#2102Jnl of Health and Social BehaviorVol.

46 146105-cockerham

Health Lifestyle Theory and the Convergence of Agency and Structure*

WILLIAM C. COCKERHAM
University of Alabama at Birmingham

Journal of Health and Social Behavior 2005, Vol 46 (March): 5167

This article utilizes the agency-structure debate as a framework for constructing a health lifestyle theory. No such theory currently exists, yet the need for one is underscored by the fact that many daily lifestyle practices involve considerations of health outcomes. An individualist paradigm has influenced concepts of health lifestyles in several disciplines, but this approach neglects the structural dimensions of such lifestyles and has limited applicability to the empirical world. The direction of this article is to present a theory of health lifestyles that includes considerations of both agency and structure, with an emphasis upon restoring structure to its appropriate position. The article begins by defining agency and structure, followed by presentation of a health lifestyle model and the theoretical and empirical studies that support it.
Delivered Ingenta to An important but undeveloped area of theo-by agency accentuate the capacity of individual UNIVERSITY OF NEVADA, RENO (cid 1060), Univ. of Nevada-Reno (cid 291575), University retical discourse in medical sociology pertains actors to choose their behavior regardless of of Nevada, Reno structural influences. When applied to health to the relative contributions of agency and struc- (cid 57010993) IP : 127.0.0.1 ture in determining health lifestyles. Medical lifestyles, the question is whether the deciTue, 13 Sep 2005 20:50:48 sociologists have paid little attention to the sions people make with respect to diet, exercise, agency-structure problem, yet it is clearly central smoking, and the like are largely a matter of to theoretical discussions of health and lifestyles individual choice or are principally shaped by (Pescosolido, McLeod, and Alegra 2000; structural variables such as social class position Williams 1995). No contemporary theoretical and gender? perspective denies that either agency or structure is unimportant; rather, the debate centers on the extent to which one or the other is THE NEED FOR A dominant. Proponents of structure emphasize HEALTH LIFESTYLE THEORY the power of structural conditions in contouring individual dispositions and behavior along It is the purpose of this article to examine the socially prescribed lines, while advocates of agency-structure debate as a framework for constructing a health lifestyle theory. No such theory currently exists. The need for a health * An earlier version of this article was presented at lifestyle theory is underscored by the fact that the 2003 American Sociological Association meeting in Atlanta, Georgia, and the 2004 joint meeting of the many daily lifestyle practices involve considEuropean Society of Health and Medical Sociology erations of health outcomes. Perhaps this is truer and the Italian Society of Health Sociology, Bologna, today than in the past. Whereas people may have Italy. The author would especially like to thank more or less taken their health for granted in Michael Hughes for his considerable insights previous historical eras, this is presently not the concerning this article, along with Mark Tausig and case. Health in late modernity has become three anonymous reviewers for their comments on an viewed as an achievementsomething people earlier version. Address correspondence to William C. Cockerham, Department of Sociology, Univer- are supposed to work at to enhance their quality sity of Alabama at Birmingham, 237 Ullman Building, of life or risk chronic illness and premature death 1530 Third Avenue South, Birmingham, AL 35294- if they do not (Clarke et al. 2003). According to Giddens (1991) and Turner (1992), lifestyle 3350 (email: wcocker@uab.edu). 51

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham 52 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

options have become integrated with bodily regi- advanced societies as a primary source of their mens in late modernity and people have become social identification (Bauman 1992; Crompton more responsible for both the health and design 1998; Giddens 1991). This situation was made of their own bodies. possible by the rise in economic productivity This situation originates from changes in promoting a general improvement in living stan(1) disease patterns, (2) modernity, and (3) social dards and purchasing power after World War II. identities. The first change is the twentieth The easier acquisition of basic material needs century epidemiological transition from acute allowed styles of consumption to supercede to chronic diseases as the major source of human occupation for signifying social similarities and mortality in most areas of the world. Medicine distinctions for many people (Crompton 1998). cannot cure these chronic diseases and negative Scott (1996), for example, f inds that the health lifestyles promote them. The realization lifestyles of British manual workers have been that this is a certainty carries with it the reve- altered, with major implications for class idenlation that the responsibility for ones health ulti- tification. He observes that social distinctions mately falls on oneself through healthy living in the working class are determined more by (Crawford 1984). Greater personal responsibility consumption patterns than relationships to the means that achieving a healthy lifestyle has means of production. become more of a life or (time of) death option. Therefore, as Crompton (1998) points out, The second change is the current era of late the claim that lifestyles have become more modern social alterations creating a new significant in class formation and social idenmodernity (Bauman 1992, 2000; Beck 1992; tification needs to be taken seriously. This obserGiddens 1991). While notions of an absolute vation is consistent with Giddenss (1991) asserbreak with the past modernity originating with tion that lifestyles not only fulfill utilitarian the industrial age are unconvincing, it is never- needs, but also give material form to a partictheless clear that society is in a transition to a ular narrative of self-identity. An important Delivered new social form (Pescosolido and Rubin 2000).by Ingenta to lifestyle configuration and the accompanying UNIVERSITY OF new world order evolving out Univ. of Nevada-Reno practices affecting health This is seen in the NEVADA, RENO (cid 1060), social marker are those (cid 291575), University of the collapse of Soviet-styleof Nevada, Reno (cid 57010993) socialism, the and the distinctions they also contribute to differIP : 127.0.0.1 expanding multiculturalization of Europe and ences in social identities (Annandale 1998). A Tue, 13 Sep 2005 20:50:48 North America, the rise of cultural and sexual theory of health lifestyles is needed to advance politics, the multiplicity of family forms, our understanding of this social phenomenon. changing patterns of social stratification, and the increasing use of knowledge as a commodity. In health matters, we see the decline in the status THE INDIVIDUALIST PARADIGM: and professional authority of physicians through A CRITIQUE lessened control over the medical marketplace. Much of what we know about lifestyles has We also see greater movement toward the mutual participation model of the physician-patient rela- its theoretical origins in the early twentieth tionship that has accelerated with the advent century work of Max Weber ([1922] 1978). of Internet medicine and the diffusion of medical However, Frohlich, Corin, and Potvin (2001:782) knowledge in the public domain (Hardey observe that the term lifestyle, widely adopted 1999; Warren, Weitz, and Kulis 1998). In the by researchers in health promotion, social still-emerging late modern society, where tradi- epidemiology, and other branches of public tional industrial age centers of power and health, has taken on a very particular and authority, such as medicine, are weakening, different meaning from that intended by Weber. adopting a healthy lifestyle accords people more Although Webers methodologies often reflected an individualist and agency-oriented bottomcontrol over their life situation. The third change is that there has also been up approach to the study of social structure, he movement in late modernity toward an adjust- did not view patterns of social action as the ment in the primary locus of social identity. uncoordinated practices of disconnected indiPreviously, work or occupation largely deter- viduals (Kalberg 1994; Sibeon 2004). Instead, mined social class position and a persons way he saw social action in terms of regularities and of life. Beginning in the second half of the twen- uniformities repeated by numerous actors over tieth century, lifestyle consumer habits have been time. His focus was on the way in which people increasingly experienced by individuals in act in concert, not individually. The bridge from

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham HEALTH LIFESTYLE THEORY 53

