Excerpted from Raphael, D. (in press). Barriers to Addressing the Societal
Determinants of Health: Public Health Units and Poverty in Ontario, Canada,
Health Promotion International.
Also see: Ebrahim, S. and Davey Smith, G. (2001), "Exporting failure? Coronary
heart disease and stroke in developing nations", International Journal of
Epidemiology, Vol. 30 pp. 201-205.
Argument 2: The downstream behavioural approach remains dominant in Canada
despite limited evidence of its effectiveness and increasing evidence of the
importance of societal determinants of health.
There are three main issues related to downstream -- 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. The very
earliest critiques of downstream approaches to health promotion were focussed on
the issue of victim blaming. Over 20 years ago the following concerns were
outlined (Labonte and Penfold, 1981; Labonte, 1994):
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 actual evidence (Tesh, 1990; Eakin
et al., 1996; Lynch et al., 1997). The theme of victim blaming is returned to
later.
The second critique of downstream, behavioural change approaches 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. This was known since the early Whitehall
Studies (Marmot et al., 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 (Feldman et al., 1989; Lantz et al., 1998; Diez-Roux et al., 2000; Roux
et al., 2001). A recent summary of this work in the area of heart disease is
available (Raphael, 2002b). Nevertheless, heart health initiatives in Ontario
and elsewhere have come to reify what terms the "holy trinity" of risks: diet,
smoking and exercise (Nettleton, 1997). 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 Ontario, the "holy trinity" has been enthusiastically deified by
Ontario's public health units and their associated heart health networks.
Perusal of any and all of their web sites documents how heart health activities
conform closely to the Ministry-imposed mandate. 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).
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 the scope of the
present paper 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" (Ebrahim and Davey Smith,
2001)p. 202).
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). In Inequality is
Bad for Our Hearts: Why Low Income and Social Exclusion are Major Causes of
Heart Disease in Canada, it was concluded that, for at least four reasons, the
emphasis on explaining poor health as a function of unhealthy behaviours and
exhorting individuals -- especially those on low income -- to give up these
behaviours was likely to be ineffective.
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