Underlying Assumptions in Health Promotion Policymaking

Abstract

This chapter explores and revisits the assumptions that underlie policymaking in the field of health promotion. It starts by clarifying what is meant by the term ‘underlying assumptions’ in the field of health promotion and disease prevention. Subsequently, the central concepts of how public health may be improved will be recapitulated in terms of their underlying assumptions and contrasted with the recent shift towards behavioural principles as applied in health promotion. By examining what a comprehensive approach that reconciles structural and behavioural interventions could look like, the role of behavioural insights in health promotion will be clarified. The chapter ends with some final remarks on future challenges in health promotion policy.

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11© The Author(s) 2019
B. Ewert, K. Loer (eds.), Behavioural Policies for Health Promotion
and Disease Prevention, Palgrave Studies in Public Health Policy
Research, https://doi.org/10.1007/978-3-319-98316-5_2
CHAPTER 2
Underlying Assumptions inHealth
Promotion Policymaking
BenjaminEwert
Abstract This chapter explores and revisits the assumptions that underlie
policymaking in the eld of health promotion. It starts by clarifying what
is meant by the term ‘underlying assumptions’ in the eld of health pro-
motion and disease prevention. Subsequently, the central concepts of how
public health may be improved will be recapitulated in terms of their
underlying assumptions and contrasted with the recent shift towards
behavioural principles as applied in health promotion. By examining what
a comprehensive approach that reconciles structural and behavioural
interventions could look like, the role of behavioural insights in health
promotion will be claried. The chapter ends with some nal remarks on
future challenges in health promotion policy.
Keywords Health promotion • Social determinants of health •
Behavioural interventions • Health nudges • Policymaking
B. Ewert (*)
FernUniversität in Hagen, Hagen, Germany
e-mail: benjamin.ewert@fernuni-hagen.de
Behavioural Policies for Health Promotion and Disease Prevention, edited by Benjamin Ewert, and Kathrin Loer, Palgrave
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12
IntroductIon
According to the World Health Organization (WHO 2017), more than
650 million adults—that is, 13% of the world’s adult population—were
obese in 2016. Even more worryingly, a new generation of abnormally
oversized people are growing up, with over 41 million children aged 0–5
being overweight or obese. As is widely known, obesity is a major risk fac-
tor for non-communicable diseases (NCDs) such as cardiovascular dis-
eases, diabetes, and (some) cancers. Despite these rather shocking statistics,
the WHO ends its report with thesomewhat reassuring remark that ‘obe-
sity is preventable’ (ibid.). Hence, for health policymakers, how to prevent
global epidemics such as obesity is a crucial question. In this chapter, I
argue that the answers to this question are far from straightforward and
emanate from policymakers ‘assumptive worlds’ (Klein and Marmor
2012a, 2)—an imaginary set of ‘theories about the causes of the problems
(…) and about the appropriate solutions’ (ibid.) that policymakers draw
from when designing policies.
With respect to the challenge posed by obesity, the available health
policy options differ signicantly in terms of their underlying assumptions:
since overeating has an obvious behavioural component—individuals are
free to choose healthier foods and eat less—policymakers are inclined to
intervene on the individual level. However, instead of addressing ‘lifestyle-
focused health culprits’ (Quigley 2013, 620), policymakers could also
pursue societal interventions that focus on the causes of unhealthy behav-
iours. In this case, the problem is not assumed to be the individual who
consumes too much fatty or sugary food, but the social environments that
entice people to make unhealthy food choices. Irrespective of the level of
health policy interventions, the selection of policy instruments has an
assumptive component too: should bans, taxes or nudges be used to com-
bat obesity? In all cases, governments’ policy choices are inevitably norma-
tive, values-based and driven by ‘underlying political beliefs and values
(…) exerting a signicant inuence on public health and health promo-
tion policy’ (Baum and Fisher 2014, 217). Considered unemotionally, it
can be stated that health policy interventions are signicantly affected by a
policy-research-practice divide (Cairney and Oliver 2017).
This chapter explores and revisits the assumptions that underlie policy-
making in the eld of health promotion. It starts by clarifying what is
meant by the term ‘underlying assumptions’ in the eld of health promo-
tion and disease prevention. Subsequently, the central concepts of how
B. EWERT
Behavioural Policies for Health Promotion and Disease Prevention, edited by Benjamin Ewert, and Kathrin Loer, Palgrave
Macmillan UK, 2018. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/fuhagen-ebooks/detail.action?docID=5627362.
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Copyright © 2018. Palgrave Macmillan UK. All rights reserved.

