Position Papers 3 & 4

Just when you thought there was time to take a break, here we are uploading papers 3 & 4 for you to mull over. Remember, please try to avoid printing these off as they will be included in your event pack if you are attending the seminar.

Professor Charles Abraham, University of Exeter Medical School

An intervention mapping approach to developing effective and useful behaviour change interventions

Translational research is needed to ensure that evidence-based models of behaviour change are adopted and applied in health services.  The Intervention Mapping approach will be outlined and its utility explained in relation to co-creation of behaviour change interventions in health care contexts. The importance of external validity to behaviour change intervention design and evaluation will be emphasised as well as the importance of understanding routine care and variability in such care.

Dr Geof Rayner, City University

The social-behavioural model of public health: some conundrums

In Ecological Public Health: Reshaping the Conditions for Good Health Tim Lang and I set out 5 models or traditions of public health.[1] We called these Sanitary-Environmental, Bio-Medical, Techno-Economic, Social-Behavioural, and Ecological, the last being newest of these traditions.

In the 1950s, Jerry Morris, later of the LSHTM, called for attention to the lifestyle components of health. Subsequently Abdel Omran’s theory of the Epidemiological Transition,[2] developed in the 1960s, highlighted the rise of chronic diseases. While Omran’s suggestions seem evidently true today (think of diabetes and obesity) other data (those of Robert Fogel and Dora Costa [3, 4]) show that many chronic diseases were in long term decline.

Whatever the resolution of this conundrum, which relates to the changing causation and form of chronic disease (or Non-Communicable Diseases, more widely understood), the Social-Behavioural model of public health is not, in fact, new at all. Rulers have attempted to influence the behaviour of their people ostensibly for health reasons for centuries. King James of England and Scotland published a diatribe against tobacco in 1604[5]. And the model is older yet when religious precepts that explicitly or implicitly include health, such as towards washing, or choice or preparation of foods, are included. Ruling groups have attempted to influence behaviour throughout history, although not entirely for the population’s own good! In the Elizabethan period Sumptuary Laws (a term which draws from Latin for expenditure) attempted to establish a means of stratifying social classes according to occupational dress (applying newly devised 'Statutes of Apparel'). In the modern period Karl Polanyi once remarked that the introduction of the New Poor Law in 1834, shaped by Malthus’ economics, was the rising bourgeois state’s attempt to institute social controls over the emergent labouring class.[6] It could be argued that the DWP’s programme of sanctions represents much the same thing, albeit without the cost of running a workhouse.

In the modern public health context the Social-Behavioural model has emerged as the main rival to the Bio-Medical model. There is a rich history of health education, some of it very effective, some less so, from early sanitarian booklets on healthy eating to the war-time use of catchy lines: ‘Coughs and Sneezes Spread Diseases’. Behaviour too was the point of focus of Tony Blair’s one and only speech on public health, where unsurprisingly - given his neoliberal perspective - matters like obesity were seen not as public health problems at all but as diseases of individual choice.[7]

Whatever the ideological format of understanding, since the 1950s, smoking, food and nutrition, alcohol use, and physical activity, and more, are increasingly highlighted as factors in chronic disease prevention, clinical areas where the biomedical model struggles. Of course, state rationality is never clear cut. The Labour government desired to expand the gambling industry but without the problems such expansion would cause. A forlorn, and to be cynical, unrealisable hope.

Late 19th century pragmatist philosophy and psychology gave focus to the importance of habit as part of the social basis of behaviour and identity formation. As William James once put it, “Habit is ... the enormous flywheel of society, its most precious conservative agent. It alone is what keeps us all within the bounds of ordinance, and saves the children of fortune from the envious uprisings of the poor.”[8] Influence habit, for example by setting or influencing social norms, perceptual cues, etc. and you have at your disposal an efficient means for regulating social behaviours. Early 20th century social science focused on the history of undirected modernization of behavioural rules over matters like eating, defecating, nasal-blowing, spitting, etc., via the analysis of social-psychological mechanisms like embarrassment and shame. [9, 10] If the royal court once decided such rules, increasingly the state, commerce and civil society assumed this role, and in a more intentionally directive manner. The Social-Behavioural model is not just a function of the state because the state (through education or public information) might not – and in fact is not - the principal means by which we obtain information about health-related behaviours or cues for habit formation. From the late 19th century, newly mass-manufactured products were marketed with health messages, catering to an increasingly segmented consumer marketplace, like products for women. [11] Personal health habits were changed by messages such as the value of regular bathing of bodies, cleanliness of the home, and about women’s domestic responsibilities and work. These were salutary. Today the marketing firepower of transnational corporations is massive. In work for the World Health Organization, Tim Lang and I showed that Coca Cola can spend more annually on its marketing of soft drinks than the entire biannual budget of the World Health Organization[12]. And yet, when modern corporate influences seem both powerful and baleful, there has been an increasingly vented argument that public health advocates should enter into alliance with these same forces, for examples through Public Private Partnerships, [13] Healthy Alliances,[14] or Corporate Social Responsibility and Responsibility Deals. [15] The press epithet ‘Nanny Statism’ misses its mark in many respects. Increasingly commerce is used to regulate or influence behaviour, even while it is approved or sanctioned by state strategy (in the case of Responsibility Deals, Change4Life, etc).

