SDOH-Listserv Bulletin No. 7, March 29, 2004
Critique of Lifestyle and Behavioural Approaches to Health Promotion

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This Bulletin is based on a number of my reports and articles that are
mentioned below. I have also appended a series of quotations that I use in
Powerpoint presentations to make some points.  These presentations are
available for your use in the Library at
http://quartz.atkinson.yorku.ca/QuickPlace/draphael/Main.nsf/

The following does not explicitly recognize the work being done by
innovative health units such as the Waterloo Region and State of Minnesota
and others that are helping to break the mould. These efforts have been
discussed in earlier editions of this Bulletin.
-------------------------------------------------------------
Lifestyle Messages about Health: A Constant Pounding Drum
      Evidence continues to accumulate that unequal distribution of income
and wealth associated with incidence of poverty, increases in food and
housing insecurity, and growing social exclusion are the primary
determinants of health and well-being (Marmot & Wilkinson, 2000; Raphael,
2004). These concepts have been present in Health Canada and Canadian
Public Health Association documents since the 1970s and have been
integrated into the health policy of many nations of Western Europe
(Mackenbach & Bakker, 2002; Raphael, 2001a). Yet, as our knowledge has
increased, so have public policy decisions that weaken these social
determinants of health. As bad as the situation is in Canada, it is
immeasurably worse in the USA (Hofrichter, 2003). SDOH subscribers
elsewhere can inform us as to your local situation.
      But if so much is known about these social determinants of health,
why do citizens in Canada and the USA hear virtually nothing about these
health issues from our elected representatives, public health officials,
and the media? Not only is there a deafening silence about the
health-related effects of the deterioration of our civic society from these
sectors, we are instead inundated with "lifestyle messages" that if we only
exercised, ate fruits and vegetables, and eliminated tobacco use, all our
health problems would disappear. The absurdity of these arguments is only
matched by their prevalence and repetition (Raphael, 2003b).
      One would have to be in a coma to have not internalized -at least in
part - these messages.  The problem is that not only do these approaches
not address the primary determinants of health, they divert public and
policy attention away more important issues, and serve to blame individuals
and communities for their own diseases and illness. There are three main
issues related to lifestyle -- especially behaviourally oriented --
approaches to health promotion: a tendency towards victim blaming; the
relative importance of individual risk factors as compared to societal
determinants in disease causation; and the questionable effectiveness of
behavioural change approaches to health promotion.
      As I entered this area, I frequently found myself reproducing work
that was done by Ronald Labonte decades ago. One of the earliest critiques
of behavioural approaches to health promotion focussed on the issue of
victim blaming. Over 20 years ago the following concerns were outlined
(Labonte, 1994; Labonte & Penfold, 1981):

"The argument was simple.  The health of oppressed people (poor, women,
persons from minority cultures, workers, and others) was determined at
least as much, if not more, by structural conditions (poverty hazards,
powerlessness, pollution, and so on) than by personal lifestyles.  Moreover
personal lifestyles were not freely determined by individual choice, but
existed within social and cultural structures that conditioned and
constrained behaviour.  Behavioural health education, social marketing, or
wellness approaches to health promotion fostered victim blaming by assuming
that individuals were entirely responsible for their choices and behaviour.
They also blamed the victim indirectly by ignoring the structural
determinants of health, those causes that are embedded within economic,
class- and gender-based patterns of social relationships."(Labonte,1994,
p.79).

