t e x-t of risk b eh a vior.
k-in g k-in a situ a ted , n a rra tive fo rm is m u ch ea sier for m ost in d ivid u a ls – a s h is sexu a l rela tion sh ip h ist o r ie s wit h lo we r c a st e In d ia n wo m e n d e m o n st ra t e. Th u s, e it h e r q u a n t it a t ive crit ica l in cid e n t m e a su re s o r q u a lita tive n a rra tive s re ga rd in g critica l in cid en ts ca n p rovid e in fo rm a -t io n o n -t h e si-t u a -t io n a l d o m a in s a sso c ia -t e d with h ea lth risk b eh a viors.
Th e p re lim in a r y e m p ir ic a l re se a rc h u sin g situ a tio n a l p resen ta tio n s rep o rted a b ove id en t ifie d a n u m b e r o f d o m a in s wh ich m a y b e im -p o r t a n t a cro ss re se a rch a re a s, a n d wh ich m a y va r y fro m situ a tio n to situ a tio n . Th e se in clu d e t h e d r ive t o re a ch t h e p a r t icu la r t a rge t b e h a v-io r, t h e a ffe ct a n d it s st re n gt h a sso cia t e d wit h th e b eh a vior, a n d th e a va ila b ility of th e m a ter i-a ls n eed ed for th e b eh i-a vior (e.g. con d om s, n eed le s, su n scre e n , p a r t icu la r t yp e s o f fo o eed , ciga -rettes, a lco h o l a n d o th er d ru gs, sea t b elts). Th e p h ysica l re st ra in t s o f t h e sit u a t io n n e e d t o b e co n sid e re d wh ich m a y fa cilit a t e o r re st rict t h e ta rge t b e h a vio r, th e tim e a va ila b le, a n d th e fa -m ilia r it y o f t h e sit u a t io n , wh ich -m a y h a ve le d t o t h e b e h a vio r in t h e sit u a t io n b e in g scr ip t e d (Ga gn o n & Sim o n , 1973). Th e a cto rs a re p ro b a -b ly t h e m o st im p o r t a n t va r ia -b le in sit u a t io n s in vo lvin g m o re t h a n o n e p e r so n : t h e y a re t h e d o m a in wh ic h m o st c lo se ly in t e r fa c e s wit h h e a lt h b e h a vio r t h e o r ie s p o st u la t in g so c ia l le a r n in g, r o le m o d e lin g, a n d p e e r n o r m s a n d p re ssu re a s sign ifica n t p re d ict o rs o f b e h a vio r. Fla y & Petra itis (1994), in th eir th eo ry o f tria d ic in flu e n c e , n o t e t h a t so c ia l se t t in gs o r m ic r o -en viro n m -en ts ca n co n trib u te to a n in d ivid u a l’s h e a lt h -re la t e d b e h a vio rs a n d in t e ra ct wit h t h e a ttitu d es, va lu es, a n d b eh a viors of oth ers in th e sa m e sit u a t io n . Esse n t ia lly, t h e b o u n d a r ie s o f th e situ a tion will b e in th e p la ce, tim e, a n d p er-so n (s) p re se n t , wit h t h e a t t it u d e s, b e lie fs, a n d va lu e s o f t h e re sp o n d e n t a ssu m e d t o b e re la tively co n sta n t with in th e set o f SITPRES stim -u li. Howe ve r, re sp o n se s o f o t h e r s p re se n t ca n b e in clu d e d , a s in t h e e xa m p le a b ove fro m t h e st u d y b y Ke la h e r e t a l. (1994), wh e re t h e a t t i-t u d e s o f i-t h e p a r i-t n e r i-t owa rd s co n d o m u se a n d t h e d e gre e t o wh ic h t h e y a re a t t ra c t e d t o t h e su b je c t a re in c lu d e d , a n d fr o m t h e st u d y b y Ro ss & Kela h er (1999), in wh ich o n e’s fa m ilia ty with oth er p a rticip a n ts a n d freq u en cy of p or d ru g sh a rin g with th em a re in clu d ed a s va ri-a b les.