agency to structure for Weber was the ideal that no health scientist has yet invented the drug type, consisting of structural entities (e.g., or written the law that will make individuals bureaucracy) or processes (e.g., formal ratio- do what those individuals must choose to do nality), whose construction allowed him to make themselves. general statements about collective forms of Consequently, health lifestyles are largely social behavior (Kalberg 1994). For example, depicted as sets of individually constructed in The Protestant Ethic and the Spirit of Capi- behaviors, with education serving as the critical talism, Weber (1958) emphasized macrostruc- feature of agency. The elements of a healthy ture in an essentially top-down fashion lifestyle are described as having nothing in showing how social institutions (Calvinist reli- common with each other except that they gion) and widespread belief systems (capitalism) improve health. In seeking health, state were powerful forces in shaping the thoughts Mirowsky and Ross (2003:199), individuals and behavior of individuals (Sibeon 2004). weave these disparate habits and practices into Yet, as Frohlich et al. (2001:783) point out: a coherent lifestyle designed to preserve and When lifestyle is currently discussed within promote health. While individuals tend to do the socio-medical discourse, there is a decided what others like them do, it is individuals who tendency for it to be used in reference to indi- take otherwise incoherent or diametric pracvidual behavioural patterns that affect disease tices allocated by subcultural forces and status, thereby neglecting its collective (struc- coalesce them into a healthy lifestyle (Mirowsky tural) characteristics. This approach is an and Ross 2003:53). example of Archers (1995:4) notion of upwards While Mirowsky and Ross make an imporconflation, a term she applies to behavioral tant contribution by highlighting the powerful models in which individuals monopolize causal role of education in the selection of health power that operates in a one-way, upward direc- lifestyles, income and occupational status join tion and seems incapable of acting back to influ- education as the major components of social Delivered Ingenta socioeconomic status (SES). As Adler ence individuals. This is seen in the standardby class or to UNIVERSITY research in public health 1060), Univ. of Nevada-Reno (cid 291575), University approach to OF NEVADA, RENO (cid and et al. (1994) point out, the three variables are of Nevada, Reno interrelated but epidemiology that treats health behavior and (cid 57010993) not identical nor fully overlapIP : 127.0.0.1 lifestyles as matters of individual choice and ping. The fact that associations between SES Tue, 13 Sep 2005 20:50:48 targets the individual to change his or her and health are found with each of the indicaharmful health practices largely through educa- tors, state Adler et al. (1994:15), suggests that tion (Lomas 1998; Sweat and Denison 1995). a broader underlying dimension of social stratThe theoretical models employed in such ification or social ordering is the potent factor. research, like the Health Belief Model, the AIDS Thus, education can also be viewed in combiRisk Reduction Model, the Common Sense nation with the other components of class to Model of Illness Danger, and the Stages of constitute a structural variable that produces topChange Model, are based on individual down distinctions in the quality and form of psychology. health lifestyles among individuals, as well as In their book Education, Social Status, and providing a social context for the practice of Health, Mirowsky and Ross (2003) indicate that such lifestyles. Other structural variables such neither individual choice nor structural limita- as age and gender also produce distinct patterns tions can be ignored in studies of health behavior in health lifestyles (Cockerham 2000a). and lifestyles. They use the term structural Sociological concepts reflecting literally all amplification to refer to situations where well- theories of social life attest to the fact that someeducated individuals accumulate advantages and thing (namely structure) exists beyond the indipoorly educated persons amass disadvantages vidual to give rise to customary patterns of that are bundled over time into cascading behavior. These concepts range from Durkheims sequences impacting either positively or nega- ([1895] 1950:13) notion of social facts as every tively on health. However, Mirowsky and Ross way of acting, fixed or not, capable of exercising concentrate more on agency than structure in on the individual an external constraint to this book. Their goal is to show that education Meads (1934:155) view of the generalized increases effective agency that, in turn, increases other as the organized attitudes of the whole the control that an individual has over his or her community and the social process through which life, thereby encouraging and enabling a healthy the community exercises control over the lifestyle. Mirowsky and Ross (2003:28) state conduct of its individual members.

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham 54 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

Structural influences on health lifestyle prac- ture on agency in relation to health lifestyles is tices are seen, for example, in the studies of still heavy-handed. He finds that assuming Demers and her colleagues (Demers, Bisson, people have the freedom to make healthy choices and Palluy 1999; Demers et al. 2002) on alcohol is out of line with what many people experience consumption by married women and univer- as real possibilities in their everyday lives. The sity students in Canada. This research shows respondents, concludes Williams (2003:147), that class position, the social relationships of understood the behavioural risk factors that the people drinking, and the social context of made ill-health more likely and for which they the drinking situation have substantial effects were in a limited sense, responsible, but they on alcohol intake and drinking behavior. It is were also aware that the risks they faced were apparent from our findings, state Demers et al. part of social conditions that they could do little (2002:422), that the individual cannot be to change. conceptualized as an autonomous actor making Consequently, the direction of this article will self-governing decisions in a social vacuum. be to bring considerations of both agency and Another example of structural influences on structure into a theory of health lifestyles, with health lifestyles is the antismoking campaign in a view to restoring structure to its appropriate the United States. For over 20 years, massive position. While agency is important, it will be efforts were made to reduce cigarette smoking argued that structural conditions can act back through educational programs on the hazards of on individuals and configure their lifestyle smoking. These individual approaches to the patterns in particular ways. Agency allows them cessation of smoking encouraged many to stop, to reject or modify these patterns, but strucconclude Sweat and Denison (1995:S252), ture limits the options that are available. This however, not until smoking was banned in many article begins with definitions of agency and public places did the prevalence of smoking structure, followed by presentation of a health significantly decline. This ban had the effect lifestyle paradigm and the research literature Delivered of labeling smokers as social outcasts andby Ingenta to it. that supports UNIVERSITY OF NEVADA, RENO (cid 1060), Univ. of Nevada-Reno (cid 291575), University deviants. Antismoking laws, social isolation, and of Nevada, Reno stigma significantly increased smoking cessa- (cid 57010993) IP : 127.0.0.1 tion far beyond the results of purely individu- AGENCY AND STRUCTURE Tue, 13 Sep 2005 20:50:48 alistic approaches (Sweat and Denison The agency-structure issue has been the 1995:S252). Whereas these studies show structural influ- central sociological question since the beginences have a significant effect on health lifestyle ning of the discipline. As Archer (1995:1) practices, there are situations in which structure explains: The vexatious task of undercan be so overwhelming that agency is rendered standing the linkage between structure and ineffective. Gareth Williams (2003) reports on agency will always retain this centrality because the high mortality of a group of Welsh coal it derives from what society intrinsically is. It miners in the 1930s. These were men unsung is crucial to any scenario of agency that the actor in any chronicle of existence (cited in Williams could have acted otherwise in particular situa2003:145). Their lives were severely curtailed tions, and that social action takes place within by their punishing work and diet of beggars. a continuous stream of time subject to the continHowever, the unremitting toll of childbirth and uing possibility of reflexive awareness on the domestic labor impaired the health and short- part of the actor (Bhaskar 1998). Emirbayer and ened the lives of the women as much or more Mische (1998) suggest, accordingly, that human as that of the men. The weight of structural agency consists of three different elements: iterconditions was so heavy that individual capa- ation (the selective reactivation of past patterns bilities and capacities were ineffective. This situ- of thought and action), projectivity (the imagiation, comments Williams (2003:146), provides native generation of possible future trajectoa salutary reminder of the way in which the ries of action in which structures of thought and balance between agency, context, and structure action may be creatively reconfigured), and is itself highly determined by structural forces. practical evaluation (the capacity to make pracIn more recent research investigating contem- tical and normative judgments among alternaporary social conditions in a working-class tive possibilities). Emirbayer and Mische (1998:970) therefore neighborhood in a city in northwest England, Williams observes that the influence of struc- define agency as the temporally constructed

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham HEALTH LIFESTYLE THEORY 55