Oddly too, the recent analytic focus on behaviour reunites public health and economics (the latter as

‘behavioural economics’), which begets the latest fad, ‘nudge’, with the hidden ideological charm being that the State should do something (warn people, edit choices), but not much[16, 17]. Ranged against the power and finance of commerce, what leverage do public health advocates possess?

What methods do they use? Is it psychology, marketing – reborn as social marketing (with pitiful budgets)? Or is it law? Furthermore, if we wish to make efforts to get people to cycle more, to use their car less, etc – all with ecological public health gain – how can we realistically achieve this aim when other public institutions promote the opposite (eg. the BBC’s Top Gear – which seemingly has the aim of inducing laughter at any suggestion that movement should be undertaken through human effort alone?)

The Canadian public health writer Nancy Milio expressed it well in the mid-1970s. It could only be a ‘minimal aim’, she said, to make healthy choices easier: the unhealthy choices must also be blocked.

And for the most widespread impact the focus should be on ‘national-level policy-making’ which would in turn change ‘the range of options for the largest number of people’ [18]. She was right although her argument was insufficient. And where are the forces to make this happen today? Or, alternatively, do public health advocates instead realign their careers according to the latest neoliberal guidance of the day, or, a further option, do we enlist celebrities with a passing health interest to tell us what do instead? [19] Sadly, too often this is what the Social-Behavioural model has become.

1. Rayner, G. and T. Lang, Ecological Public Health: reshaping the conditions for good health.

2012, Abingdon: Routledge / Earthscan.

2. Omran, A., R, The Epidemiologic Transition: A Theory of the Epidemiology of Population

Change. Milbank Memorial Fund Quarterly, 1971. 49.(4): p. 509-538.

3. Costa, D.L. and M.E. Kahn, Public Health and Mortality: What Can We Learn from the Past?,

in Berkeley Symposium on Poverty, the Distribution of Income and Public Policy. 2003.

4. Fogel, R.W. and D.L. Costa, A theory of technophysio evolution, with some implications for

forecasting population, health care costs, and pension costs. Demography, 1997. 34(1): p.

49-66.

5. Stuart, J.K., A Counter-blaste to Tobacco. 1604, London: R.B. CHECK.

6. Polanyi, K., The Great Transformation. 1957, Boston: Beacon Press.

7. Blair, T., Our Nation's Future: Public Health. Speech by the Prime Minister on healthy living.

Nottingham. July 26. 2006, Prime Minister's Office, London: http://www.number-

10.gov.uk/output/Page9921.asp, accessed 7 May 2009.

8. James, W., The Principles of Psychology. 1890, New York: Dover Publications.

9. Elias, N., The Civilizing Process Vol.I. The History of Manners. 1969, Oxford: Basil Blackwell.

10. Elias, N., The Civilizing Process, Vol.II. State Formation and Civilization. 1982, Oxford:

Blackwell.

11. Mokyr, J., The Gifts of Athena: Historical Origins of the Knowledge Economy. 2002, Princeton,

New Jersey: Princeton University Press.

12. Lang, T., G. Rayner, and E. Kaelin, The Food Industry, Diet, Physical Activity and Health: a

Review of Reported Commitments and Practice of 25 of the World's Largest Food Companies.

Report to the World Health Organisation. 2006, London: City University Centre for Food

Policy.

13. Simon, P.A. and J.E. Fielding, Public health and business: a partnership that makes cents.

Health Aff (Millwood), 2006. 25(4): p. 1029-39.

14. Andreasen, A.R. and P. Kotler, Strategic marketing for nonprofit organizations. 6th ed. 2003,

Upper Saddle River, N.J.: Pearson Prentice Hall. vii, 536 p.

15. Lang, T. and G. Rayner, Corporate responsibility in public health. BMJ, 2010. 341: p. c3758.

16. Rayner, G. and T. Lang, Is nudge an effective public health strategy to tackle obesity? No.

BMJ, 2011. 342: p. d2168-d2168.

17. Thaler, R. and C. Sunstein, Nudge: Improving Decisions about Health, Wealth, and Happiness.

2008, New Haven CT: Yale University Press.

18. Milio, N., A framework for prevention: changing health-damaging to health-generating life

patterns. American Journal of Public Health, 1976. 66(5): p. 435-439.

19. Rayner, G., Does celebrity involvement in public health campaigns deliver long term benefit?

No. BMJ, 2012. 345.