Thursday, December 13, 2012

Should Public Health Campaigns Change Their Messages?

The following is an Op-Ed that appeared in several Canadian news outlets:

Exercise is good for you. Eat more fruits and vegetables. Stop smoking. Drink less alcohol. Such messages abound in public health campaigns, and are based on the assumption that at-risk individuals will ultimately change their behaviour and mitigate their risk by living healthier.

But according to a study just released by Statistics Canada, that is not the case.

In fact, the 12 years of longitudinal data from the Canadian National Population Health Survey among Canadians aged 50 or older shows that three in four smokers with respiratory disease do not quit smoking; most people with diabetes or heart disease will not become more physically active and virtually no one diagnosed with cancer, heart disease, diabetes or stroke will increase their intake of fruit and vegetables.

This does not bode well for public-health promotion campaigns that simply appeal to Canadians to give up unhealthy behaviours to reduce their future risk of disease.

If even those who are most likely to immediately benefit from changing their lifestyles fail to live healthier, what is to be expected of those for whom such recommendations merely promise better health somewhere in the distant future?

Or, if even already having the condition does not change behaviour, why would we expect mere fear of developing the condition to be enough of a motivator?

The solution cannot be more drastic or broader messaging. One would assume that people with chronic diseases are already being provided a fair dose of health education and messaging from their health providers, certainly more than could ever be offered to the general public through broader health-information campaigns.

As many experts in health promotion are well aware, knowledge and warnings are the least effective measures to change health behaviours.

This is why many call for health policies that ban or restrict access to tobacco, alcohol and unhealthy foods as well as punitive measures, including taxation and fines or higher health premiums for those who persist.

However, such measures fail to acknowledge the key drivers — why people adopt unhealthy behaviours in the first place — and why these behaviours are so difficult to change.

Most people make decisions about what they eat based on taste, cost and convenience rather than on health benefits or health risks.

Most people fail to exercise regularly because they either lack the time or simply do not enjoy being physically active.

In certain social circles, smoking and excessive alcohol consumption are an accepted part of cultural identity — a value that supersedes potential health risks. And, let us not forget that food, nicotine and alcohol can all be used as coping strategies for a life that has its everyday stressors and challenges.

It is therefore not surprising that forward-thinking public-health strategies (such as New Brunswick’s “Live Well — Be Well” strategy) focus considerable effort on promoting mental fitness and resilience rather than on simplistic messages around “healthy-active living.”

Research shows a higher degree of mental fitness not only increases a person’s ability to efficiently respond to life’s challenges, but also to effectively restore a state of balance, self-determination and positive change.

Resilience is strengthened by positive relationships, experiences and inner strengths such as values, skills and commitments. It is particularly fostered by addressing our needs for relatedness (a heightened sense of belonging in the workplace, schools, communities and homes), competency (building on existing individual strengths and capacity) and autonomy (self-determination of activities that will enhance health and wellbeing).

Obviously, these determinants of health behaviours are far more difficult to legislate than simply banning or taxing unhealthy foods or imposing punitive levies on tobacco or alcohol. Indeed, fostering a societal discourse on the role of culture and values -including how we deal with poverty and social inequities — as a contributor to our health and wellbeing may well be beyond the scope of current public-health initiatives.

AMS
Edmonton, Alberta

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5 Responses to “Should Public Health Campaigns Change Their Messages?”

  1. Dr. Robert Strang says:

    Dr. Sharma,

    I couldn’t agree more and would even go so far as to say that health promotion campaigns should only be a small part of the work of public health, if at all. Instead, public health should be working in partnership to ii) create enviroments and policies that support health and ii) bring attention to the social determinants of health and health inequities. An excellent, and short, reference for this is Frieden T. Framework for Public Health Action. AJPH. 2010;100:590–595

    This really means that PH needs to be working much more outside the health system with a broad range of partners and needs to find a way to, directly or indirectly, have a strong voice on government policy. This will take time and effort but in Nova Scotia Public Health has made a clear decision to move in that direction. For example, within the government’s focus on childhood obesity prevention we have moved the attention from children and weight to the creation of environments and policies that support increased opportunities for all Nova Scotians to be physically active and eat a healthier diet website – thrive.novascotia.ca

  2. Ginette Lenham says:

    Dear Dr Sharma,
    I can not thank you enough for articulating so beautifully thoughts and concerns that I have had for years. Building resilience has been one of the foundations of my counselling practice when it comes to weight issues. Until Public health programs start to acknowledge just how important resilience, self esteem , culture and coping skills are when managing behaviours around health I fear we will keep going around the same merry go round.

  3. Sasha Stiles MD says:

    Where do you see the concept of Resilience as a cornerstone of “Evidence Based” guidelines from the CDC, the AAP, Endocrine societies or AAFP? You Do not. Fruits and veggies, less screen time, less fast food, family solutions, 150-300 minutes a week of moderate intensity exercise etc ( we all know the drill) are the concepts we are to present to our patients. I recently took the new ABOM exam and did not see one question concerning the seat of obesity, a lack of resilience. The large provider groups that espouse evidence based care actually get very nervous if we talk about resilience rather than fruits and veggies. The providers that realize how critical this concept is will get accused by the rigid evidence based provider organizations as being not on message. This is tragic and stupid.

  4. Arya M. Sharma, MD says:

    Sasha – you make a good point with regard to the “tunnel vision” of the evidence. E.g. although any patient will tell you that lack of time is the number one barrier to regular exercise, I know of no study study showing that counselling patients on time management will increase their activity levels. There may be no “evidence” but common sense dictates that addressing time management skills would be a first step towards making time for exercise or anything else.

  5. RNegade (hopefulandfree) says:

    “…Indeed, fostering a societal discourse on the role of culture and values -including how we deal with poverty and social inequities — as a contributor to our health and wellbeing may well be beyond the scope of current public-health initiatives.”

    Sadly, the final statement in your post conveys a powerful perspective that few can fully understand, given our current dominant discourses. However, unless the scope of public-health studies expands—and adopts a far more critical stance—individuals will continue to carry the health burdens of social injustice and social domination. As social beings, humans do not need to increase efficiency and technical rationality (to improve time management skills, for instance, or to learn to adjust and adapt better, as individuals, to forces of social domination).

    We need to understand how to create social institutions and systems that foster mutual aid, compassion, social justice, and full recognition and respect for all—regardless of one’s abilities to function as efficient consumers and regardless of one’s capacity to produce effective commodities. We are more than market driven cogs in the machinery of capitalism. The goal of helping more individuals (the public) to cope better (to increase their resilience) while surviving the bottom-line machinery of the state might sound “effective” and (of course) “more efficient”, but it’s just another form of social domination that shifts ever more burdens and responsibilities onto the least among us.

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