      Since then, the critique of individual risk factor approaches has
been further developed with analyses of how the conceptualization of health
risk -- especially the individualization of risk -- is dependent upon
prevailing political and economic ideologies rather than evidence (Eakin,
Robertson, Poland, Coburn, & Edwards, 1996; Lynch, Kaplan, & Salonen, 1997;
Tesh, 1990). The theme of blaming individuals for their own health problems
is returned to later.
      The second critique of downstream, behavioural change approaches to
disease prevention concerns findings that individual risk behaviours
account for rather modest proportions of variation in the incidence of a
number of diseases.  This is especially the case for cardiovascular disease
and as increasing evidence is indicating, type 2 diabetes. This has been
known since the early Whitehall Studies (Marmot, Rose, Shipley, & Hamilton,
1978).  And to date, any number of studies have documented how societal
markers such as individual and community socioeconomic status are far and
away the best predictors of the incidence of heart disease in developed
nations (Diez-Roux, Link, & Northridge, 2000; Feldman, Makuc, Kleinman, &
Cornoni-Huntley, 1989; Lantz et al., 1998; Roux, Merkin, Arnett, & et al.,
2001). Recent reviews of this work in the area of heart disease are
available (Raphael, 2001b, 2002).
      Similar analyses have been applied to the issue of type 2 diabetes.
Increasing evidence is implicating material deprivation and stress as
significant precursors to its incidence.  Type 2 diabetes is much more
prevalent among materially deprived populations and mortality rates are
increasing in Canada especially among these deprived populations. A summary
of this work is available (Raphael, Anstice, & Raine, McGannon, Rizvi, &
Yu, 2003)
      The accumulation of this evidence base has occurred in conjunction
with increasing conceptualization and model building in the area of
population health and social epidemiology.  As one example, the work of
Davey Smith and his colleagues provides compelling evidence in support of a
life-course approach to heart disease (Davey Smith, Ben-Shlomo, & Lynch,
2002; Davey Smith, Grunnell, & Ben-Shlomo, 2001). Further evidence
concerning the influence of adverse conditions during the very early years
upon the incidence of heart disease and diabetes in later life is also
abundant (Barker, Forsen, Uutela, Osmond, & Eriksson, 2001; Eriksson et
al., 1999; Eriksson, Forsen, Tuomilehto, Osmond, & Barker, 2001; Forsen,
Eriksson, Tuomilehto, Osmond, & Barker, 1999; Lawlor, Ebrahim, & Smith,
2002). Nevertheless, heart health initiatives in Canada and elsewhere have
come to reify what Sarah Nettleton terms the "holy trinity" of risks: diet,
smoking and exercise. She argues:

"As with any area of medical or scientific research, the selection of
factors to be studied cannot be immune from prevailing social values and
ideologies. ... It is also evident that so called lifestyle or behavioural
factors (such as the holy trinity of risks - diet, smoking and exercise)
receive a disproportionate amount of attention. As we have seen, the
identification and confirmation of risk factors is often subject to
controversy and the evidence about causal links is not unequivocal"
(Nettleton, 1997, p. 318).

      In Canada's, the "holy trinity" has been enthusiastically deified by
virtually all public health units and their associated heart health
networks. Perusal of any and all of their web sites and documents reveal
how heart health activities conform closely to the individual risk factor
behavioural approach. The issue is not whether eating poorly, using
tobacco, and remaining sedentary are bad for health.  Such activities
clearly do not contribute to health.  But their impact is limited as
compared to other societal determinants, and the sole emphasis upon
individual risk factors to the exclusion of all other considerations is
problematic (Shaw, 2002). Two new initiatives in Canada continue this
dispiriting trend: the Federal Healthy Living Initiative and the Chronic
Disease Alliance of Canada (Chronic Disease Prevention Alliance of Canada,
2003; Health Canada, 2003).
      The third issue related to downstream, behavioural approaches to
health promotion in general, and heart health promotion in particular, is
the increasing recognition of the limited effectiveness of such approaches,
especially among disadvantaged groups. It is well beyond this Bulletin to
provide a comprehensive review of these but Ebrahim and Davey Smith (2001)
commenting on the most well-known heart health community-based programs,
concluded: "Intriguingly, these uniformly disappointing developed country
programmes have been reported as successes" (p. 202).  In Canada, two
consultants for Health Canada reached a similar conclusion in their review
of lifestyle approaches to heart health promotion:
      The difficulty encountered when trying to change lifestyle (heart
disease prevention) in individuals from a low socio?economic neighbourhood
is illustrated in a Montreal study (O'Loughlin, Paradis, Gray-Donald, &
Renaud, 1999). This 4?year, community?based cardiovascular disease
prevention program was aimed at adults aged 18 to 65 years living in
St?Henri, a low?income, inner?city neighborhood. Over 40 interventions were
implemented (i.e., smoking cessation workshops, contests, heart health
cooking classes and recipe contests, nutrition education workshops, direct
mail and ad campaigns...). The authors address the substantial challenges
of working in a community in which social and economic problems were a
greater priority than heart health.  Although they carefully adapted each
intervention to local needs, the results were dismal (Lyons & Langille,
2000, p.1)
      The researchers involved in the St. Henri project reinforce the point
that:

"?unless or until basic living needs are ensured, persons living in
low?income circumstances will be unlikely or unable to view CVD prevention
as a priority", (O'Loughlin et al., 1999, p.1826).

