Two Approaches to Health
Between the 1970s and 1990s, researchers began examining the ‘causes of the causes’ of poor health. They were interested in the social conditions that give rise to a higher risk of non-communicable disease in some groups, and studied the differences in mortality rates in British civil servants. In particular, Marmot and Rose’s Whitehall studies provided evidence that the relationship between poverty and health may not be characterised by a threshold, but by a gradient. It is not the case, they found, that achieving a certain socio-economic status is
sufficient to achieve good health. Instead, throughout class ranks each group does better in health than the one below [
50,
51]. Marmot and Rose theorised that these disparities in health were caused by a combination of unhealthy behaviours and the effects of impossibly stressful lives [
42,
51,
69]. The ‘social determinants’, as they became known, include factors like housing and living environment, exposure to environmental pollutants, educational attainment, food quality and availability, and many other factors that impact our health, outside of genetic predispositions or accidental illness or injury. Since the 1990s, a growing amount of research has confirmed the observation that those with greater economic and social resources are more likely to have better health outcomes insofar as they may do better regarding the social determinants, resulting in predictable disparities in health between groups [
13,
19,
32,
41,
63].
Despite this research, establishing causation between socio-economic status and health outcomes has been difficult because of the various complex, and often covert, ways in which determinants like housing, employment, transportation, educational attainment, childcare, food provision, and a variety of other factors have a cumulative impact upon health over time. As such, teasing out and analysing the multiplicity of covariates has proved challenging. However, researchers continue to find correlations between poor health and low socioeconomic status. For example, a recent analysis of active transportation among school-age children in California found an unexpected positive relation between using active transit to get to school and having obesity. The researchers proposed that the link between these factors may be poverty: children who are poor are both more likely to bike or walk to school and also to be obese [
17]. As such, public health’s messaging to groups with higher rates of obesity to be more active may miss the audience, and the point. Other researchers in the US have found that racial and economic disparities lead to worse health outcomes and higher obesity rates [
2,
17,
79]. Some commentators have noted that results like these reveal a blind spot in the public health policy literature. While public health researchers seem to have reached a consensus that low socioeconomic status begets poor health, many of the policy reports in public health continue to call for individual changes, not the mitigation of social determinants connected to poverty, or the regulation of various social systems (such as the food provision system) [
17,
68].
Amongst the reports which emphasise individual changes are those which propose policy influenced by behavioural science. Although behaviour-change approaches are not new, behavioural science-influenced strategies have come to the political fore in recent times. The Behavioural Insights Team (BIT) in the UK, established in 2010, leads the way in this regard. Sometimes called the ‘nudge unit’, BIT originally started within the Cabinet Office, before separating out and becoming a public–private partnership with both the Cabinet Office and the National Endowment for Science, Technology, and the Arts [
7]. The influence of the UK-based team spread internationally. Members of the BIT went on to advise the New South Wales Office of Premier and Cabinet in Australia on a range of policy measures. That Office now has its own team [
24]. Following this, in 2015 the Australian Government created a Federal level unit [
25]. In the US, under the Obama administration, the White House set up the Social and Behavioural Sciences Team (SBST). This team was created with the aim of translating “findings and methods from the social and behavioral sciences into improvements in Federal policies and programs” [
71], which was subsequently specified in an Executive order [
56]. The fate of the SBST under the current administration is yet uncertain (but appears safe). Across Europe, several countries also have dedicated behavioural teams within Government or are explicitly using behavioural science research to inform policy-making; for instance, the Netherlands, Germany, and Denmark [
28]. Moreover, at European Commission level, the Joint Research Centre (JRC) provides support for behavioural research in Commission service areas [
27].
