Why behavioural health promotion endures despite its failure to reduce health inequities

Abstract

Increasing rates of chronic conditions have resulted in governments targeting health behaviour such as smoking, eating high-fat diets, or physical inactivity known to increase risk for these conditions. In the process, many have become preoccupied with disease prevention policies focused excessively and narrowly on behavioural health-promotion strategies. These aim to improve health status by persuading individuals to change their health behaviour. At the same time, health promotion policy often fails to incorporate an understanding of the socialdeterminants of health, which recognises that health behaviour itself is greatly in?uenced by peoples environmental, socioeconomic and cultural settings, and that chronic diseases and health behaviour such as smoking are more prevalent among the socially or economically disadvantaged. We identify several reasons why behavioural forms of health promotion are inadequate for addressing socialinequities in health and point to a dilemma that, despite these inadequacies and increasing evidence of the social determinants of health, behavioural approaches and policies have strong appeal to governments. In conclusion, the article promotes strategies addressing social determinants that are likely to reduce health inequities. The article also concludes that evidence alone will not result in health policies aimed at equity and that political values and will, and the pressure of civil society are also crucial.

Introduction

Although average life expectancy has doubled over the past two centuries (Williams 2004), people with a low health status, including those with chronic disease, are concentrated in disadvantaged areas and towards the lower end of the social gradient. Health inequities closely follow this gradient (Bankset al.2006, Commission on the Social Determinants of Health 2008, Crombieet al.2005, Mackenbach 2005, Turrellet al.2006). There is also mounting evidence in developed nations that disparities in health status have begun to widen in response to changing social and economic conditions (Draperet al.2004, Kroll and Lampert 2011, Sta- matakiset al.2010) and that inequities between rich and poor countries are also increasing (Labonte et al. 2007, Sanders et al. 2005). The persistence of health inequities has been the focus of policy concern for decades and most recently has been highlighted by the World Health Organization (WHO) Commission on the Social Determinants of Health (CSDH) whichconcluded that social injustice is killing people on a grand scale (2008: 26). The CSDH made a series of recommendations on ways in which health inequities could be reduced both between and within countries. However, it did not call for measures to directly change behaviour that is known to be risky to health. Instead it emphasised the need to change environ- ments and introduce regulations.

The history of public health policy is characterised by a chasm between two central views of how population health may be improved through action to prevent ill health and promote health. On the one hand there is a focus on unhealthy behaviour (for example, the US Depart- ment of Health, Education and Welfare 1979)and on the other are the views that underlying social and economic factors are the primary determinant of health outcomes (CSDH 2008). This tension has existed since at least the 19^thcentury, when public health reformers such as Virchow in Silesia, Engels and Chadwick in the UK, and Villerme in France pointed to ;the impact of industrialisation and urbanisation on health among the working class and promotedstructural and political reforms accordingly, while others claimed that the poor health of the working class was the product of their own behaviour and immorality (Porter 1999).

These differences foreshadowed tensions that are still evident in public health policy andpolicy debates today (Nutbeam and Boxall 2008). While public health advocates continue to call for healthy public policy to address the social factors shaping health and health behaviour, governments and international agencies are still inclined to direct their policy actions at chang- ing risky behaviour directly through social marketing and other means of exhorting individuals to change (Alvaroet al.2011, Bryantet al.2010, Glass and McAtee 2006).

This article examines why behavioural forms of health promotion are an inadequate strategy for addressing social inequities in health and are unlikely to resolve social differences in risky health behaviour. It then considers why, despite these inadequacies and increasing evidence on the social determinants of health (SDH), behavioural approaches may be appealing to govern- ments and thus come to dominate health promotion policy. The article concludes with a dis- cussion of health promotion strategies consistent with addressing the SDH and health inequities, and why these are more likely to improve population health and health behaviour.;

Behavioural health promotion and its limitations in reducing inequities in health and health behaviour

Behavioural health-promotion strategies are typically aimed at addressing widely recognised behaviour known to increase health risks, including tobacco smoking, excessive use of alcohol, consuming a high-fat diet or being physically inactive (Davies and Macdowall 2006). A basic example is disseminating information about health and lifestyle risks or bene?ts associated with different behaviour, on the assumption that this will motivate individuals to modify their behaviour (Lefebvre and Flora 1988).

Behavioural approaches to health promotion have drawn on theories of behavioural change and health behaviour stemming from social psychology, such as social cognitive theory (Bandura 2004), the health belief model (Becker 1974), reasoned action and planned behaviour theory (Ajzen 1991) and social marketing (Eggeret al.1990). While some such theories do take account of the potential in?uence of wider social factors, the main focus has been on individual action and choice as the key mechanisms for improving health behaviour (Nutbeam and Harris 2004). The idea that providing knowledge of health risks and bene?ts to people will lead them to change their unhealthy behaviour has an inherently logical appeal, and cer- tainly in some circumstances behavioural strategies can in?uence individual health behaviour, especially among those with a high socioeconomic status (SES) (for example, Montagueet al.