      More recently, Fitzpatrick has offered a comprehensive and critical
assessment of the limited effectiveness of behavioural change-oriented
health promotion programs -- an assessment that is, as noted, consistent
with an emerging academic and scholarly literature (Fitzpatrick, 2001).
Williamson's and Green's comments on the downstream emphasis of Canadian
public health units seem increasingly appropriate:
"While these initiatives likely play an important role in reducing the
negative effects that poverty has on health, they do little to alter the
socioeconomic and political conditions that contribute to the poverty
experienced by Canadians. Until these broad structural conditions are
addressed and altered, efforts to improve the health of Canadians will be
limited" (Williamson & Green, 1999, p. 10).
      In contrast, evidence is accumulating of how upstream policy-oriented
approaches can influence population health.  The Widening Gap report in the
UK details how macro-level policy changes clearly influence population
health. As income inequality increases health differentials between areas
increase, and as income inequality decreases, health differentials decline
(Shaw, Dorling, Gordon, & Smith, 1999).  Similar analyses on the effect of
policy environment upon childhood development and subsequent health are
contained in the recent volume Developmental Health and the Wealth of
Nations (Keating & Hertzman, 1999).  Analyses of the policy environment and
its impacts on the health and well-being of women within five nations are
documented in a recent work on Canadian women's quality of life (Raphael &
Bryant, 2004). Navarro does the same in an examination of population health
and overall political and social policy for a number of developed nations
(Navarro, 2002; Navarro & Shi, 2002).

Negative Effects of Behavioural Approaches
      As mentioned, over 20 years ago, a Canadian critique existed of
behavioural change-oriented approaches to health promotion. Since then,
numerous critical explorations of health promotion programs have raised
profound questions about the unintended effects of downstream approaches to
public health issues (Bunton, Nettleton, & Burrows, 1995; Nettleton &
Bunton, 1995).  In the breakfast program area, it has been suggested that
these programs foster material dependency and lead to stigmatization of
poor children and families.  It may well be that these programs perpetuate
inequalities rather than reduce them (Hay, 2000; McIntyre, Travers, &
Dayle, 1999).
      Downstream approaches warp the understanding policy makers, the
media, and the public have about the causes of disease in general and heart
disease in particular. While working on the social determinants of heart
disease reports, I made numerous presentations on the societal determinants
of heart disease.  In virtually every instance - regardless of the audience
being addressed - I was greeted with the perception that heart disease is
more common among stressed middle class individuals rather than low-income
people. Similarly, members of these audiences rarely identified risk
factors or conditions beyond the "holy trinity" of risks with the exception
of  "cholesterol" and "stress."
      These informal observations were verified by a study recently
published in the Canadian Journal of Public Health (Paisley, Midgett,
Brunetti, & Tomasik, 2001). A survey asked 601 residents of Hamilton
Ontario to identify "the major cause of heart disease."  Respondents were
then provided with six additional opportunities to identify "any other
cause of heart disease." In response to these open ended questions, only
one respondent of 601 identified poverty as a cause of heart disease -- out
of 4200 potential responses.
      What are low income residents of Hamilton, Ontario -- and elsewhere
-- to make of the greater incidence of cardiovascular disease among their
low income neighbours, friends, and relatives than that seen among their
more well-off neighbours? Research evidence indicates that the greater
incidence of cardiovascular disease should be attributed to their lower
income status that in most cases results from factors outside their
personal control.  But the ideology of lifestyle choices being responsible
for cardiovascular disease promulgated by heart health workers -- and
clearly internalized by Hamilton respondents -- lead them to blame
themselves for their higher incidence of disease and illness, subsequently
relieving government policy makers from taking responsibility for their
health threatening policies. In Canada, it has been noted that government
policies have reduced social assistance benefits, eliminated new social
housing, and transferred wealth from the poor to the wealthy through income
tax reduction for the well-off, among other policies.
      This process is especially insidious in light of the limited evidence
that these lifestyle choices -- especially physical inactivity and diet --
are major causes of heart and other disease.  Essentially, individuals and
communities encountering health difficulties as a result of governmental
policies are doubly damaged.  First, they experience health threatening
life situations, and second, they fall under the accusatory and blaming
gazes of health and other governmental authorities. Sadly, health workers
espousing lifestyle messages can become complicit in this process of "poor
bashing," a process of Ignoring facts and repeating stereotypes about
people who are poor (Swanson, 2001, p. 12.)
To summarize, lifestyle or behavioural approaches remove the social
determinants of cardiovascular and other diseases right off the public
debate agenda. The lack of pressure for governments to address these
fundamental determinants of health allows these health-threatening
conditions to remain or even worsen. This situation threatens the health of
all citizens. Second, low income people are made to feel that they are
responsible for their own poor health.  The impact of this perception --
also known as victim-blaming -- adds to the psychosocial difficulties these
people are experiencing. By masking the source of people's cardiovascular
and other health problems, and providing no means to effect these
determinants, these approaches, therefore, do nothing to enable people to
gain control over the determinants of their health -- the key component of
health promotion as outlined in the Ottawa Charter for Health Promotion.
Macdonald and Davies provide a compelling argument for commitment to the
principles, values, and definition of health promotion contained in the
Ottawa Charter for Health Promotion: Health promotion is the process of
enabling people to increase control over, and improve their health (World
Health Organization, 1986).  In their view:

"The key concepts in this definition are "process" and "control"; and
therefore effectiveness and quality assurance in health promotion must
focus on enabling and empowerment. If the activity under consideration is
not enabling and empowering it is not health promotion"(MacDonald & Davies,
1998, p.6).

Within this framework, lifestyle approaches to health do little enabling
and even less empowering of those most at risk for cardiovascular and other
diseases.  This is not health promotion.

Towards the Future
      It is beyond the scope of this Bulletin to document how this gap
between knowledge and action on health determinants has reached this point.
But it is difficult to ignore the role that health care and public health
authorities have played by not speaking up concerning these issues. Not
only have they not discussed the deterioration of the social determinants
of health, but they have been content to deliver the message that
"lifestyle choices" are primarily responsible for the health problems that
exist. Such analyses are not only palpably incorrect but serve in the end
to blame victims of oppressive economic and social policies for the health
problems that result from such policies. As I wrote elsewhere:

"Political pressures for federal, provincial, and local governments to
conform to these shifting ideological sands [neo-liberal and conservative
approaches to governance] blend well with the persistent bias of health
workers to stress individualistic, biomedical and lifestyle approaches to
health. The media also prefers easy-to-understand biomedical and lifestyle
headlines. The social determinants of health approach is lost among such
ideological imperatives" (Raphael, 2003a, p. 38.)

      Across Canada and elsewhere, citizens are working to address economic
and social conditions that influence the well-being of the population.
These citizens should be aware that the conditions they are concerned with
are also the primary determinants of health and the incidence of disease
and illness. Elected representatives, health care, and public health
officials profess a concern with the sustainability of health care systems,
and a burning desire to spare us from the burdens of illness and disease.
Yet elected representatives offer policies that threaten health, while
health care and public health officials barrage us with lifestyle messages
that have little to do with the key health issues of the day. It is time to
bell the cat (Raphael, 2004).

This Bulletin is drawn from the following works:

Raphael, D. (2001). Canadian policy statements on income and health: sound
and fury -- signifying nothing. Canadian Review of Social Policy, 48,
121-127.
Raphael, D. (2001). Inequality Is Bad For Our Hearts: Why Low Income And
Social Exclusion Are Major Causes Of Heart Disease In Canada. North York
Heart Health Network. Retrieved, from the World Wide Web:
Http://www.Loveyourheart.Org/Reports.Html
Raphael, D. (2002). Social Justice Is Good For Our Hearts: Why Societal
Factors -- Not Lifestyles -- Are Major Causes Of Heart Disease In Canada
and Elsewhere. Centre for Social Justice Foundation for Research and
Education (CSJ). Retrieved, from the World Wide Web:
http://www.socialjustice.org/pubs/justiceHearts.pdf
Raphael, D. (2003). Addressing the social determinants of health in Canada:
Bridging the gap between research findings and public policy. Policy
Options, 24(3), 35-40. March 2003 issue available at
http://www.irpp.org/po/index.htm.
Raphael, D. (2003). Barriers to addressing the determinants of health:
public health units and poverty in Ontario, Canada. Health Promotion
International, 18, 397-405.
Raphael, D. (2004). A prescription for poor health. In M. MacAdam (Ed.),
Lives in the Balance: ISARC's Community-Based Social Audits. Toronto:
Interfaith Social Assistance Reform Coalition.

