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Journal of Health and

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Health Lifestyle Theory and the Convergence of Agency and Structure


William C. Cockerham
Journal of Health and Social Behavior 2005 46: 51
DOI: 10.1177/002214650504600105

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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.

An important but undeveloped area of theo- agency accentuate the capacity of individual
retical discourse in medical sociology pertains actors to choose their behavior regardless of
to the relative contributions of agency and struc- structural influences. When applied to health
ture in determining health lifestyles. Medical lifestyles, the question is whether the deci-
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 struc-
ture 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
the 2003 American Sociological Association meeting
lifestyle theory is underscored by the fact that
in Atlanta, Georgia, and the 2004 joint meeting of the many daily lifestyle practices involve consid-
European 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
3350 (email: wcocker@uab.edu). Giddens (1991) and Turner (1992), lifestyle
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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 iden-
lation 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 iden-
modernity (Bauman 1992, 2000; Beck 1992; tification needs to be taken seriously. This obser-
Giddens 1991). While notions of an absolute vation is consistent with Giddenss (1991) asser-
break 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 partic-
theless clear that society is in a transition to a ular narrative of self-identity. An important
new social form (Pescosolido and Rubin 2000). lifestyle configuration and the accompanying
This is seen in the new world order evolving out social marker are those practices affecting health
of the collapse of Soviet-style socialism, the and the distinctions they also contribute to differ-
expanding multiculturalization of Europe and ences in social identities (Annandale 1998). A
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.
We also see greater movement toward the mutual Much of what we know about lifestyles has
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
control over their life situation. an individualist and agency-oriented bottom-
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 indi-
Previously, 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

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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 prac-
vidual 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 impor-
conflation, 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
ence individuals. This is seen in the standard class or socioeconomic status (SES). As Adler
approach to research in public health and et al. (1994) point out, the three variables are
epidemiology that treats health behavior and interrelated but not identical nor fully overlap-
lifestyles as matters of individual choice and ping. The fact that associations between SES
targets the individual to change his or her and health are found with each of the indica-
harmful 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 strat-
The 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 combi-
Risk 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 top-
Change 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 some-
educated individuals accumulate advantages and thing (namely structure) exists beyond the indi-
poorly 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.

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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 struc-
conclude 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
of labeling smokers as social outcasts and that supports it.
deviants. Antismoking laws, social isolation, and
stigma significantly increased smoking cessa-
tion far beyond the results of purely individu- AGENCY AND STRUCTURE
alistic approaches (Sweat and Denison
1995:S252). The agency-structure issue has been the
Whereas these studies show structural influ- central sociological question since the begin-
ences 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 under-
can 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 situa-
2003:145). 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 contin-
However, 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: iter-
conditions 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 imagi-
ation, comments Williams (2003:146), provides native generation of possible future trajecto-
a 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 prac-
In more recent research investigating contem- tical and normative judgments among alterna-
porary social conditions in a working-class tive possibilities).
neighborhood in a city in northwest England, Emirbayer and Mische (1998:970) therefore
Williams observes that the influence of struc- define agency as the temporally constructed

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HEALTH LIFESTYLE THEORY 55


engagement of actors of different structural envi- A HEALTH LIFESTYLES PARADIGM
ronmentsthe temporal-relational contexts of
actionwhich, through the interplay of habit, Health lifestyles are defined here as collec-
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 dialec-
ered 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 repre-
action (Emirbayer and Mische 1998:963). sent class positioneither empower or constrain
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.
schemas and resources that empower or Weber associated lifestyles not with indi-
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 phenom-
rules 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 partic-
manufactured) that can be used to enhance or ular status group are required to adopt the appro-
maintain power. Sewell equates resources with priate lifestyle. Status groups are stratified
the power to influence action consistent with according to their patterns of consumption.
Giddenss (1984) notion of the duality of These patterns not only establish differences
structure as both constraining and enabling. This between groups, but they also express differ-
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 some-
from 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 (Cock-
what is possible. As Bauman (1999) observes, erham 2000a; dHoutaud and Field 1984). More-
individual choices in all circumstances are over, health lifestyles are supported by an exten-
confined 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 member-
and appropriateness of preferences. ships) promoting consumption as an inherent
Although agency theorists maintain that component of participation.
agency will never be completely determined by Additionally, as Gochman (1997) points
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
taken. debate over whether or not there is an overall