Future applications: virtual reality
Th e e xa m p le s p re se n t e d a b ove a re lim it e d b y th e tech n ology availab le (at th e tim e of writin g, color lap top 486 com p u ters were u sed ).
However, th e fu tu re p oten tial of th e SITPRES m eth od -o l-o gy is lim it e d -o n ly b y t h e t e c h n -o l-o gy a va ila b le, ila n d we en visila ge th ila t virtu ila l reila lity sim u la tion s will exp a n d th e rea lism p ossib le in a sit -u a tio n b y a n o rd er o f m a gn it-u d e. Fo r e xa m p le, p rovid in g a c t u a l p h o t o gr a p h s o f a n e n vir o n -m en t, o r en a b lin g th e su b ject to -m ove th ro u gh it o n scre e n a n d o b se r ve it fro m d iffe re n t p e r-sp ectives, o r a d d in g ta ctile a n d a u d ito ry in p u t, o r h a vin g t h e sit u a t io n p r o gre ss in re a l t im e, a re a ll with in rea ch a n d p resen t p ossib ilities for m a kin g th e SITPRES m ore rea listic. Th e rea lism o f th e situ a tio n a l vign e tte p re se n te d is lim ite d on ly by th e tech n ology, a lth ou gh it is likely th a t t h e n u m b e r o f p a ra m e t e r s in t h e sit u a t io n m ea su red will rem a in a ro u n d seven , given th a t b eyo n d th is n u m b er, th e sa lien ce o f a d d itio n a l va ria b les m a y d eclin e. Fligh t sim u la to rs fo r p i-lo t tra in in g a lrea d y p rovid e h igh ly rea listic a n d clo se ly b o u n d e d sit u a t io n s in wh ich b e h a vio r ca n b e a ccu ra tely m ea su red .
Interventions based on situational models
-th er, -th e ro le o f situ a tio n a lly-elicited a ffect a n d em otion s ca n b e p resen ted a s a set of p oten tia l d e m a n d c h a ra c t e r ist ic s. Fr it h & Kit zin ge r (1998) h igh ligh t t h e im p o r t a n c e o f “em ot ion w ork ”in a fe m in ist a n a lysis o f wo m e n wh o m a ke se xu a l d e c isio n s b a se d o n t h e n e e d t o ta ke ca re o f m e n’s em o tio n s a n d to a vo id h u rt-in g m e n’s fe e lrt-in gs. Su ch “em otion w ork”(m a n -a ge m e n t o f e m o t io n s o r “em ot ion a l la b or”) fu n ct io n s t o p rovid e p a r t icip a n t s wit h a n u n -d ersta n -d in g o f th e -d em a n -d ch a ra cteristics a n -d e m o t io n -a sso cia t e d r isks in se xu a l sit u a t io n s. Frith & Kitzin ger (1998) u se th is co n cep t to exp la in wo m e n’s re sist a n ce t o d a t e ra exp e e d u ca -t io n . Th e y n o -t e -t h a -t in wo m e n -t h e e m o -t io n a l la rge ss is u su a lly o t h e r-o r ie n t e d : h owe ve r, t h e c o n c e p t o f “em ot ion w ork ”wh ic h is u se d a s a se lf- o r situ a tio n a lly-o rie n te d in te r ve n tio n is a u se fu l m o d e l fo r p r ovid in g so m e p o we r ove r th e situ ation al “h ot” cogn itive or affective com -p o n e n t s. S-p e c ific a lly, it m a y -p rovid e -p e o -p le with a n u n d erstan d in g of th e em otion al factors wh ich m a y ove r r id e c o gn it io n s in r isk sit u a -tion s.