13
public health may be improved will be recapitulated in terms of their
underlying assumptions and contrasted with the recent shift towards
behavioural principles as applied in health promotion. By examining what
a comprehensive approach that reconciles structural and behavioural
interventions could look like, the role of behavioural insights in health
promotion will be claried. The chapter ends with some nal remarks on
future challenges in health promotion policy.
underlyIng AssumptIons concernIngthe cAuses
ofdIseAse Andhow Best topromote heAlth
Public policymaking can be described as the art of nding new and timely
solutions for old problems. According to Peters and Zittoun (2016, 12)
‘[m]ost of the fundamental questions about public policy that we ask
today are those that have been asked for years and even decades’. How to
promote and maintain public health is certainly one of those questions,
and revolves around related issues such as Who is to be deemed responsible
when it comes to risk avoidance? and What is the role of government in health
promotion? As shown in this section, analysing the assumptions that under-
lie health promotion can provide answers to these recurring dilemmas.
However, two preliminary remarks ought to be made: First, there are
sound arguments that health creates an additional dimension to policy-
making. Carpenter (2012, 35) has shown that health politics are indeed
different to other policy elds, foremost due to its ‘equality and justice
claims’. Second, when we speak about underlying assumptions in health
promotion, we refer to two distinguishing features which are closely linked
to each other: rstly, the degree to which policymakers pursue behavioural
or structural interventions, that is, whether the relevant policies take place
at the individual level and/or the societal level. Basically, this distinction
could be applied for all health promotion policies.
Second, policymakers choose health promotion policies from a range of
available options, and pursuing one particular policy strategy always
involves rejecting an alternative option. With regard to both features, poli-
cymakers’ decisions emanate from conscious and often political- ideological
preferences for or against specic policies (Raphael 2011, 2014). These
preliminary decisions are labelled as underlying assumptions in this chap-
ter. Moreover, the policy preferences that dominate can seem largely
immune to scientic evidence regarding the real impact of multifaceted
UNDERLYING ASSUMPTIONS INHEALTH PROMOTION POLICYMAKING
Behavioural Policies for Health Promotion and Disease Prevention, edited by Benjamin Ewert, and Kathrin Loer, Palgrave
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14
health determinants (Baum and Fisher 2014) or, as recent behavioural
public policies demonstrate, are fed by selective rather than comprehen-
sive evidence (Strassheim and Korinek 2016). In practice, then, the under-
lying assumptions of health policymakers are largely shaped by ideological
beliefs on how to promote public health (and how not to). This being the
case, the next question is: on what normative basis do policymakers select
one approach to health promotion over another?
In this regard, Hagen Kühn’s (1993) explanatory model of a ‘norma-
tive aetiology’, developed for a study on ‘healthism’ (Crawford 1980) in
the UnitedStates, is a useful starting point for further analysis. The term
aetiology, borrowed from the eld of medicine, provides four major rea-
sons why people become ill: (1) pathogens and genetic conditions; (2)
individual unhealthy behaviours; (3) factors emerging from the physical
environment; and (4) social conditions and relations. The normative
dimension of the aetiology refers to different levels of social acceptance of
the various causes of disease and illness. As a basic rule, the probability
that public policy will respond to one of these four causes of disease
diminishes progressively as one moves further down the list outlined
above—from very high (1) to very low (4). Hence, Kühn’s compelling
argument is that ‘certain factors, causes and conditions seem to have a
much better chance of being addressed and researched than others’ (Kühn
1993, 130). For example, health risks caused by viral infections such as
bird u are much more likely to be addressed than those caused by
inequality of living conditions. Following the model, whether approaches
to health promotion ‘receive political consideration, gain social accep-
tance, or appear scientically respectable’ (Lemke 2013, 82) depends
much on political interests. Policymakers’ preferred assumptions, that is,
those that shape their mind- set and actions when designing health poli-
cies, are heavily inuenced by ‘power relations in society’ (ibid., 83).
What is more, Kühn’s normative aetiology corresponds well with the
dominant biomedical paradigm. The latter explains disease through rather
simple causes-and-effects relationships that ‘fail to consider the complexity
and interrelatedness of social systems’ (Spotswood 2016, 6). Accordingly,
there is a strong tendency to assume that pathogens and individual behav-
iours are the most important causes for diseases, while the impact of social
problems on health is underplayed (or even neglected). Thus, policy-
makers do not select and apply a specic health promotion concept on
the basis of its ‘internal consistency or scientic truth’ (Lemke 2013, 83),
but with regard to its overall compatibility with society’s dominant
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15
rationales and social norms. In this survival of the ttest contest, health
promotion policies that lead to the ‘[least] resistance or the biggest for-
bearance’ (Kühn 1993, 128) towards social conditions and power rela-
tions are the most likely to be selected.
Without explicitly referring to it, contemporary critical health policy
analysts conrm the essence of Kühn’s normative aetiology. For example,
Raphael (2011) identies—mainly in the Canadian context—seven dis-
courses on the social determinants of health (such as income, education,
employment or housing) and ranked these on the basis of their implica-
tions for political action. Carter (2015, 380) concludes from a US case
study on a local health promotion initiative that ‘addressing underlying
‘social determinants’ of health is a political non-starter’. Consequently,
policymakers’ strong tendency ‘to base their health-promotion policies on
behaviourism’ (Baum and Fisher 2014, 217) provides fertile ground for
new forms of behavioural health promotion such as nudging (see section
‘Nudge-Based Health Promotion: Game Changer or More of the Same?’).