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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).
practices, and multiple unhealthy practices were The seminal study detailing class as the most
most common among lower socioeconomic decisive variable in the determination of
groups. A significant body of research attaches health lifestyles is Bourdieus (1984) Distinc-
the 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
Phelan 2000). male body than to its shape, and to favor food
It therefore appears that health lifestyles are that is both cheap and nutritious; in contrast, the
not the uncoordinated behaviors of disconnected professional class prefers food that is tasty,
individuals, but are personal routines that merge healthy, light, and low in calories. As for leisure
into an aggregate form representative of specific sports such as sailing, skiing, golf, tennis, and
groups and classes. While definitions and a horseback riding, Bourdieu noted that the
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 tradi-
further the development of health lifestyle tion, obligatory dress and behavior, and early
theory, a preliminary paradigm is presented in socialization.
Figure 1. The arrows between boxes indicate Thus, Bourdieu formulated the notion of the
hypothesized causal relationships. distance from necessity that emerges as a key
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 priv-
tivities, 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
the research literature. position, in which acquiring items of necessity
is paramount.
In Great Britain, Blaxter (1990) found that
Class Circumstances important differences in health lifestyles
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 circum-
connection between class and lifestyles has been stances and environment determined the
observed since the nineteenth century when extent to which health lifestyles were prac-
Marx (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-

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HEALTH LIFESTYLE THEORY 57


FIGURE 1. Health Lifestyles Paradigm

vidual choice, but to a large extent depended Elsewhere, in Russia and Eastern Europe,
upon a persons social and material environment middle-age male members of the working class
for its success. Other research in Britain also have been identified as the major social carriers
found major distinctions in the health lifestyles of a particularly unhealthy overall lifestyle
of the various classes, with less positive lifestyles featuring heavy alcohol consumption and binge
practiced the lower the rung a person occupies drinking, smoking, high fat diets, and an absence
on the social ladder (Adonis and Pollard 1997; of exercise (Cockerham 1997, 1999, 2000b;
Jarvis and Wardle 1999; Reid 1998). A decline Janec^kov 2001; Ostrowska 2001). This lifestyle
in smoking, for example, has been far greater pattern, associated with traditional male social-
among the affluent, but very little change has izing and limited life opportunities, is norma-
been observed among the British poor (Jarvis tive for many men. The result is high levels of
and Wardle 1999). premature male mortality due to increased heart

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58 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR


disease, alcohol-related accidents, and alcohol significantly more their higher strata counter-
poisonings. 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 nega-
with respect to positive health lifestyles, with tive changes in their food habits or to disre-
greater 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 suffi-
pation 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; Shif-
Wickrama et al. 1999). flett and McIntosh 198687). Structural vari-
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.
study confirms this. These classes have the Gender is a highly significant variable in that
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 exer-
and 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;
2002). Grzywacz and Marks 2001; Roos et al. 1998;
The upper and upper-middle classes are Ross and Bird 1994). Furthermore, in adoles-
also 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
are able to move in a more fluid fashion to lifestyles into adulthood (Wickrama et al. 1999).
embrace new health behaviors, such as adopting Whereas gender is an especially powerful
low cholesterol and low carbohydrate diets. predictor of health lifestyles, its effects can also
Advantaged classes were able to reduce their be moderated by distinctions between classes.
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 exer-
is 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,
social strata to be healthy. where Ford et al. (1991) found that lower-class
women were exceedingly less likely to engage
in physical activity (other than housework) than
Age, Gender, and Race/Ethnicity higher strata women or males generally. In
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 impor-
resting 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 Hoff-
from lower social strata, for instance, smoke mann 2000; Lindquist, Cockerham, and Hwang

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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 collec-
more functional health problems and living in tivities that enter into the thinking of the indi-
less 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 rela-
poor 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 (2002) on although neither group demonstrated excep-
the respective influences of agency and struc- tionally positive health practices (Cockerham,
ture on the health of ethnic minorities in Great Snead, and DeWaal 2002). Prosocialists had a
Britain. Ethnic identity was considered a conse- particularly passive approach to health lifestyles
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 gener-
tion/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
Collectivities of housing and access to basic utilities (e.g.,
electricity, gas, heating, sewers, indoor
Collectivities are collections of actors plumbing, safe piped water, hot water), neigh-
linked 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-

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60 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR


wide British survey that the conditions within lation of Lebensfhrung, which in German liter-
which a person lives has important implications ally means conducting or managing ones life.
for health-related behavior. Health lifestyles were Life choices are a process of agency by which
most effective in positive circumstances and individuals critically evaluate and choose their
least effective under negative conditions. In course of action. Webers notion of life choices
the United States, living in disadvantaged neigh- differs from rational choice theory in that it
borhoods has been associated with a less posi- accounts for both means-ends rationality as well
tive health status (Browning and Cagney 2002). as the interpretive process whereby the poten-
Other research, as previously noted, shows that tial outcomes of choices are imagined, evalu-
living in less safe neighborhoods significantly ated, and reconstructed when necessary (Emir-
contributes to the low participation of adult bayer and Mische 1998). Weber (1949)
blacks in vigorous outdoor exercise (Grzywacz maintained that individuals have the capacity to
and Marks 2001). Consequently, living condi- interpret their situation, make deliberate choices,
tions can constrain (or enhance) health lifestyles. and attach subjective meaning to their actions.
All social action in his view takes place in
contexts that imply both constraints and
Socialization and Experience opportunities, with the actors interpretive under-
standing (Verstehen) of the situation guiding
Class circumstances and the other variables behavioral choices (Kalberg 1994).
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 expe- Class circumstances and to a lesser degree
rience, with class position providing the social the other variables in box 1 constitute life
conditions for this process. The present para- chances (structure) shown in box 4. Weber was
digm, however, adds the additional structural ambiguous about what he meant by life chances,
categories depicted in box 1, since they may also but the term is usually associated with the advan-
influence the social environment within which tages and disadvantages of relative class situa-
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 satisfac-
individual by significant others and secondary tion for interests, wants and needs, thus the prob-
socialization 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 (probabili-
is 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 struc-
ture 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 expe-