Th e t h ird st e p is t o u se t h e c o n c e p t o f a n -ticip a ted regre t to re -p resen t th e situ a tio n a n d it s a ft e r m a t h . Go ld (1993) h a s n o t e d t h a t wit h “h ot” cogn ition s, an u rgen t d esire th at d em a n d s im m e d ia t e fu lfillm e n t is u su a lly se t a ga in st n ega tive co n seq u en ces th a t a re m u ch m o re re-m o t e , a n d t h u s t h e u r ge n t d e sire is like ly t o lo o m la r ge r a n d t o b e a c c o rd e d c o n sid e ra b le va lu e. Th e c o n c e p t o f a n t ic ip a t e d re gre t a im s t o lin k t h e sit u a t io n wit h t h e a ft e r m a t h in t h e h o p e t h a t t h is lin ka ge will su rvive t h e h e a t in g o f th e co gn itio n s a n d th a t th e situ a tio n will a ct a s a cu e to its recollection . An ticip a ted regret is n o t a n e w c o n c e p t in p u b lic h e a lt h : va n d e r Pligt & Rich a rd (1994) review th e h isto ry o f th is a p p ro a c h a n d su gge st t h a t t h is m a y b e a stro n ger p red icto r o f b eh a vio r ch a n ge in m a les t h a n in fe m a le s. An t ic ip a t e d re gre t is t h e a t -te m p t to in flu e n ce th e tim e p e rsp e ctive b y d e-scrib in g th e a ffect a sso cia ted with (in th e stu die s o f va n d e r Pligt & Rich a rd ) h a vin g h a d u n -sa fe se x. Th e in d ivid u a l is a ske d t o im a gin e h ow t h e y fe e l a ft e r h a vin g h a d u n sa fe se x, wh en th ey rea lize th e co n seq u en ces o f th e risk t h e y h a ve t a ke n . By m a kin g t h e fe e lin gs a ft er
t h e e ve n t m o re sa lie n t , t h e y fo u n d t h a t su b -je c t s we re like ly t o re p o r t b e in g m u c h m o re ca u tiou s in th e fu tu re. Th is m a n ip u la tion of fu t u re t im e p e rsp e ct ive is a p p ro p r ia t e fo r sit u a t io n a l in t e r ve n t io n s b e c a u se it se r ve s t o e m p h a size t h e a ffe c t ive a n d t e m p o ra l c o n n e c -tion s ra th er th a n focu sin g on a m om en t in tim e d ise m b o d ie d fr o m a sit u a t io n’s a n t e c e d e n t s a n d c o n se q u e n c e s. Th u s, e a c h r isk b e h a vio r
h a s b e e n c o n n e c t e d wit h a n im m e d ia t e p a st a n d a n im m e d ia te fu tu re to cre a te a risk situ a -t io n . In a d d i-t io n , a fo c u s o n h o w -t h e p e r so n will fe e l a ft er t h e e ve n t is c o n sist e n t wit h ch o ice th e o rie s wh ich p re d ict th a t risk-a sso cia t e d d e cisio n s m cia y b e in flu e n ce d m o re b y in -fo r m a t io n t h a t e m p h a size s lo sse s t h a n ga in s ( Tversky & Ka h n em a n , 1974).