Selected Quotations

There is a growing body of evidence that the determinants of health go
beyond individual genetic endowment, lifestyle behaviour, and the health
care system to the more pervasive forces in the physical, social and
economic environment... Health policy makers and analysts have emphasized
that these underlying determinants need to be addressed in order to prevent
heart disease and stroke.  They urge us to direct attention towards
modifying not only risk factors and risk behaviours but also such 'risk
conditions' as poverty, powerlessness and lack of social support.
- Heart and Stroke Foundation of Canada (2001). The Changing Face of Heart
Disease and Stroke in Canada 2000. Ottawa: HSF.

It is clear that promoting heart health in the community requires
consideration of a complex social, economic and cultural context which goes
much beyond the immediate issues of risk reduction.
 - Promoting Heart Health in Canada: A Focus on Health Inequalities, A.
Petrasovits. Ottawa: Health Canada, 1992.

Our results suggest that despite the presence of significant socioeconomic
differentials in health behaviours, these differences account for only
modest proportion of socioeconomic disparities in mortality. Thus, public
health policies and interventions that exclusively focus on individual risk
behaviours have limited potential for reducing socioeconomic disparities in
mortality (p. 1707).
-     Socioeconomic Factors, Health Behaviors, and Mortality, P.M. Lantz,
J.S. House, J.M. Lepkowski, D.R. Williams, R.P. Mero, & J.J. Chen, Journal
of the American Medical Association, 1998, 279, 1703-1708.

The failure of risk factors to explain differences in the risk of
cardiovascular disease among socioeconomic groups is a common finding even
in studies focussing on traditional measures of personal income, education,
and occupation. (pp.103-104)? More generally, our findings point to the
role of the broader social and economic forces that generate differences
among neighbourhoods in shaping the distribution of health outcomes. (p
.105)
- Neighbourhood of Residence and Incidence of Coronary Heart Disease, A.
Roux, S. Merkin, D. Arnett, et al.  New England Journal of Medicine, 2001,
345, 99-106.

These estimates of risk reduction may be compared with the much smaller
estimates of the effects of improvements in adult lifestyle... Our findings
add to the evidence that protection of fetal and infant growth is a key
area in strategies for the primary prevention of coronary heart disease
(p.953)
- Early Growth and Coronary Heart Disease in Later Life: Longitudinal
Study.  J.G. Eriksson, T. Forsen, J. Tuomilehto, C. Osmond, D.J. Barker.
British Medical Journal, 2001, 322, 949-953.

Health-related behaviours - such as smoking and diet - are strongly
influenced by the social environment in which people live.  People do not
have equal choices about how they live their lives. (p. 65)
- The Widening Gap: Health Inequalities and Policy in Britain. M. Shaw, D.
Dorling, D. Gordon, & G. Davey Smith.  Bristol UK: The Policy Press, 1999.

Given the disturbing increases in income inequality in the United States,
Great Britain, and other industrial countries, it is vital to consider the
impact of placing ever larger numbers of families with children into lower
SES groups.  In addition to placing children into conditions which are
detrimental to their immediate health status, there may well be a negative
behavioural and psychosocial health dividend to be reaped in the future (p.
817).
- Why Do Poor People Behave Poorly?  Variation in Adult Health Behaviours
and Psychosocial Characteristics by Stages of the Socioeconomic Life
Course, J.W. Lynch, G.A. Kaplan, & J.T. Salonen.  Social Science and
Medicine, 1997, 44, 809-819.


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Social Exclusion Are Major Causes Of Heart Disease In Canada. North York
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