Behavioural Policies for Health Promotion and Disease Prevention

Benjamin Ewert, Kathrin Loer, Benjamin Ewert, Kathrin Loer

• Publisher: Palgrave Pivot
• Year: 2018
• ISBN:
  9783319983165
• Topic: Politique et relations internationales
• Subtopic: Politique publique

Policy-making in public health is highly complex, which is one reason why the behavioural turn is now playing a significant role in this field. Against this backdrop, this book aims to develop a theoretical understanding of how policymakers take up public health challenges and how policies change over the course of time. Accordingly, the book reveals policy-makers' underlying assumptions, which influence the way in which public policy seeks to promote the health status of citizens. In a second step, the book presents a typology of policy instruments and applies this to the field of health promotion. This typology introduces an option that adds behaviourally informed insights to the toolbox of political analysis. Empirical evidence of behavioural health policies can be found in various countries around the world, and the book presents both relevant country studies and examples from the supra- and international level. Finally, the book discusses the implications of the rise of behavioural health policies, proposes a specific concept of health citizenship and reviews state-citizen relations. The book is useful for academics from health-related disciplines, such as political science, sociology, and public health, as well as for policy-makers, practitioners and students.

© The Author(s) 2019

Benjamin Ewert and Kathrin Loer (eds.)Behavioural Policies for Health Promotion and Disease PreventionPalgrave Studies in Public Health Policy Researchhttps://doi.org/10.1007/978-3-319-98316-5_1

Begin Abstract

1. Understanding the Challenges in Public Health Policymaking: Introduction

Kathrin Loer¹ and Benjamin Ewert¹

(1)

FernUniversität in Hagen, Hagen, Germany

Kathrin Loer (Corresponding author)

Email: [email protected]

Benjamin Ewert

Email: [email protected]

Abstract

Loer and Ewert introduce the key issues of the book and initiate the discussion on contemporary public health policymaking: they point out how individual and societal parameters interfere with policy interventions. The introduction to the book explains how this idea of reciprocity will be combined with the current debate on struggles against lifestyles being (potentially) dangerous to health. The reader will learn how public health can be conceptualised in the light of the most relevant challenges to policymaking. Furthermore, the introduction gives a brief overview of the following chapters.

Keywords

Public healthContemporary challengesPolicymakingIndividual and societal dimensions

End Abstract

Introduction

‘Prevention is better than cure’ is a frequently heard truism, and indeed it may seem obvious that preventing a potential or impending problem is far preferable to having to deal with a problem after it has occurred. However, when it comes to public policy, it seems that preventing societal problems is no simple matter, since preventative measures can often conflict with political and social realities and must also contend with a complex tangle of influencing factors. This seems especially true for most issues in public health, which are influenced by both societal and individual factors: for example, even when a person’s living environment provides sanitation facilities, infrastructure, information, advice and support for a healthy life, this still does not guarantee that this person will adopt a healthy lifestyle, and the converse is equally true. It is easy to imagine the complexity that is intrinsic to both spheres of public health, whether in relation to communicable diseases or non-communicable diseases (NCDs) such as asthma and diabetes or causes of NCDs such as obesity.

As we will argue in this book, policymakers may seek to break free of budget constraints (at least in part) by re-inventing approaches that aim to address and influence individual lifestyles. Above all, dietary and exercise habits seem to constitute the largest risk factors when it comes to a range of adverse health outcomes. If we were to ignore for a moment the political context and to overlook the values of the liberal twenty-first-century society, it would be easy to envisage the strict prohibitions and orders that policymakers might introduce to ensure that people desisted from unhealthy behaviours and adopted healthier ones. Alternatively, high taxes might be imposed to discourage people from consuming certain products known to pose a health risk (for a systematic overview of the literature on policy instruments, see Chap. 3). But to return to reality, depending on the political context and political culture in the country concerned, these kinds of intervention would not only be politically risky but would also undo some of the key achievements of the liberal democracies in which we live. Of course, we could easily identify the spectrum of policy instruments (Lowi 1972; Vedung 2003; Howlett 2011) which are considered in political science debate. But, we have to link the literature to public health debates (see Chap. 3).