rience (box 2) provides the capacity for life Choice and Chance Interplay
choices (agency) depicted in box 3. As previ-
ously noted, the term life choices was intro- The arrows in Figure 1 indicate the dialec-
duced by Weber and refers to the self-direction tical interplay between life choices (box 3) and
of ones behavior. It is an English language trans- life chances (box 4). This interaction is

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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 prac-
and 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 partic-
Archer (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.
their goals, needs, and desires with their prob- The influence of exterior social structures and
abilities 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, pref-
their 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 norma-
selected, while realistic choices are based tive patterns of social behavior, but they also
upon what is structurally possible. encompass action that is habitual and even intu-
In this context, choices and chances not itive. Through selective perception the habitus
only are connected dialectically, but are molds aspirations and expectations into cate-
analytically distinct. Archer (1998:369) articu- gories of the probable that impose perceptual
lates this point: Because the emergent prop- boundaries on dispositions and the potential for
erties of structures and the actual experiences action. As an acquired system of generative
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.
separate components in the activation and When Bourdieu speaks of the internalization
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
without either losing their distinctiveness. describing conditions similar to Webers concept
of life chances that determine materially, socially,
and culturally what is probable, possible, or
Dispositions to Act (Habitus) impossible for a member of a particular social
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 impos-
originates 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,

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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
from a style of a class that relates back to the Figure 1 shows that dispositions (box 5)
common style by its difference. produce practices (action) that are represented
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 situa-
find 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 prac-
constraining, and producing human agency. tical than abstract logic (Williams 1995).
Simon Williams (1995) also defends Bourdieu The four most common practices measured
by pointing out that choice is not precluded by in studies of health lifestyles are alcohol use,
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 phys-
lifestyles among the social classes. ical checkups and automobile seatbelt use that
comprise typical forms of action taken or not
It can also be argued that the process of expe-
taken. The practices themselves may be positive
rience rescues Bourdieus concept of habitus
or negative, but they nonetheless comprise a
from the charge of social determinism. Through
persons overall pattern of health lifestyles as
experience, agency acquires new information
represented in box 8. It is important to note that
and rationales for prompting creativity and
these practices sometimes have a complexity of
change through the habitus. As Bourdieu (Bour- their own. Smoking tobacco in any form is nega-
dieu 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 phys-
reinforces 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 sched-
dispositions. 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 there-
we should bestow on some creative free will the fore necessary that researchers take the multi-
exclusive 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 partic-
habitus 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
not unpredictable noveltytypically prevail. Figure 1 by the arrow showing movement

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HEALTH LIFESTYLE THEORY 63


from box 8 back to box 5. This is consistent with A limitation of correspondence analysis is
Bourdieus (1977, 1984) assertion that when that it can be used only for displaying relation-
dispositions are acted upon they tend to repro- ships, not hypothesis testing. Since many vari-
duce or modify the habitus from which they are ables that have been discussed are interrelated,
derived. As conceptualized by Bourdieu, the statistical techniques are required for testing
habitus is the centerpiece in the health lifestyle hypotheses that measure the relationships that
paradigm. have predictive power exclusive of the effects
of the other variables. Several statistical models
(e.g., regression analysis, path or structural equa-
MEASURING 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 con-
choices, the aggregate influence of collective struction of independent variables having collec-
entities 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 partici-
vation 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 repre-
patterns. However, as Sibeon (2004) observes, senting its collective position vis--vis the
there are limits to what can be achieved by marketplace (Erickson and Goldthorpe 1992).
microlevel methods in addressing agency-struc- This outcome is evident when the parents social
ture questions, since such methods are not standing is passed to their children and the
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 asso-
dence 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 condi-
relationships (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 indi-
dependent 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 illus- In 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

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64 JOURNAL OF HEALTH AND SOCIAL BEHAVIOR


(level 2), and sequentially higher levels, if neces- constitute patterns of (8) health lifestyles whose
sary, depending on the variables conceptual posi- reenactment results in their reproduction (or
tion in a structural hierarchy. By comparing modification) through feedback to the habitus.
changes in the regression equations, the relative This theory is an initial representation of the
effects of each level of variables on health health lifestyle phenomenon and is subject to
lifestyle practices can be simultaneously verification, change, or rejection through empir-
determined. ical application. It is a beginning for theoretical
formulations concerning a major aspect of day-
to-day social behavior for which no other theory
CONCLUSION now exists.

A central theme of this article is that the indi-


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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.

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