Both the BIT and the European Commission’s JRC have produced reports which encompass a range of policy areas, including the application of behavioural science to health [
4,
5,
37,
76]. To highlight the kinds of interventions being trialed and implemented, and the findings from behavioural science which inform them, consider some measures in relation to smoking. In the UK and Iceland, it is illegal to openly display tobacco products, and in the UK, Ireland and France, plain packaging regulations are in force. In the UK, this legislation came into force in May 2017, following an unsuccessful legal challenge by the tobacco industry [
26]. Draft plain packaging regulations are also being considered in a number of other European countries [
28]. Both restrictions on display and plain packaging initiatives aim to decrease the visibility and social acceptability of tobacco products. The way these measures work is two-fold. First, the visual cues which can trigger consumption are reduced by restricting displays. Second, the power of social norms is harnessed. By hiding the products and removing ‘attractive’ and branded packaging, these measures send a message that smoking is not socially acceptable. Although these initiatives involve legislation, the behaviour of individual citizens is not being
directly regulated. Whilst it may be illegal for shops to display tobacco products, it is not illegal to smoke, and the committed smoker can still buy cigarettes. There is no ban on tobacco products, or their purchase or sale. It is for this reason that strategies such as these, which alter the choice environment, are sometimes labelled ‘nudges’ or ‘libertarian paternalism’ [
59,
73].
Consider also food and diet. In a recent BIT report on health, suggestions relating to food include decreasing the size of food packaging and tableware, and changing the placement of healthy foods in shops to make them more accessible (conversely one could make ‘unhealthy’ foods less accessible) [
73]. Such suggestions draw on research which points to the biases and other factors which affect eating. For instance, ‘present bias’ means that we give more weight to our present desires, and tend to discount our future or longer-term goals. This can manifest through undervaluing the longer-term disadvantages of unhealthy diet or of skipping exercise, and overvaluing the immediate benefits of food experiences. The benefits of hyper-palatable food (food that is created to be very high in salt, sugar, and fat) to us
now is more salient than any longer-term disadvantages it may have. As such, we might favour high-convenience food in the present, seeking to impose greater self-control on our future selves. We tell ourselves ‘I’ll eat better tomorrow’, something which may not materialise [
46]. In addition to present bias, things like menu layout in restaurants, as well as portion sizes can affect what we choose and how much we eat [
46]. Rather than placing regulations around the added ingredients in hyper-palatable food, policies informed by behavioural science often suggest changing the decision environment; for example, calorie-postings on menu boards, changing the size of plates at self-serve food outlets, or rearranging food displays.
3 These are individual-focused initiatives, which operate on a one-person-at-a-time basis, and thus, the success of these measures to change eating behaviours are highly variable between people. In “
(In)equality and Social (In)justice II: What Kind of public Health?” section, we will discuss a regulation in the food system which is not individual-focused, and which has great public health potential.
Ships in the Night?
The drive to utilise behavioural science in (public) health policy has thus far taken little account of macro-level social determinants. Take, for example, three prominent policy reports: (1) the 2010 Behavioural Insights Team’s
Applying Behavioural Insight to Health [
4]; (2) the European Commission Joint Research Centre’s (JRC) 2013 ‘Applying Behavioural Sciences to EU Policy-making’ [
75]; and (3) the JRC’s most recent ‘Behavioural Insights Applied to Policy European Report 2016’ [
47]. The BIT report is exclusively focused on health. The other two are more broadly focused, but they mention health and health-related interventions to varying degrees. As can be seen from examples given in the previous section, the usual public health suspects are a prevalent focus in policy reports drawing on research in behavioural science. Smoking, alcohol, diet, and physical activity take up the greater part of health issues discussed across all three reports. The 2010 BIT report discusses other topics, examining organ donation, teenage pregnancy, diabetes control and compliance, and food hygiene [
4]. Nevertheless, we can see that this list does not include the ‘social, material, political and cultural inequalities’ which constitute the macro determinants of health status and outcomes. The 2016 BIT report on health reaffirms this ‘lifestyle’ focus, saying:
… Around half of the global burden of disease arises from behavioral and lifestyle factors. Unhealthy eating, smoking and alcohol consumption contribute to the development of long-term conditions such as diabetes; cardiovascular diseases; chronic respiratory diseases; and musculoskeletal disorders [
37].
