The Change4Life campaign just launched by NHS England is the latest attempt to persuade people to adopt healthier lifestyles. But, says Dr Stanley Blue, this type of public health campaign is not enough to tackle fast rising rates of ‘lifestyle diseases’.
Current public health policy is focussed on getting people to change their eating, drinking and exercising behaviours by providing them with access to more information so that they might choose to behave in healthier ways.
Yet lessons from recent research are clear. Campaigns aimed at persuading people to change their lifestyles and behaviours have not been sufficiently effective in transforming the social habits and practices necessary to significantly improve population health.
The epidemics of non-communicable disease (NCD) resulting from smoking, alcohol consumption and obesity are major problems throughout the developed and the developing world.
Despite information about the risk factors of practices linked to these so-called ‘lifestyle diseases’ being more readily available than ever before, current patterns of smoking and drinking, over-eating and under-exercising continue to lead to high rates of cardiovascular disease, cancer and type 2 diabetes. These are rising year on year. Giving people more information about the health implications of their actions is not working fast enough to combat these trends and a significant shift is required to address these epidemics.
Public health policy is currently dominated by models of individual behaviour change. These focus on persuading individuals to make ‘better’ choices for themselves on the basis of information given to them by governments and other agencies. Research has shown that humans do not always act rationally, or calculate and assess information before they act. Instead, people routinely respond much more automatically to their environments. As such, behaviours are not simply chosen by the individual: they are patterned in the routines of daily life.
Alternative explanations of patterns of health and health inequalities have consequently focussed on ‘wider determinants’: for example, by highlighting links between social class and patterns of well-being. Such approaches focus on the freedoms and constraints that influence individuals in choosing to behave in particular ways.
Interventions centred on individuals’ behaviours and ‘wider determinants’ have had some success, but have not brought about changes on the scale required to halt the overall rise in NCDs. Our research concludes that this is because neither approach provides much insight into the establishment, maintenance and decline of those social habits, patterns and routines that make up people’s lives and which sustain current epidemics of NCD.
The extent and seriousness of the problem require new ideas and methods that will enable public health policy to better understand and intervene in shaping routine practices like smoking, drinking, exercising and eating.
If we focus on these kinds of routine practices themselves, it becomes obvious that such activities have shared histories – they are shaped by social institutions, commercial interests and the myriad of other practices that make up daily lives. They are not simply expressions of personal choice.
With this in mind, public health agencies would do better to attend to curbing certain social practices and cultivating alternatives that would lead to healthier lives. One way to achieve this is to influence the making and breaking of links between social practices such as smoking and drinking, and between eating and not exercising.
Public health policy already impacts on and shapes these social habits and practices and the relationships between them. For example, interventions like the smoking ban in public places reorganised Saturday night routines, effectively breaking previously strong links between the practices of smoking and eating out at a restaurant. By changing when and where smoking happens, the smoking ban effectively changed the nature of smoking as an activity, doing so by changing the social meanings, locations and timings involved.
A self-conscious and ‘practice-oriented’ public health – one that is explicitly focussed on shaping the ‘lives’ of more and less healthy practices – would stand a better chance of stemming the scourge of NCD than more traditional methods which rely on providing more information to people in the hope that they will make ‘healthy choices’.
We need new theoretical approaches within public health that are able to shape and take account of the histories and futures of smoking, drinking, exercising and eating as shared social practices. These approaches can be drawn from ideas which have a long standing history in the social sciences and have already been taken up to good effect in other areas of policy, such as sustainability and environmental change.
Current approaches reproduce a model of intervention tied-up with concerns about the freedoms and constraints of individuals’ behaviours and which are focused on the rights and responsibilities of the individual. A radical shift away from this model will enable public health to take a stand against the grim reaper of NCD.