engagement of actors of different structural envi- A HEALTH LIFESTYLES PARADIGM ronmentsthe temporal-relational contexts of Health lifestyles are defined here as collecactionwhich, through the interplay of habit, imagination, and judgment, both reproduces and tive patterns of health-related behavior based on transforms those structures in interactive choices from options available to people response to the problems posed by changing according to their life chances (Cockerham historical situations. Agency can thus be consid- 2000a). This definition incorporates the dialecered a process in which individuals, influ- tical relationship between life choices and life enced by their past but also oriented toward chances proposed by Weber in his lifestyle the future (as a capacity to imagine alternative concept ([1922:53139] 1978:92639). In a possibilities) and the present (as a capacity to Weberian context, life choices are a proxy for consider both past habits and future situations agency and life chances are a form of structure. within the contingencies of the moment), criti- Whereas health and other lifestyle choices are cally evaluate and choose their course of voluntary, life chanceswhich primarily represent class positioneither empower or constrain action (Emirbayer and Mische 1998:963). Sewell (1992:19) provides a definition of choices as choices and chances work off each structures as sets of mutually sustaining other to determine behavioral outcomes. Weber associated lifestyles not with indischemas and resources that empower or constrain social action and tend to be reproduced viduals but with status groups, thereby showing by that social action. Schemas are transposable they are principally a collective social phenomrules or procedures applied to the enactment enon. Status groups are aggregates of people of social life. Resources are of two types, either with similar status and class backgrounds, and human (e.g., physical strength, dexterity, knowl- they originate through a sharing of similar edge) or nonhuman (naturally occurring or lifestyles. People who wish to be part of a particmanufactured) that can be used to enhance or ular status group are required to adopt the approDelivered Ingenta to maintain power. Sewell equates resources withby priate lifestyle. Status groups are stratified UNIVERSITYinfluence actionRENO (cid 1060), Univ. of Nevada-Reno (cid 291575), University the power to OF NEVADA, consistent with according to their patterns of consumption. of Nevada, of These patterns Giddenss (1984) notion of the dualityReno (cid 57010993) not only establish differences IP : 127.0.0.1 structure as both constraining and enabling. This between groups, but they also express differTue, 13 Sep 2005 20:50:48 duality, while correct, nonetheless contains a ences that are already in place (Bourdieu 1984). contradiction. The enabling function suggests Health lifestyles are a form of consumption in resources increase the range and style of options that the health that is produced is used for somefrom which the actor can choose, but constraint thing, such as a longer life, work, or enhanced means that resources invariably limit choices to enjoyment of ones physical being (Cockwhat is possible. As Bauman (1999) observes, erham 2000a; dHoutaud and Field 1984). Moreindividual choices in all circumstances are over, health lifestyles are supported by an extenconfined by two sets of constraints: (1) choosing sive health products industry of goods and from among what is available and (2) social rules services (e.g., running shoes, sports clothing, or codes telling the individual the rank order diet plans, health foods, club and spa memberships) promoting consumption as an inherent and appropriateness of preferences. Although agency theorists maintain that component of participation. Additionally, as Gochman (1997) points agency will never be completely determined by structure, it is also clear that there is no hypo- out, positive health lifestyle behaviors are the thetical moment in which agency actually gets opposite of risk behaviors. Good nutrition, for free of structure; it is not, in other words, some example, is the reverse of bad nutrition. The pure Kantian transcendental free will (Emir- binary nature of health lifestyle practices means bayer and Mische 1998:1004). While agency that the outcome generated from the interplay refers to the capacity to choose behavior, of choices and chances have either positive or structure pertains to regularities in social inter- negative effects on health. Gochman also action (e.g., institutions, roles), systematic social observes that health lifestyles are intended to relationships (e.g., group affiliations, class avoid risk in general and are oriented toward and other forms of social stratification), and overall health and fitness. However, while the resources that script behavior to go in particular term health lifestyle is meant to encompass a directions as opposed to others that might be general way of healthy living, there has been debate over whether or not there is an overall taken.

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham 56 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

health lifestyle. The best evidence suggests ([1899] 1994) used the concept of lifestyles as that for many people their health lifestyle can a basis for his theory of the leisure class. It be characterized as either generally positive or remained for Weber ([1922] 1978), however, negative. Vickers, Conway, and Hervig (1990) to produce the most insightful account of the found, for example, in a study of U.S. Navy link between lifestyles and socioeconomic status. personnel that positive health behaviors clus- Weber (1946) not only found that lifestyles tered along two dimensions, one promoting well- expressed distinct differences between status ness and the other avoiding risk. More recent groups and their adoption was a necessary research from Finland provides strong evidence feature of upward social mobility, but he also that associations between health practices are observed that powerful strata were social related, with people who behave unhealthily in carriers of particular ways of living. These one respect doing so in others and vice versa carrier strata were important causal forces in (Laaksonen, Prttl, and Lahelma 2002). their own right as they transmitted class-specific Smoking had the strongest and most consis- norms, values, religious ethics, and ways of life tent associations with other unhealthy lifestyle across generations (Kalberg 1994). The seminal study detailing class as the most practices, and multiple unhealthy practices were most common among lower socioeconomic decisive variable in the determination of groups. A significant body of research attaches health lifestyles is Bourdieus (1984) Distincthe most positive health lifestyle practices to tion that included a survey of differences in higher social strata and women and the most sports preferences and eating habits between negative to lower strata and men (Abel et al. French professionals (upper-middle class) and 1999; Blaxter 1990; Cockerham 1997, 1999, the working class. Bourdieu found the working 2000a; Grzywacz and Marks 2001; Link and class to be more attentive to the strength of the male body than to its shape, and to favor food Phelan 2000). It therefore appears that health lifestyles are that is both cheap and nutritious; in contrast, the Delivered professional class prefers food that is tasty, not the uncoordinated behaviors of disconnectedby Ingenta to UNIVERSITY OF NEVADA, RENOthat merge Univ. of light, and low in calories. As for leisure individuals, but are personal routines (cid 1060), healthy, Nevada-Reno (cid 291575), University of Nevada, Reno sports such as into an aggregate form representative of specific (cid 57010993) sailing, skiing, golf, tennis, and IP : a horseback riding, Bourdieu noted that the groups and classes. While definitions and 127.0.0.1 Tue, 13 Sep 2005 20:50:48 general concept of health lifestyles exist in the working class not only faces economic barriers literature, an overall theoretical paradigmas to participation, but also barriers in the form notedis missing. In order to fill this gap and of hidden entry requirements of family tradifurther the development of health lifestyle tion, obligatory dress and behavior, and early theory, a preliminary paradigm is presented in socialization. Thus, Bourdieu formulated the notion of the Figure 1. The arrows between boxes indicate distance from necessity that emerges as a key hypothesized causal relationships. Beginning with box 1, in the top right-hand explanation of class differences in lifestyles. He box in Figure 1, four categories of structural points out that the more distant a person is from variables are listed that have the capacity to foraging for economic necessity, the greater the shape health lifestyles: (1) class circumstances, freedom and time that person has to develop and (2) age, gender, and race/ethnicity, (3) collec- refine personal tastes in line with a more privtivities, and (4) living conditions. Each of ileged class status. Lower social strata, in turn, these categories is suggested by a review of tend to adopt the tastes consistent with their class position, in which acquiring items of necessity the research literature. is paramount. In Great Britain, Blaxter (1990) found that important differences in health lifestyles Class Circumstances persisted between classes, with the upper and The first category of structural variables is upper-middle classes taking better care of class circumstances, which is likely the most their health than the working and lower classes. powerful influence on lifestyle forms. The close Blaxter concluded that socioeconomic circumconnection between class and lifestyles has been stances and environment determined the observed since the nineteenth century when extent to which health lifestyles were pracMarx (1960) mentioned lifestyle differences in ticed effectively. Consequently, living a writing about politics in the 1850s, and Veblen healthy lifestyle was not simply a matter of indi-

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham HEALTH LIFESTYLE THEORY

FIGURE 1. Health Lifestyles Paradigm

57

Delivered by Ingenta to UNIVERSITY OF NEVADA, RENO (cid 1060), Univ. of Nevada-Reno (cid 291575), University of Nevada, Reno (cid 57010993) IP : 127.0.0.1 Tue, 13 Sep 2005 20:50:48

vidual choice, but to a large extent depended upon a persons social and material environment for its success. Other research in Britain also found major distinctions in the health lifestyles of the various classes, with less positive lifestyles practiced the lower the rung a person occupies on the social ladder (Adonis and Pollard 1997; Jarvis and Wardle 1999; Reid 1998). A decline in smoking, for example, has been far greater among the affluent, but very little change has been observed among the British poor (Jarvis and Wardle 1999).

Elsewhere, in Russia and Eastern Europe, middle-age male members of the working class have been identified as the major social carriers of a particularly unhealthy overall lifestyle featuring heavy alcohol consumption and binge drinking, smoking, high fat diets, and an absence of exercise (Cockerham 1997, 1999, 2000b; ^ Janeckov 2001; Ostrowska 2001). This lifestyle pattern, associated with traditional male socializing and limited life opportunities, is normative for many men. The result is high levels of premature male mortality due to increased heart