Yet, despite the report noting that we need to better understand the “ways that ill-health develops” and “why unhealthy behaviours happen” [
37], it contains no engagement with issues regarding the social determinants of health.
The academic literature does not fare much better. The two areas—behavioural science and the social determinants of health—currently occupy two almost separate spheres of academic debate. While some articles mention these together, there is not generally any substantive discussion of the relationship (or potential relationship) between them.
4 From the behavioural sciences side of things, some articles include references to social determinants, while not actually being about them. For example, Glanz and Bishop state in the abstract to their paper that “influential contemporary perspectives stress the multiple determinants and multiple levels of determinants of health and health behaviour” [
33]. They write that public health and health promotion initiatives will be most effective if they are based on an ecological understanding of health behaviours, which are attentive to the social and political environment a person has to operate within. However, it becomes clear that Glanz and Bishop, like other commentators, find choice architecture to be a sufficiently ecological approach. They provide an overview of the theories of behavioural science as they apply to health promotion, and then claim that the most prominent contributors to death and disease in the US and globally are individual behavioural factors [
33]. Thus, while their piece initially appears to engage with the SDoH, the focus on behavioural factors and choice architecture actually leads to their exclusion [
33,
44,
68]. Others, such as Roberto and Kawachi, fare slightly better, offering a brief consideration of how behavioural strategies could complement other “long-term and structural barriers to achieving optimal health in people’s lives” [
64]. Here there is a broad acknowledgement that wider factors are determinative of a person’s health. But again there is no in-depth engagement with this and with the (potential) relationship with behavioural science-inspired approaches.
Those articles and documents which approach the issue from a public health or SDoH perspective engage with behavioural science in a more substantive fashion than vice versa. However, this engagement is critical in nature. The criticism of behavioural science from within public health is exemplified by a recent WHO report that suggests that a focus on individual behaviours and nudges contribute to the failure to address health equity and the social determinants of health in Europe. The report noted that WHO studies found a tendency “to focus on intermediate or proximal determinants such as access to health services, lifestyle or behaviour, living conditions (housing, water and sanitation) and social cohesion” [
80]. This focus was symptomatic of a failure to properly conceptualise the multiple factors involved in the health of a population, and to “intervene with the magnitude and intensity necessary to affect their distribution” [
80]. The proposed reasons for this echo the Marmot Working Committee’s findings outlined earlier; that is, the tendency to focus on proximal issues affecting health is influenced by many factors, including political ideology and the interests of different stakeholders
5 [
80]. The WHO report notes that part of this “includes a resurgence of the trickle-down effect and a focus on individual responsibilities and behaviour change, such as ‘nudge’ strategies” [
80]. Taken in the broader context of the report, this represents a clear statement that the WHO does not think that nudge-type interventions from behavioural science can address significant health concerns, health equity, or the fundamental social determinants of health.
Similar critiques can also be found in other places. For instance, Rayner and Lang argue that behaviourally-focused policies in their current form do not take account of the complicated reality of the decisions that most people face [
61]. There is also a concern that nudges provide at best a smokescreen for governmental inaction, and at worst a marketing ploy in concert with industry actors [
11,
48,
53,
61]. Regarding social determinants, Bonell and colleagues argue that the UK government’s promotion of nudging as an alternative to ‘hard’ policy interventions misrepresents the original theory behind nudging (as one of a suite of regulatory tools). Misleading the public about the nature of nudges “serves to obscure the government’s failure to propose realistic actions to address the upstream socioeconomic and environmental determinants of disease” [
11]. A related, but deeper, issue with the emphasis on nudge-type initiatives is that public health is reduced to the ‘managerial’ [
45]. Lang and Rayner surmise that the increasingly technical language of policy ‘delivery’, and now the micro-level focus on nudging individuals, frames thought around health and well-being in such a way that it discourages public health attention on the “macro, big picture, framing contexts of life” [
45]. Nudge, for them, is the current fad within the general trend towards a managerial and reductionist approach to public health, which ultimately threatens to make public health irrelevant [
45].