There is also an ethical dimension when it comes to current health policymaking in the sphere of disease prevention and health promotion: who is ultimately responsible for preserving people’s health? How much can and should public policymaking seek to promote ‘healthy lifestyles’ that help to prevent NCDs? And moreover, who should be responsible for deciding what is healthy and what makes people sick? When we analyse the determinants of the health of populations (e.g. Evans et al. 1994), the complex range of factors that influence people’s health becomes obvious. Despite such comprehensive knowledge, an often rather simplistic public debate continues to emphasise certain—apparently undisputed—factors that everybody should be able to address in order to prevent NCDs: better nutrition, more physical activity, giving up smoking and the like. However, the question really is at what proximal or distal level of the causation chain policymakers are willing to focus their policy intervention. Is it lifestyle and behaviour, or rather the systems that create the options for lifestyles and behaviours? This book draws from the strand of literature that has already highlighted the imbalanced frequency how policymakers chose between these options in health policy practice. The frequent absence of effective policies for tackling social inequality (Baum and Fisher 2014) is further fuelled by newly emerging and rapidly growing approaches in public health that focus on individual behaviours. The following chapters of this book will acknowledge the reciprocal nature of individual and societal parameters and policy interventions which refer to these parameters. This basic idea will be combined with the current debate on tackling individual lifestyles that constitute a (potential) health risk.

However, before we turn our attention to the question of how policymakers can deal with the complexity involved in public health, we would first like to take a conceptual step back. What do we typically mean by public health? Following Bergenheim et al. (2018) in a first step, we see a difference between public health, national health and population health (Bergenheim et al. 2018, 1), as well as between medicine and health policy. Second, we agree with the important notion that ‘health is created largely outside the health sector’ (de Leeuw 2017, 330), which means that public health would need methods of engagement across levels, action-logics and governance-policy-action permutations (de Leeuw 2017, 314)—or, to put it differently, ‘in the health society health has become a “co-produced” good which needs the cooperation of many sectors and actors in society’ (Kickbusch 2007, 158). Additionally, we learn a lot about the differences in conceptualising public health, in particular with regard to political and cultural factors, from this strand of literature (Kananen et al. 2018). Despite interesting national differences in the concept of public health, especially between Nordic countries on the one hand and Western European or North American countries on the other, Kananen et al. (2018) also underline historical changes in the concept of public health. These changes relate to processes of individualisation (active and passive), but they are also strongly linked to the expansion of market mechanisms and the growing relevance of private-sector actors and corporations. This historical research prepares the ground nicely for a better understanding of the challenges of policymaking in public health. The second chapter of this book builds on these findings by exploring and revisiting the assumptions that underlie policymaking in the field of health promotion. Ewert develops a comprehensive and balanced approach to health promotion that integrates the ideas of behavioural sciences. The chapter explains how behavioural insights could be a useful tool in future health promotion policy.

In line with Kananen et al. (2018), and having reviewed a broad swathe of literature, we can attest that the field of public health policy has a number of challenges to contend with, included blurred concepts, a constantly changing environment and the complex tangle of factors that can influence individual health. Factors that affect health and cause diseases do not stop at frontiers. They are independent of administrative levels and do not conform to the idea of policy areas. They therefore demand comprehensive solutions in policymaking. The prevention of diabetes, for example, seems to be resistant to quick-fix solutions since it relates to contemporary living environments (e.g. walkability), food supply and nutrition, education, working routines and many more societal and individual factors, many of which are closely intertwined. The issue of diabetes illustrates the host of issues in public health—particularly with regard to NCDs—that policymakers are now confronted with. However, political actors at various levels are seeking policies that can help prevent disease and promote health.

In a comprehensive perspective, Nancy Milio (1981) outlined how health can be promoted through public policy and presented her analysis of the USA. Her study laid the groundwork for future work on public health promotion and yielded insights that continue to play a decisive role in current debates: Milio unveils a spectrum of obstacles that help explain why a comprehensive approach to disease prevention and health promotion was still missing. She pointed out that a ‘clear health policy goal’ was absent and that political actors lack responsibility and accountability with regard to ‘health-making policy options’ (Milio 1981, 207). We find a large number of promising individual studies in public health, as well as a small but very significant research literature that takes a public policy perspective on public health (e.g. Clavier and de Leeuw 2013; F...