Th e fou rth step is on e of situ a tion a l retra in in g, wh ic h is sim ila r t o r o le p la y in t h a t it in volves a reh ea rsa l of th e situ a tion wh ere th e in d ivid u a l is le a d t h ro u gh t h e st e p s o f t h e sit u a t io n a s it d e ve lo p s, wit h p a rt icu la r co n ce n t ra -t io n o n d e c isio n p o in -t s – c r i-t ic a l p o in -t s o r p la ces wh ere th e d irectio n o f th e em ergin g sit-u a t io n ca n b e ch a n ge d . Th e se d e cisio n p o in t s sh o u ld b e h igh ligh t e d by cu e s (wit h e m p h a sis o n t h e a ffe c t ive a n d p h ysic a l c u e s, su c h a s a rou sa l, goin g in to a vid eo p a rlor b ooth ) a s well a s t h e co gn it ive o n e s. Th e sit u a t io n a l re t ra in -in g sh o u ld th en b e exten d ed to th e co m p letio n o f t h e sit u a t io n a n d a n t ic ip a t e d re gre t e xa m -in e d a s t h e p a r t ic ip a n t le a ve s t h e sit u a t io n , t h u s m a kin g t h e a n t ic ip a t e d re gre t t h e p ro xi-m a l fo c u s o f t h e sit u a t io n . An t ic ip a t e d re gre t m a y th u s a ct a s a n ega tive rein forcer to a situ a -t io n in wh ic h -t h e re wa s r isk b e h a vio r, a n d a p o sit ive re in fo rc e r wh e re t h e sit u a t io n wa s wit h o u t r isk. Th is a p p r o a c h t o sit u a t io n a l in -te r ven tio n s u ses existin g a p p ro a ch es to h ea lth b e h a vio r in t e r ve n t io n s – t h e u se o f t h e p sy-c h o t h e ra p e u t isy-c sy-c o n sy-c e p t o f in sigh t , t h e u se o f cu es to b eh a vio r, a n ticip a ted regret a s a m ea n s o f in t ro d u cin g a ffe ct a n d p rovid in g re in fo rce m e n t , a n d ro le p la yin g t o e n a b le t h e d e ve lo p -m e n t a n d re h e a r sa l o f t h e sc r ip t . Howe ve r, t h e ir co m b in a t io n in e m p h a sizin g t h e e n ca p su la t e d sit u a t io n a llows fo r a fo cu s o n t h e e n tire situ a tio n ra th e r th a n ju st th e d e co n te xtu -a lize d p e rso n -a l ve rb -a l in t e r-a ct io n s -a s o ft e n is t h e c a se in r o le - p la yin g. Th e c o m b in a t io n o f t h e se a p p ro a ch e s in t o a sit u a t io n fo cu se d in t e r ve n t io n m a y e n a b le t h e p owe r o f t h e sit u a t io n t o b e m o re re a list ic a lly a d d re sse d b y re h ea rsin g b eh a vio r ch a n ge wh ich h a s b een em -b e d d e d in a sit u a t io n – wh ich sh o u ld a lso a d d to th e rea lism of th e reh ea rsa l.
Conclusions
o f a ct io n is e xt e r n a l ra t h e r t h a n in t e r n a l, o r wh e re t h e cu lt u re is b a se d o n in t e rd e p e n d e n t ra t h e r t h a n in d e p e n d e n t in t e r a ct io n s. Eve n in circu m st a n ce s wh e re t h e in d ivid u a l h a s a d e -gree o f a u to n o m y with rega rd to h ea lth -rela ted b eh a vio rs, th e situ a tio n m a y a d d a n a d d itio n a l sign ifica n t a m o u n t o f va ria n ce to th e e xp la n a -t io n o f r isk b e h a vio r. Th e si-t u a -t io n a l m o d e l is b a se d o n fo u r sim p le p re m ise s: first , t h a t t h e sit u a t io n is a so u rce o f a d d it io n a l e xp la n a t io n o f h e a lt h r isk; se co n d , t h a t it s im p o r t a n ce is ro u gh ly in ve rse t o t h e d e gre e o f in d ivid u a l a gen cy; th ird , th a t it is m ea su ra b le; a n d fo u rth , th a t in te rve n tio n s a ttu n e d to situ a tio n a l m o d -e ls ca n b -e -e ff-e ct iv-e wh -e r-e t h -e r-e is sign ifica n t situ a tio n a l va ria n ce in h ea lth r isk b eh a vio rs. It is e m p h a size d t h a t t h e sit u a t io n a l m o d e l, a s p re se n t e d h e re, d o e s n o t re p la ce a n y e xist in g th eory or m od el b u t is com p lem en tar y: it seeks t o a d d a n a d d it io n a l d im e n sio n t o o u r u n d e r-sta n d in g o f risk b e h a vio r. As Ke yn e s (1936:viii) n o t e d in t h e p re fa ce t o h is Gen era l Th eory,
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