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham 58 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

disease, alcohol-related accidents, and alcohol significantly more their higher strata counterpoisonings. In the United States, the poor have parts (Jarvis and Wardle 1999). Low income been found to be especially disadvantaged elderly, in turn, have been found to make negawith respect to positive health lifestyles, with tive changes in their food habits or to disregreater cigarette consumption, more unhealthy gard their diet in response to a negatively eating and drinking practices, and less partici- anticipated future, while older people with suffipation in exercise across adulthood (Grzywacz cient incomes tend to make positive changes and Marks 2001; Snead and Cockerham 2002; with their diet as they age (Shifflet 1987; Shifflett and McIntosh 198687). Structural variWickrama et al. 1999). Overall, the lifestyles of the upper and upper- ables (class and age) were the decisive factors middle classes are the healthiest. Virtually every in each outcome. Gender is a highly significant variable in that study confirms this. These classes have the highest participation in leisure-time sports and women eat more healthy foods, drink much less exercise, healthier diets, moderate drinking, little alcohol, smoke less, visit doctors more often for smoking, more physical checkups by physicians, preventive care, wear seatbelts more frequently and greater opportunities for rest, relaxation, when they drive, and, with the exception of exerand coping with stress (Blaxter 1990; Grzywacz cise, have more healthier lifestyles overall than and Marks 2001; Jarvis and Wardle 1999; Robert men (Abel et al. 1999; Blaxter 1990; Cockerham and House 2000; Snead and Cockerham 2000a, 2000b; Denton and Walters 1999; Grzywacz and Marks 2001; Roos et al. 1998; 2002). The upper and upper-middle classes are Ross and Bird 1994). Furthermore, in adolesalso the first to have knowledge of new health cence males tend to adopt the health lifestyles risks and, because of greater resources, are most of their fathers and females those of their able to adopt new health strategies and practices mothers, thereby establishing the parameters for (Link and Phelan 2000). The advantaged classes the gender-specif ic transmission of health Delivered lifestyles into are able to move in a more fluid fashion toby Ingenta to adulthood (Wickrama et al. 1999). UNIVERSITYhealth behaviors,RENO (cid 1060), Univ. of Nevada-Reno (cidespecially University Whereas gender is an 291575), powerful embrace new OF NEVADA, such as adopting of Nevada, Reno (cid 57010993) low cholesterol and low carbohydrate diets. predictor of health lifestyles, its effects can also Advantaged classes were able to reduceIP : 127.0.0.1 their be moderated by distinctions between classes. Tue, 13 Sep 2005 20:50:48 risk of heart disease (which at one time was high There is evidence that people on the higher rungs relative to lower classes) so that lower class indi- of the socioeconomic ladder, regardless of viduals are now at greater risk. While education gender, participate more in leisure-time exeris obviously a critical factor, it is, as noted, only cise, eat healthier foods, and smoke less (Adonis one dimension of the broader context of class and Pollard 1997; Blaxter 1990; Reid 1998). membership that enables members of higher This is seen in research in the United States, where Ford et al. (1991) found that lower-class social strata to be healthy. women were exceedingly less likely to engage in physical activity (other than housework) than higher strata women or males generally. In Age, Gender, and Race/Ethnicity Britain, Calnan (1987) found that middle-class Weber did not consider other stratification women placed a greater emphasis on the need variables such as age, gender, and race/ethnicity, for a balanced diet high in fiber and low in yet contemporary empirical studies show that fats and carbohydrates; working-class women these variables influence health lifestyles. Age were signif icantly more likely to insist on affects health lifestyles because people tend to substantial meals containing meat and two take better care of their health as they grow older vegetables. by being more careful about the food they eat, Race and ethnicity are presumed to be imporresting and relaxing more, and either reducing tant, but there is a paucity of research directly or abstaining from alcohol use and smoking comparing the health lifestyles of different racial (Backett and Davison 1995). Exercise, however, and ethnic groups. Black-white comparisons is one major health lifestyle activity that declines in the United States show that whites often drink, and is often lost with advancing age (Grzywacz smoke, exercise, and practice weight control and Marks 2001). Yet class can also intersect more than blacks (George and Johnson 2001; with age to produce further differences. Youth Grzywacz and Marks 2001; Johnson and Hofffrom lower social strata, for instance, smoke mann 2000; Lindquist, Cockerham, and Hwang

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham HEALTH LIFESTYLE THEORY 59

1999), but the extent of the differences has not subjectivity that reflect a particular collective been fully documented. There is evidence that world view (Zerubavel 1997). The notion of exercise declines more steeply for blacks than thought communities is akin to Meads (1934) whites across the course of adulthood, yet this concept of the generalized other in that both are tendency may be explained by blacks having abstractions of the perspectives of social collecmore functional health problems and living in tivities that enter into the thinking of the indiless safe neighborhoods (Grzywacz and Marks vidual. Religion and ideology are examples of 2001). Most health studies on race address collective perspectives that have implications differences in levels of morbidity and mortality for health lifestyle choices. This is seen in the rather than specific health practices. These usual preference of highly religious persons and studies often suggest that racial disparities in groups to have positive health lifestyles since health are largely but not exclusively determined their beliefs affect their choices of food and by class position, with disadvantaged socioe- discourage drinking and smoking, while conomic circumstances and the adverse life promoting exercise and personal hygiene (Brown experiences associated with them promoting et al. 2001). However, the full extent of the relapoor health (Robert and House 2000; Smaje tionship between religiosity and health lifestyles 2000). is not known because of a lack of relevant Research is also needed that investigates the studies. This is an important area that needs relationship between health lifestyles and further research. different ethnic groups, including how to best Little is known also about ideology and health conceptualize and measure ethnicity (Aspinall lifestyles. Research on the effects of the socialist 2001). Existing studies of ethnicity, like those heritage in contemporary Russia show that of race, have focused more on overall health prosocialists (those who are in favor of a profiles than health lifestyles. Nevertheless, return to socialism as it was before Gorbachev) some of these studies are instructive, as seen have less healthy lifestyles than antisocialists, in research by Karlsen and Nazroo Delivered by although neither group demonstrated excep(2002) on Ingenta to UNIVERSITY OF NEVADA, RENOand struc- Univ. of Nevada-Reno (cid 291575), University the respective influences of agency (cid 1060), tionally positive health practices (Cockerham, of Nevada, Reno Snead, and DeWaal 2002). Prosocialists had a ture on the health of ethnic minorities in Great (cid 57010993) IP : 127.0.0.1 Britain. Ethnic identity was considered a conse- particularly passive approach to health lifestyles Tue, 13 Sep 2005 20:50:48 quence of agency, even though it is subject to that seemed leftover from Soviet times. The external constraints, because a persons identity choices of individuals in Soviet society were is also self-constructed and internally defined. confined to a single social and political ideology Racial discrimination and harassment, along (communism) and expected to conform to it. with class position, were used to measure the If a person got sick, the state was responsible effects of structure. However, our findings for taking care of that person as a benefit of state suggest, state Karlsen and Nazroo (2002:18), socialism. Individual incentives in health matters that ethnicity as identity does not appear to were not encouraged. Thus it could be argued influence health; rather ethnicity as structure that communism was bad for ones health. both in terms of racialisation [discrimina- However, the extent to which ideology genertion/harassment] and class experienceis ally affects health lifestyles beyond this example strongly associated with health for ethnic has not been determined. minority people living in Britain. When it comes to health lifestyles, the effects of race and ethnicity may indeed reside more powerfully Living Conditions in structure than agency. Living conditions are a category of structural variables pertaining to differences in the quality of housing and access to basic utilities (e.g., Collectivities electricity, gas, heating, sewers, indoor Collectivities are collections of actors plumbing, safe piped water, hot water), neighlinked together through particular social rela- borhood facilities (e.g., grocery stores, parks, tionships, such as kinship, work, religion, and recreation), and personal safety. To date, there politics. Their shared norms, values, ideals, and has been little research linking living conditions social perspectives constitute intersubjective to health lifestyles but the connection is thought communities beyond individual important. Blaxter (1990) found in her nation-

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham 60 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR lation of Lebensfhrung, which in German literally means conducting or managing ones life. Life choices are a process of agency by which individuals critically evaluate and choose their course of action. Webers notion of life choices differs from rational choice theory in that it accounts for both means-ends rationality as well as the interpretive process whereby the potential outcomes of choices are imagined, evaluated, and reconstructed when necessary (Emirbayer and Mische 1998). Weber (1949) maintained that individuals have the capacity to interpret their situation, make deliberate choices, and attach subjective meaning to their actions. All social action in his view takes place in contexts that imply both constraints and opportunities, with the actors interpretive understanding (Verstehen) of the situation guiding behavioral choices (Kalberg 1994).

wide British survey that the conditions within which a person lives has important implications for health-related behavior. Health lifestyles were most effective in positive circumstances and least effective under negative conditions. In the United States, living in disadvantaged neighborhoods has been associated with a less positive health status (Browning and Cagney 2002). Other research, as previously noted, shows that living in less safe neighborhoods significantly contributes to the low participation of adult blacks in vigorous outdoor exercise (Grzywacz and Marks 2001). Consequently, living conditions can constrain (or enhance) health lifestyles. Socialization and Experience