2001, Powles and Gifford 1993). There are, however, a range of reasons why this approach will have only a limited effect on the health status of a population, and why the more unfa- vourable the social and economic conditions of a population group, the less effective behavio- ural change strategies are likely to be.

Contemporary behavioural-health promotion strategies fall into two broad types; those applied across a large population (universal), and those implemented in a local area or in an identi?ed at-risk group (targeted). Universal strategies such as social marketing campaigns tend to work best with people who have access to a range of social and economic resources, and they are therefore more likely to decrease prevalence of risky behaviour in high SES groups (Slama 2010). They may also help to decrease the overall rate of a form of behaviour in a population, especially when used with a mix of complementary strategies and sustained over time (Gordonet al.2006, Lefebvre and Flora 1988, Randolph and Viswanath 2004). However, there is also evidence that they tend to generate signi?cantly less or little improvement with low SES or other disadvantaged groups (Alvaroet al.2011, Layte and Whelan 2009, Leeet al.1991). The overall effect, therefore, may be to entrench or exacerbate inequality in health behaviour and so in health outcomes, as has been found with a number of tobacco control campaigns (Baum 2007, Layte and Whelan 2009, Slama 2010). This is despite the fact that most tobacco control involves both behavioural strategies and restrictive policies and regulations.

A similar pattern of outcomes has been found in the strongly behaviourally oriented US Healthy People 2010 strategy. A US Health and Human Services (2005) mid-course review of the strategy notes that health performance targets had been less successful for a number of dis- advantaged groups, including those with a low income or education, than for more advantaged groups (p. 8).

Several large-scale, targeted behaviour-change interventions of the 1970s and 1980s, which sought to address smoking and other health behaviour, also failed to produce suf?cient evi- dence to support their value (Glass 2000, Syme 2004). Evidence showing the limitations or failure of behavioural health-promotion strategies appears to inform policy rarely. If it did, then it would follow that there would be much less tendency to adopt behavioural strategies (See also Baum 2008: 4605, Eggeret al.1983).

Small-scale targeted strategies such as intensive behaviour-change interventions with high- risk individuals have produced some limited positive results (for example, Laatikainenet al.2007). These trials require signi?cant resources and may produce bene?ts for a small group, usually those with other aspects of their life are going well. However, this form of evidence is not helpful in terms of changing risk factors across a whole population because even a large change in such a small proportion of the population will not have any signi?cant effect on overall population health (Chapman 1985, Rose 1992), and the intensive intervention methods required are not feasible on a large scale.

Behavioural health-promotion strategies tend to assume that people are blank sheets ready to be receptive to health promotion messages. The reality is that peoples lives re?ect a range of factors, including their current social and economic resources, and risk factors are accumu- lated over the life span, with negative conditions in early life being particularly damaging (Lantzet al.2007, Lindsay 2010). This means that peoples abilities both to respond to health

promotion messages and improve their health and risk factor status as a result of the messages

vary signi?cantly, and the overall impact is likely to be greater in economically advantaged groups (Link and Phelan 2005).

This point is illustrated by the experience of Aboriginal people in Australia who as a group face overwhelming structural impediments to their ability to act on health promotion messages, including poverty, a low education, high rates of incarceration, sub-standard or crowded

housing (Thomsonet al.2010), and racism (Zierschet al.2011). Thomaset al.(2008) report that Aboriginal people removed as children from their families under a previous government policy (Human Rights and Equal Opportunity Commission 1997) are twice as likely to be a current smoker as those who were not removed, indicating the powerful impact of social fac- tors on health behaviour.

This example is consistent with evidence that exposure to psychosocial stressors can increase engagement in risky health behaviour as a form of seeking relief (Krueger and Chang 2008). These stressors often co-exist with a low SES and exposure to environments where risky health behaviour such as smoking are encouraged by social norms or corporate sales pro- motion (Smithet al.2004). When people behave in ways that are not good for their health it is generally not because they are unaware of the risk but rather that the constraints of their life and accumulated dispositions over the life-course means they are unable or unwilling to change their behaviour (Anthonyet al.2004).

Bourdieu (1984) bridges the agencystructure divide with his theory that explains how indi- viduals accumulate durable and transposable values and dispositions through socialisation and then adapt their ambitions and actions to the social circumstances and context of their lives. He maintains that values, beliefs and worldviews are created through thehabitus(Bourdieu 1986), which re?ects and helps to maintain class, gender or cultural position, and can be more or less supportive of health-promotion practices in everyday life. Bourdieu sees that economic capital is maintained and reproduced through cultural, social and symbolic capital and these capitals are crucial in determining opportunities to adopt healthy lifestyles over the life course.

What is the appeal of behavioural health promotion to governments and others?