Economists can be dull people.
But one economist said something that has remained with me for years – that ‘poor diets’ are often excellent decisions on a money-to-calorie basis. You get more calories for what you spend, which is why ‘poor diets’ are a good thing for those lower down the socioeconomic gradient.
From a health perspective, of course, ‘poor diets’ are a bad decision – that’s where my use of ‘poor’ clearly comes from. And so, in health, especially in the worlds of health promotion and prevention, there’s a fascination with getting people to eat ‘better’.
This is one of the aims of so-called behaviour change.
But the idea that behaviour can be changed relies on the assumption that an act is discrete, stable and homogenous. It is these assumed characteristics that help make it identifiable and observable – and hence measurable. But what if these assumptions are wrong?
The idea of behaviour change started from the idea that decisions relating to health were anchored in ‘health beliefs’; decisions derived from deliberation and reason. This gave rise to research into, and the practice of, using education to change behaviours.
But researchers and practitioners have found a stubborn gap between how people think about what to do and what they do. To make sense of this, they’ve reached back to the idea of self-efficacy, first described in 1977. The idea behind self-efficacy is that between intentions and actions lies the treacle of whether someone thinks they can do what they want to do.
But despite this deeper understanding the gap has persisted.
Sadly, that persistence hasn’t made many researchers and practitioners ask themselves whether the basic assumptions of behaviour are right. Assuming that behaviour is discrete, stable and homogenous has made it measurable, and hence amenable to study, but are the conclusions of studies based on flawed assumptions worth anything?
Probably not much.
In 2014, Sociology of Health & Illness dedicated an entire issue examining the idea of behaviour change. In his excellent introduction, Simon Cohn of the London School of Hygiene & Tropical Medicine, chastises his fellow scientists for accepting the concept of health behaviour “too readily”. By doing so, behaviour became “removed from any comprehensive, detailed description of what people were actually doing”.
Cohn advocates for a deeper understanding of the “emergent and contingent properties of people’s activities in particular situations”. Along the way he points to the “remarkably little discussion of power [or] sociality” in academia’s attempts to understand behaviour.
The doctrine of behaviour change continues to parade through health promotion and prevention like the most naked of naked Emperors. But the fight back is emerging.
Public Health England (PHE) recently partnered with the gambling industry for a campaign to reduce problem gambling that focussed on individual gamblers. By backing an individual-level narrative, PHE effectively reinforced the idea that changing someone’s behaviour is about educating them. In The Lancet, May van Schalkwyk and colleagues disabused them of this notion in an article that also wove in the eloquent term, ‘the wider corporate determinants of health’.
Zooming out, and staying with The Lancet, Sandra Galeo of the School of Public Health at Boston University recently argued that the unstinting focus on individual lifestyle has obscured the core drivers of health, leaving them to be undermined by large-scale forces, such as corporations that aggressively market unhealthy products, tax loopholes that deepen economic inequality, and the dismantling of regulations that keep our environments clean and safe.
As the fight back grows in the corridors of world-renowned academic centres and the pages of crusading journals, keep four words in mind: Emergent, Contingent, Power, and Sociality.
People’s behaviours are emergent – they come from multiple, hard-to-predict influences. People’s behaviours are contingent – they’re subject to a variety of social and material factors that act alongside, rather than prior to, a decision. People’s behaviours depend on their power – it’s impossible to ignore a community’s political context. And people’s behaviours have sociality – they are influenced by, and tied to, their social groups.
If you’re in a ‘community health’ meeting this week, and if the idea of ‘behaviour change’ surfaces, ask yourself if these four ideas are present in the discussion. If not, how can you introduce them? If you can’t, who can you enlist to? And if there’s no one, how can you bring such a person into the work?
I’m sorry to make your work harder but the easy stuff has been tried.
- The special issue of Sociology of Health & Illnesswas called ‘From Health Behaviours to Health Practices: Critical Perspectives’ [link]
- Simon Cohn’s article was titled ‘From health behaviours to health practices: an introduction’ [link]
- May van Schalkwyk and colleagues wrote ‘Gambling control: in support of a public health response to gambling’ [link]
- And Sandro Galea’s piece was called, ‘What we need to talk about when we talk about health’ [link]
Photo by Hello I’m Nik on Unsplash