Class circumstances and the other variables shown in box 1 provide the social context for socialization and experience as depicted by the arrow leading to box 2. This is consistent with Life Chances (Structure) Bourdieus (1977) view that dispositions to act are constructed through socialization and expeClass circumstances and to a lesser degree rience, with class position providing the social the other variables in box 1 constitute life Delivered conditions for this process. The present para-by Ingenta to chances (structure) shown in box 4. Weber was UNIVERSITY OF NEVADA, RENO structural Univ. of Nevada-Reno he meant by life chances, digm, however, adds the additional (cid 1060), ambiguous about what (cid 291575), University of Nevada, Reno but 57010993) categories depicted in box 1, since they may also (cid the term is usually associated with the advanIP : 127.0.0.1 influence the social environment within which tages and disadvantages of relative class situaTue, 13 Sep 2005 20:50:48 socialization and experience occur. tions. Dahrendorf (1979:73) finds that the best Whereas primary socialization represents the meaning of life chances in Webers work is the imposition of societys norms and values on the crystallized probability of finding satisfacindividual by significant others and secondary tion for interests, wants and needs, thus the probsocialization results from later training, expe- ability of the occurrence of events which bring rience is the learned outcome of day-to-day about such satisfaction. Consequently, the activities that comes about through social inter- higher a persons position in a class hierarchy, action and the practical exercise of agency. It the better the persons life chances (probabiliis through both socialization and experience that ties for satisfaction) and vice versa. Dahrendorf the actor acquires reflexive awareness and the (1979:65) adds the following clarification: For capacity to perform agency, but experience Weber, the probability of sequences of action with respect to life choicesprovides the essen- postulated in the concept of chance is not merely tial basis for agencys practical and evaluative an observed and thus calculable probability, but dimensions to evolve over time. This is espe- is a probability which is invariably anchored in cially the case as people confront new social structural conditions. Webers thesis is that situations and conditions. chance is socially determined and social structure is an arrangement of chances. Therefore, life chances represent the influence of structure Life Choices (Agency) in Webers oeuvre and this paradigm. Figure 1 shows that socialization and experience (box 2) provides the capacity for life choices (agency) depicted in box 3. As previously noted, the term life choices was introduced by Weber and refers to the self-direction of ones behavior. It is an English language transChoice and Chance Interplay The arrows in Figure 1 indicate the dialectical interplay between life choices (box 3) and life chances (box 4). This interaction is

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham HEALTH LIFESTYLE THEORY 61

Webers most important contribution to concep- dispositions, structured structures predisposed tualizing lifestyle construction (Cockerham, to operate as structuring structures, that is, as Abel, and Lschen 1993; Cockerham, Rtten, principles which generate and organize pracand Abel 1997). Choices and chances operate tices and representations that can be objectively in tandem to determine a distinctive lifestyle for adapted to their outcomes without presupposing individuals, groups, and classes. Life chances a conscious aiming at ends or an express mastery (structure) either constrain or enable choices of the operations necessary in order to attain (agency); agency is not passive in this process, them. Put another way, the habitus serves as a however. As Archer (2003) puts it, whether cognitive map or set of perceptions that routinely constraints and enablements are exercised as guides and evaluates a persons choices and causal powers is based on agency choosing the options. It provides enduring dispositions toward practices to be influenced. Contraints, says acting deemed appropriate by a person in particArcher (2003:4), require something to ular social situations and settings. Included are constrain, and enablements something to dispositions that can be carried out even without enable. Consequently, people have to consider giving them a great deal of thought in advance. a course of action if their actions are to be either They are simply habitual ways of acting when constrained or enabled. People therefore align performing routine tasks. The influence of exterior social structures and their goals, needs, and desires with their probabilities for realizing them and choose a lifestyle conditions are incorporated into the habitus, as according to their assessments of the reality of well as the individuals own inclinations, preftheir resources and class circumstances. Unre- erences, and interpretations. The dispositions alistic choices are not likely to succeed or be that result not only reflect established normaselected, while realistic choices are based tive patterns of social behavior, but they also encompass action that is habitual and even intuupon what is structurally possible. In this context, choices and chances not itive. Through selective perception the habitus Delivered Ingenta to only are connected dialectically, but areby molds aspirations and expectations into cateUNIVERSITY OF NEVADA, RENO (cid 1060), Univ. of Nevada-Reno (cid 291575), perceptual analytically distinct. Archer (1998:369) articu- gories of the probable that impose University of Nevada, Reno boundaries on lates this point: Because the emergent prop- (cid 57010993)dispositions and the potential for IP : 127.0.0.1 erties of structures and the actual experiences action. As an acquired system of generative Tue, 13 Sep 2005 20:50:48 of agents are not synchronized (due to the schemes, observes Bourdieu (1990:55), the very nature of society as an open system), then habitus makes possible the free production of there will always be the inescapable need for a all the thoughts, perceptions, actions, inherent two-part account. Weber provides such a frame- in the particular conditions of its production work. He conceptualizes choice and chance as and only those. When Bourdieu speaks of the internalization separate components in the activation and conduct of a lifestyle, and he merges the of class conditions and their transformation into different functions of agency and structure personal dispositions toward action, he is describing conditions similar to Webers concept without either losing their distinctiveness. of life chances that determine materially, socially, and culturally what is probable, possible, or impossible for a member of a particular social Dispositions to Act (Habitus) group or class (Swartz 1997:104). Individuals Figure 1 shows that the interaction of life who internalize similar life chances share the choices and life chances produce individual same general habitus because, as Bourdieu dispositions toward action (box 5). These dispo- (1977:85) explains, they are more likely to have sitions constitute a habitus. The notion of habitus similar shared experiences: Though it is imposoriginates with Edmund Husserl ([1952] sible for all members of the same class (or even 1989:26693) who used the term to describe two of them) to have the same experiences, in habitual action that is intuitively followed and the same order, it is certain that each member anticipated. The concept has been expanded of the same class is more likely than any member by Bourdieu (1977:7295) to serve as his core of another class to have been confronted with explanation for the agency-structure relation- the situations most frequent for members of that ship in lifestyle dispositions (Bourdieu class. As a result, there is a high degree of 1984:169225). Bourdieu (1990:53) defines aff inity in health lifestyle choices among habitus as systems of durable, transposable members of the same class. Bourdieu holds that,

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham 62 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

while they may depart from class standards, Completing the Paradigm personal styles are never more than a deviation Figure 1 shows that dispositions (box 5) from a style of a class that relates back to the produce practices (action) that are represented common style by its difference. Even though Bourdieu allows agency some in box 6. The practices that result from the autonomy (e.g., agents are determined only to habitus can be based on deliberate calculations, the extent that they determine themselves), his habits, or intuition. Bourdieu (1984) helps us emphasis on structure with respect to routine recognize that practices linked to health lifestyles operations of the habitus clearly delineates a can be so integrated into routine behavioral lesser role for agency than the individualist repertories that they can be acted out more or health lifestyles paradigm. Some have argued less unthinkingly once established in the habitus. that Bourdieu strips agency of much of its crit- Bourdieu observes that people tend to adopt ical reflexive character (Bohman 1999). generalized strategies (a sense of the game) Turner and Wainwright (2003:273) disagree and oriented toward practical ends in routine situafind that Bourdieu gives full recognition to tions that they can habitually follow without agency through his notions of strategy and prac- stopping to analyze them. As a routinized feature tices, while illustrating the powerful role of of everyday life, it is therefore appropriate to institutions and resources in shaping, view health lifestyles as guided more by a pracconstraining, and producing human agency. tical than abstract logic (Williams 1995). The four most common practices measured Simon Williams (1995) also defends Bourdieu in studies of health lifestyles are alcohol use, by pointing out that choice is not precluded by the habitus, and he is able to account for the smoking, diet, and exercise. These are shown in relative durability of different forms of health box 7 along with other practices such as physical checkups and automobile seatbelt use that lifestyles among the social classes. comprise typical forms of action taken or not It can also be argued that the process of expeDelivered by Ingenta to practices themselves may be positive taken. The rience rescues Bourdieus concept of habitus UNIVERSITY OF NEVADA, RENO (cid 1060), Univ. of Nevada-Reno nonetheless comprise a or negative, but they (cid 291575), University from the charge of social determinism. Through (cid 57010993) of Nevada, Reno persons overall pattern of health lifestyles as experience, agency acquires new information IP : 127.0.0.1 represented in box 8. It is important to note that Tue, 13 and and rationales for prompting creativity Sep 2005 20:50:48 these practices sometimes have a complexity of change through the habitus. As Bourdieu (Bour- their own. Smoking tobacco in any form is negadieu and Wacquant 1992:133) explains, even tive, but moderate alcohol use reduces the risk though experiences confirm habitus, since there of heart disease more so than heavy drinking is a high probability that most people encounter (which promotes it) and abstinence (Klatsky circumstances that are consistent with those that 1999). Eating fruits and vegetables is positive, originally fashioned it, the habitus neverthe- but consuming meat can be either positive or less is an open system of dispositions that is negative depending on how it is cooked and its constantly subjected to experiences, and there- fat content. Relatively vigorous leisure-time fore constantly affected by them in a way that exercise has more health benefits than physreinforces or modifies its structures. Thus the ical activity at work because the latter is subject habitus can be creative and initiate changes in to stress from job demands and time scheddispositions. ules, while walking and other everyday forms Bourdieu (1996) calls for the abandonment of exercise have some health value (Dunn et of theories that explicitly or implicitly treat al. 1999). However, measures of leisure-time people as mere bearers (Trgers) of structure. exercise may not fully represent the physical Yet he also maintains that the rejection of mech- activities of women who take care of children anistic theories of behavior does not imply that and do housework (Ainsworth 2000). It is therewe should bestow on some creative free will the fore necessary that researchers take the multiexclusive power to generally constitute the mean- faceted features of health lifestyle practices into ings of situations and determine the intentions account when analyzing them of others. The dispositions generated by the Action (or inaction) with respect to a partichabitus tend to be compatible with the behav- ular health practice leads to its reproduction, ioral parameters set by the wider society; there- modification, or nullification by the habitus fore, usual and practical modes of behaving through a feedback process. This is shown in Figure 1 by the arrow showing movement not unpredictable noveltytypically prevail.

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham HEALTH LIFESTYLE THEORY from box 8 back to box 5. This is consistent with Bourdieus (1977, 1984) assertion that when dispositions are acted upon they tend to reproduce or modify the habitus from which they are derived. As conceptualized by Bourdieu, the habitus is the centerpiece in the health lifestyle paradigm. 63

A limitation of correspondence analysis is that it can be used only for displaying relationships, not hypothesis testing. Since many variables that have been discussed are interrelated, statistical techniques are required for testing hypotheses that measure the relationships that have predictive power exclusive of the effects of the other variables. Several statistical models (e.g., regression analysis, path or structural equaMEASURING HEALTH LIFESTYLES tion modeling) exist that can accomplish this. However, determining the effects of structure Although individuals make health lifestyle on health lifestyle practices requires the conchoices, the aggregate influence of collective struction of independent variables having collecentities and conditions on these choices also tive properties indicative of such structures. needs to be measured if the reality of everyday Measuring class effects is a challenge because life is to be captured. This strategy presents the usual socioeconomic variables of income, methodological issues since approaches empha- education, and occupational prestige can also sizing the effects of structure on individuals may be depicted as individual characteristics. One overlook the creativity of social agents. Con- approach is to apply class categories to the versely, microsociological approaches that family/household rather than the concentrate on individuals may underestimate respondent/individual. The status of the person the effects of structure on personal choices. (or perhaps persons) in the family/household Qualitative methods such as participant obser- with the highest level of labor-market particivation have to be alert to patterned health pation can be conceptualized as providing a practices and the collective basis for those master social status to the household repreDelivered Ingenta its patterns. However, as Sibeon (2004) observes,by senting to collective position vis--vis the UNIVERSITY OFto what can RENO (cid 1060), Univ. of Nevada-Reno (cid 291575), University there are limits NEVADA, be achieved by marketplace (Erickson and Goldthorpe 1992). of Nevada, Reno This outcome is microlevel methods in addressing agency-struc- (cid 57010993) evident when the parents social IP : 127.0.0.1 ture questions, since such methods are not standing is passed to their children and the Tue, 13 Sep 2005 20:50:48 equipped theoretically or methodologically to household as a whole is accorded a particular measure macrophenomena. social position in the community. Education can Bourdieu (1984) selected correspondence also be measured with respect to the prestige of analysis for his lifestyle research. Correspon- the institution attended, so that the status assodence analysis is a method to organize data, ciated with an individuals education can be investigate similarities and differences between considered a reflection of the institution rather categories of variables, and graphically depict than the individual. An index of living condirelationships (Greenacre and Blasius 1993). It tions can be constructed from the percentage of is similar to cluster analysis, but it identifies households in particular neighborhoods or complex patterns of behavior in relation to census tracts with basic utilities, indoor sociodemographic variables more efficiently and plumbing, and hot water, as well as the quickly, while reducing the potential for insta- percentage of parks, recreational facilities, bility by using a fixed algorithm. Correspon- restaurants, and grocery stores. Variables such dence analysis produces plots showing how as these are not the properties of similar indidependent variables (e.g., lifestyle practices) viduals, but those of structures that constrain or cluster in particular relationships with inde- enable individuals in their health lifestyle pendent variables (e.g., structural variables such choices. as class, age, gender, and race), and it also illusIn order to determine the relative effects of trates the relative strengths and weaknesses of individual and structural characteristics on a those relationships according to their spatial dependent variable, multilevel analysis using distance from each other. Bourdieu (1984) various hierarchical regression techiques (e.g., formulated his concept of social space as a multilevel regression models, HLM, VARCL, structure using correspondence analysis to merge MLn) is required (Luke 2004). Briefly stated, a space of social positions and space of multilevel analysis examines the interaction lifestyles into one space that can be displayed between variables that describe individuals at and interpreted simultaneously. one level (level 1), structural entities at the next

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham 64 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR constitute patterns of (8) health lifestyles whose reenactment results in their reproduction (or modification) through feedback to the habitus. This theory is an initial representation of the health lifestyle phenomenon and is subject to verification, change, or rejection through empirical application. It is a beginning for theoretical formulations concerning a major aspect of dayto-day social behavior for which no other theory now exists.

(level 2), and sequentially higher levels, if necessary, depending on the variables conceptual position in a structural hierarchy. By comparing changes in the regression equations, the relative effects of each level of variables on health lifestyle practices can be simultaneously determined. CONCLUSION

A central theme of this article is that the individualistic paradigm of health lifestyles is too REFERENCES narrow and unrealistic because it fails to consider structural influences on health lifestyle Abel, Thomas, Esther Walter, Steffen Niemann, and Rolf Weitkunat. 1999. The Berne-Munich choices. In order to correct this course and Lifestyle Panel. Sozial- und Prventivmedizin formulate a theory where none currently exists, 44:91106. a health lifestyle model is presented that accords Adler, Nancy E., Thomas Boyce, Margaret A. structure a role that is consistent with its influChesney, Sheldon Cohen, Susan Folkman, Robert ence in the empirical world. There are times L. Kahn, and S. Leonard Syme. 1994. Socioewhen structure outweighs but does not negate conomic Status and Health: The Challenge of agency and other times when structure overthe Gradient. American Psychologist 10:1524. whelms agency, and these situations need to Adonis, Andrew and Stephen Pollard. 1997. A be included in concepts explaining health Class Act: The Myth of Britains Classless Society. London: Penguin. lifestyle practices. A macrosocial orientation Ainsworth, Delivered does not mean that action is structurally prede-by Ingenta to Barbara E. 2000. Issues in the Assessment Nevada-Reno (cid 291575), University UNIVERSITY OF NEVADA, RENO (cid 1060), Univ. of of Physical Activity in Women. Research termined; rather, it recognizes that social of Nevada, Reno (cidQuarterly for Exercise and Sport 71:3750. 57010993) structures influence the thoughts, decisions, and Annandale, Ellen. 1998. The Sociology of Health and IP : 127.0.0.1 actions of individuals (Sibeon 2004). Medicine: Tue, 13 Sep 2005 20:50:48 A Critical Introduction. Cambridge, The theoretical paradigm presented in this United Kingdom: Polity Press. article is strongly influenced by Weber and Bour- Archer, Margaret S. 1995. Realist Social Theory: The dieu. Although Bourdieu, in particular, has his Morphogenetic Approach. Cambridge, United critics, his notion of habitus nevertheless repreKingdom: Cambridge University Press. sents a novel and logical conceptualization of . 1998. Realism and Morphogensis. Pp. 35681 in Critical Realism, edited by Margaret the internalization of external structures in the Archer, Roy Bhaskar, Andrew Collier, Tony mind and perceptual processes of the individual. Lawson, and Alan Norrie. London: Routledge. The result is a registry of dispositions to act in ways that are practical and invariably consistent . 2003. Structure, Agency and the Internal Conversation. Cambridge, United Kingdom: with the socially approved behavioral pathways Cambridge University Press. of the larger social order or some class or group Aspinall, Peter J. 2001. Operationalising the Collectherein. tion of Ethnicity Data in Studies of the Sociology The theoretical model of health lifestyles of Health and Illness. Sociology of Health and presented here states that four categories of (1) Illness 23:82982. structural variables, especially (a) class circum- Backett, Kathryn C. and Charlie Davison. 1995. Lifecourse and Lifestyle: The Social and Cultural stances, but also (b) age, gender, and race/ Location of Health Behaviours. Social Science ethnicity, (c) collectivities, and (d) living condiand Medicine 40:62938. tions, provide the social context for (2) socialization and experience that influence (3) life Bauman, Zygmunt. 1992. Intimations of Postmodernity. London: Routledge. choices (agency). These structural variables also . 1999. In Search of Politics. Stanford, CA: collectively constitute (4) life chances (strucStanford University Press. ture). Choices and chances interact and commis- . 2000. Liquid Modernity. Cambridge, sion the formation of (5) dispositions to act United Kingdom: Polity Press. (habitus), leading to (6) practices (action), Beck, Ulrich. 1992. Risk Society: Towards a New involving (7) alcohol use, smoking, diet, and Modernity. Translated by Mark Ritter. London: other health-related actions. Health practices Sage.

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham HEALTH LIFESTYLE THEORY 65

Health Lifestyles: Moving beyond Weber. The Bhaskar, Roy. 1998. The Possibility of Naturalism. Sociological Quarterly 38:32142. 3d ed. London: Routledge. Blaxter, Mildred. 1990. Health and Lifestyles. Cockerham, William C., M. Christine Snead, and Derek F. DeWaal. 2002. Health Lifestyles in London: Routledge. Russia and the Socialist Heritage. Journal of Bohman, James. 1999. Practical Reason and Cultural Health and Social Behavior 43:4255. Constraint: Agency in Bourdieus Theory of Practice. Pp. 12952 in Bourdieu: A Critical Crawford, Robert. 1984. A Cultural Account of Health: Control, Release, and the Social Body. Reader, edited by Richard Shusterman. Oxford, Pp. 60103 in Issues in the Political Economy of United Kingdom: Blackwell. Health Care, edited by John McKinley. New York: Bourdieu, Pierre. 1977. Outline of a Theory of Tavistock. Practice. Translated by Richard Nice. Cambridge, Crompton, Rosemary. 1998. Class and Stratification. United Kingdom: Cambridge University Press. 2d ed. Oxford, United Kingdom: Polity Press. . 1984. Distinction. Translated by Richard Nice. Cambridge, MA: Harvard University Press. Dahrendorf, Ralf. 1979. Life Chances. Chicago, IL: University of Chicago Press. . 1990. The Logic of Practice. Translated by Richard Nice. Stanford, CA: Stanford Univer- Demers, Andre, Jocelyn Bisson, and Jzabelle Palluy. 1999. Wives Convergence with Their sity Press. Husbands Alcohol Use: Social Conditions as . 1996. The Rules of Art. Translated by Susan Mediators. Journal of Studies of Alcohol Emanuel. Cambridge, United Kingdom: 60:36877. Cambridge University Press. Bourdieu, Pierre and Loc J. D. Wacquant. 1992. An Demers, Andre, Sylvia Kairouz, Edward M. Adlaf, Louis Glickman, Brenda Newton-Taylor, and Introduction to Reflexive Sociology. Chicago, IL: Alain Marchand. 2002. Multilevel Analysis of University of Chicago Press. Situational Drinking among Canadian UnderBrown, Tamara L., Gregory S. Parks, Rick S. graduates. Social Science and Medicine Zimmerman, and Clarenda M. Phillips. 2001. 55:41524. The Role of Religion in Predicting Adolescent Denton, Margaret and Vivienne Walters. 1999. Alcohol Use and Problem Drinking. Journal of Gender Differences in Structural and Behavioral Studies on Alcohol 65:696706. Delivered by Ingenta to Determinants of Health: An Analysis of the Social Browning, Christopher and Kathleen A. Cagney. UNIVERSITY OF NEVADA, RENO (cid 1060), Univ. of Nevada-Reno (cid 291575), University Production of Health. Social Science and Medi2002. Neighborhood Structural Disadvantage, (cid 57010993) of Nevada, Reno cine 48:122135. Collective Efficacy, and Self-Rated Physical IP : 127.0.0.1 dHoutaud, A. and Mark G. Field. 1984. The Health in an Urban Setting. Journal of13 Sep 2005 20:50:48 Health Tue, Image of Health: Variations in Perception by Social and Social Behavior 43:38399. Class in a French Population. Sociology of Health Calnan, Michael. 1987. Health and Illness. London: and Illness 6:3059. Tavistock. Dunn, Andrea L., Bess H. Marcus, James B. Kampert, Clarke, Adele E., Janet K. Shim, Laura Mamo, Melissa E. Garcia, Harold W. Kohl III, and Steven Jennifer Ruth Fosket, and Jennifer R. Fishman. N. Blair. 1999. Comparison of Lifestyle and 2003. Biomedicalization: Technoscientific TransStructural Interventions to Increase Physical formations of Health, Illness, and U.S. BiomediActivity and Cardiorespiratory Fitness. Journal cine. American Sociological Review 68:16194. of the American Medical Association 281:32734. Cockerham, William C. 1997. The Social Deter- Durkheim, Emile. [1895] 1950. The Rules of Sociominants of the Decline of Life Expectancy in logical Method. New York: Free Press. Russia and Eastern Europe: A Lifestyle Expla- Emirbayer, Mustafa and Ann Mische. 1998. What nation. Journal of Health and Social Behavior Is Agency? American Journal of Sociology 38:13148. 103:9621023. . 1999. Health and Social Change in Russia Erickson, Robert E. and John H. Goldthorpe. 1992. and Eastern Europe. London: Routledge. The Constant Flux: A Study of Class Mobility in . 2000a. The Sociology of Health Behavior Industrial Society. Oxford, United Kingdom: and Health Lifestyles. Pp. 15972 in Handbook Clarendon Press. of Medical Sociology, 5th ed., edited by Chloe Ford, Earl S., Robert K. Merritt, Gregory W. Heath, Bird, Peter Conrad, and Allen M. Fremont. Upper Kenneth E. Powell, Richard A. Washburn, Andrea Saddle River, NJ: Prentice-Hall. Kriska, and Gwendolyn Halle. 1991. Physical . 2000b. Health Lifestyles in Russia. Social Activity Behaviors in Lower and Higher SocioeScience and Medicine 51:131324. conomic Status Populations. American Journal Cockerham, William C., Thomas Abel, and Gnther of Epidemiology 133:124656. Lschen. 1993. Max Weber, Formal Rationality, Frohlich, Katherine L., Ellen Corin, and Louise and Health Lifestyles. The Sociological QuarPotvin. 2001. A Theoretical Proposal for the Relaterly 34:41335. tionship between Context and Disease. Sociology Cockerham, William C., Alfred Rtten, and Thomas of Health and Illness 23:77697. Abel. 1997. Conceptualizing Contemporary George, Valerie A. and Paulette Johnson. 2001.

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham 66 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR

Weight Loss Behaviors and Smoking in College Lindquist, Christine, William C. Cockerham, and Students of Diverse Ethnicity. American Journal Sean-Shong Hwang. 1999. Drinking Patterns of Health Behavior 25:11524. in the American Deep South. Journal of Studies Giddens, Anthony. 1984. The Constitution of Society: on Alcohol 60:66366. Outline of the Theory of Structuration. Berkeley: Link, Bruce and Jo Phelan. 2000. Evaluating the University of California Press. Fundamental Cause Explanation for Social Dispar. 1991. Modernity and Self-Identity: Self and ities in Health. Pp. 3347 in Handbook of Society in the Late Modern Age. Stanford, CA: Medical Sociology, 5th ed., edited by Chloe E. Stanford University Press. Bird, Peter Conrad, and Allen M. Fremont. Upper Gochman, David S. 1997. Health Behavior Research, Saddle River, NJ: Prentice-Hall. Cognate Disciplines, Future Identity, and an Orga- Lomas, Jonathan. 1998. Social Capital and Health: nizing Matrix: An Integration of Perspectives. Implications for Public Health and Epidemiology. Pp. 395425 in Handbook of Health Behavior, Social Science and Medicine 47:118188. vol. 4, edited by David Gochman. New York: Luke, Douglas A. 2004. Multilevel Modeling. ThouPlenum. sand Oaks, CA: Sage. Greenacre, Michael and Jrg Blasius, eds. 1993. Marx, Karl. 1960. Politische Schriften [Political WritCorrespondence Analysis in the Social Sciences. ings]. Edited by H. Lieber. Stuttgart, Germany: London: Academic Press. Enke. Grzywacz, Joseph G. and Nadine F. Marks. 2001. Mead, George Herbert. 1934. Mind, Self and Society. Social Inequalities and Exercise during AdultChicago, IL: University of Chicago Press. hood: Toward an Ecological Perspective. Journal Mirowsky, John and Catherine E. Ross. 2003. Educaof Health and Social Behavior 42:20220. tion, Social Status, and Health. New York: Aldine Hardey, Michael. 1999. Doctor in the House: The de Gruyter. Internet as a Source of Lay Knowledge and the Ostrowska, Nina. 2001. In and Out of Communism: Challenge to Expertise. Sociology of Health and The Macrosocial Context of Health in Poland. Illness 21:82035. Pp. 33446 in The Blackwell Companion to Husserl, Edmund. [1952] 1989. Ideas Pertaining to Medical Sociology, edited by William Cockerham. a Pure Phenomenology and to a PhenomenologOxford, United Kingdom: Blackwell. Delivered ical Philosophy. Translated by R. Rojecwicz andby Ingenta to Bernice A., Jane McLeod, and Margarita Pescosolido, UNIVERSITY OF NEVADA, RENO (cid 1060), Univ. of Nevada-Reno (cid 291575), University A. Schuwer. London: Kluwer Academic. Alegra. 2000. Confronting the Second Social ^ of Nevada, Reno 57010993) Janeckov, Hana. 2001. Transformation of the Health (cidContract: The Place of Medical Sociology in IP : 127.0.0.1 Care System in the Czech RepublicA SocioResearch and Policy for the Twenty-First Century. Tue, 13 Sep logical Perspective. Pp. 34764 in The Blackwell 2005 20:50:48 in Handbook of Medical Sociology, Pp. 41126 Companion to Medical Sociology, edited by 5th ed., edited by Chloe Bird, Peter Conrad, and William Cockerham. Oxford, United Kingdom: Allen M. Fremont. Upper Saddle River, NJ: PrenBlackwell. tice-Hall. Jarvis, Martin J. and Jane Wardle. 1999. Social Pescosolido, Bernice A. and Beth A. Rubin. 2000. Patterning of Individual Health Behaviours: The The Web of Group Affiliations Revisited: Social Case of Cigarette Smoking. Pp. 24056 in Social Life, Postmodernism, and Sociology. American Determinants of Health, edited by Michael Sociological Review 65:5276. Marmot and Richard G. Wilkinson. Oxford, Reid, Ivan. 1998. Class in Britain. Cambridge, United United Kingdom: Oxford University Press. Kingdom: Polity Press. Johnson, Robert A. and John P. Hoffmann. 2000. Robert, Stephanie A. and James S. House. 2000. Adolescent Cigarette Smoking in the U.S. Socioeconomic Inequalities in Health: An Racial/Ethnic Subgroups: Findings from the Enduring Sociological Problem. Pp. 7997 in National Education Longitudinal Study. Journal Handbook of Medical Sociology, 5th ed., edited of Health and Social Behavior 41:392407. by Chloe E. Bird, Peter Conrad, and Allen M. Kalberg, Stephen. 1994. Max Webers ComparativeFremont. Upper Saddle River, NJ: Prentice-Hall. Historical Sociology. Chicago, IL: University of Roos, Eva, Eero Lahelma, Mikko Virtanen, Ritva Chicago Press. Prttl, and Pirjo Pietinen. 1998. Gender, Karlsen, Saffron and James Y. Nazroo. 2002. Agency Socioeconomic Status and Family Status as Deterand Structure: The Impact of Ethnic Identity and minants of Food Behaviour. Social Science and Racism on the Health of Ethnic Minority People. Medicine 46:151929. Sociology of Health and Illness 24:120. Ross, Catherine E. and Chloe E. Bird. 1994. Sex Klatsky, Arthur L. 1999. Moderate Drinking and Stratification and Health Lifestyle: Consequences Reduced Risk of Heart Disease. Alcohol Research for Mens and Womens Perceived Health. Journal and Health 23:1523. of Health and Social Behavior 35:16178. Laaksonen, Mikko, Ritva Prttl, and Eero Lahelma. Scott, John. 1996. Stratification and Power: Struc2002. Sociodemographic Determinants of Multures of Class, Status, and Command. Cambridge, tiple Unhealthy Behaviours. Scandinavian United Kingdom: Polity Press. Journal of Public Health 30:17. Sewell, William H. 1992. A Theory of Structure:

#2102Jnl of Health and Social BehaviorVol. 46 146105-cockerham HEALTH LIFESTYLE THEORY 67

Duality, Agency, and Transformation. American Hervig. 1990. Demonstration of Replicable Journal of Sociology 98:129. Dimensions of Health Behaviors. Preventive Shifflett, Peggy A. 1987. Future Time Perspective, Medicine 19:377401. Past Experiences, and Negotiation of Food Use Warren, Mary Guptill, Rose Weitz, and Stephen Patterns among the Aged. Gerontologist Kulis. 1998. Physician Satisfaction in a Changing 27:61115. Health Care Environment: The Impact of ChalShifflett, Peggy A. and William A. McIntosh. lenges to Professional Autonomy, Authority, and 198687. Food Habits and Future Time: An Dominance. Journal of Health and Social Behavior Exploratory Study of Age-Appropriate Food 39:35667. Habits among the Elderly. International Journal Weber, Max. 1946. From Max Weber: Essays in Sociof Aging and Human Development 24:117. ology. Translated and edited by Hans Gerth and Sibeon, Roger. 2004. Rethinking Social Theory. C. Wright Mills. New York: Oxford University London: Sage. Press. Smaje, Chris. 2000. Race, Ethnicity, and Health. . 1949. The Methodology of the Social Pp. 11428 in Handbook of Medical Sociology, Sciences. Edited by Edward Shils and H. Finch. 5th ed., edited by Chloe Bird, Peter Conrad, and New York: Free Press. Allen M. Fremont. Upper Saddle River, NJ: Pren. 1958. The Protestant Ethic and the Spirit tice-Hall. of Capitalism. Translated by Talcott Parsons. New Snead, M. Christine and William C. Cockerham. 2002. York: Scribners. Health Lifestyles and Social Class in the Deep . [1922] 1978. Economy and Society. 2 vols. South. Research in the Sociology of Health Care Translated and edited by Guenther Roth and Claus 20:10722. Wittich. Berkeley: University of California Press. Swartz, David. 1997. Culture and Power: The Sociology of Pierre Bourdieu. Chicago, IL: Univer- Wickrama, K. A. S., Rand D. Conger, Lora Ebert Wallace, and Glen H. Elder, Jr. 1999. The sity of Chicago Press. Intergenerational Transmission of Health-Risk Sweat, Michael D. and Julie A. Denison. 1995. Behaviors: Adolescent Lifestyles and Gender Reducing HIV Incidence in Developing CounModerating Effects. Journal of Health and Social tries with Structural and Environmental InterDelivered by Ingenta to 40:258272. Behavior ventions. AIDS 9:S251S257. UNIVERSITY OF NEVADA, RENO (cid 1060), Univ. of Nevada-Reno (cid 291575), University Turner, Bryan S. 1992. Regulating Bodies: Essays in Williams, Gareth H. 2003. The Determinants of of Nevada, Reno (cidHealth: Structure, Context, and Agency. Soci57010993) Medical Sociology. London: Routledge. ology of Health and Illness 25:13154. Turner, Bryan S. and Steven P. Wainwright. IP : 127.0.0.1 2003. Tue, 13 Sep Williams, Simon J. 1995. Theorising Class, Health Corps de Ballet: The Case of the Injured Dancer. 2005 20:50:48 and Lifestyles: Can Bourdieu Help Us? SociSociology of Health and Illness 25:26988. ology of Health and Illness 17:577604. Veblen, Thorstein. [1899] 1994. Theory of the Leisure Zerubavel, Eviatar. 1997. Social Mindscapes. Class. New York: Dover. Cambridge, MA: Harvard University Press. Vickers, Ross R., Terry L. Conway, and Linda K.

William C. Cockerham is professor of sociology, medicine, and public health and co-director of the Center for Social Medicine at the University of Alabama at Birmingham. He is the 2004 recipient of the universitys Ireland Prize for Scholarly Distinction.