To sum up, the underlying assumptions concerning the causes of dis-
eases and how to promote health vary widely. As a result, policymaker’s
selection—or deliberate neglect—of specic health promotion strategies is
often ideologically motivated. Above all, ‘a strong commitment to neolib-
eralism’ (ibid., 220) has led to recent behavioural policies in health pro-
motion and has tended to restrict the degree of social change. In the next
section, health promotion’s ‘built-in tension that sometimes degenerates
into a full-blown “paradigm war”’ (Van Den Broucke 2014, 597) will be
revisited with regard to its policy implications.
comprehensIve concepts, unBAlAnced polIcIes:
themIsmAtch Betweentheory AndprActIce
InheAlth promotIon
In the face of the ideological ‘chasm’ (Baum and Fisher 2014, 214)
between advocates of different health promotion concepts, it is worth
remembering that health promotion, or at least its recent history, has been
based on a common conviction: ‘Health is made outside the health care
sector’ (de Leeuw and Clavier 2011, ii237). Admittedly, even by the end
of the nineteenth century, major public health achievements such as clean
drinking water, sanitation facilities and workplace safety (Eyler and
Brownson 2016) had been achieved through a broad suite of public
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16
policies not limited to health policy as such. After the Second World War,
as national welfare systems were established and the ‘healthcare state’
came into being (Moran 1999), health maintenance became a profession-
alised and sectoralised affair. This meant that health policy was, in the
main, limited to ensuring citizens’ access to medical care in the case of
illness, following a rationale of cure rather than prevention. Against this
backdrop, new perspectives on health such as the Lalonde Report (1974)
and Nancy Milio’s (1981) famous book Promoting Health through Public
Policy were ground-breaking. These pioneers of comprehensive health
promotion concepts changed the underlying assumptions of health poli-
cies by putting ‘health in the driving seat of social change’ (Klein and
Marmor 2012b, 506).
A New perspective on the Health of Canadians, a report commissioned
by the then Canadian federal health (and former nance) minister Marc
Lalonde (for detailed information on the making of the report, see McKay
2000), inspired other blueprints for health policymaking beyond the
healthcare sector. Proposing an innovative health-eld concept that con-
sists of four health-affecting elements—human biology, environment, life-
style and healthcare organisation—Lalonde’s report provided ‘a sort of
map of the health territory’ (Lalonde 1974, 31). Milio built on Lalonde’s
change of perspective concerning the nature of health by systematising the
conditions for a more comprehensive approach, which was later labelled
‘healthy public policy’ (de Leeuw and Clavier 2011). Making the argu-
ment for cross-sectorial cooperation (in today’s terms Health-in-all-
policies approaches), Milio focused more specically on the structural
dimensions of promoting public health than Lalonde’s conceptual ideas
on the interplay between health determinants, and ‘expounded a strategy
rather than a program’ (Klein and Marmor 2012b, 505). In retrospect, we
can say that the Lalonde Report and Milio’s book triggered a process that
led to lasting changes in the underlying assumptions surrounding health.
Both authors set the scene for a more holistic perspective on health (rather
than healthcare), which culminated a few years later in the declaration of
the Ottawa Charter (WHO 1986). The latter dened health promotion
explicitly as a comprehensive social and political ‘process of enabling peo-
ple to increase control over, and improve their health (Nutbeam 1998,
351). Ideally, this vision is realised through a ‘healthy public policy’ (de
Leeuw and Clavier 2011) based on ‘enabling, mediating and advocating’,
as Kökény (2011) reminded us on the occasion of the 25th anniversary of
the charter.
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17
Problematically, at the level of policy implementation, policymakers
have turned health promoters’ carefully formulated both-and assumptions
on health determinants and how to inuence them into either-or deci-
sions. In practice, policymakers have cherry-picked single recommenda-
tions (usually involving lifestyle aspects) while neglecting the overall thrust
of health promotion concepts. Thus, in line with the normative aetiology
outlined previously, health promotion policies that involve action at the
level of individual behaviour have vastly outnumbered those that seek to
change the structures and contexts within which individual health behav-
iour occurs (Baum 2015, 519–20). Moreover, as ‘[h]ealth translates into
a product that can be bought on the market’ (Kickbusch 2007, 152), new
inroads for behavioural health promotion have emerged that turn healthy
lifestyles into choices to be taken by health consumers.
On the other hand, mounting evidence concerning the impact of the
social determinants of health (SDH) on health equity (Marmot 2005) has
led to the foundation of a standing working unit on SDH by the WHO in
2008. So far, however, the imbalance in health promotion strategies pur-
sued through public policy varies by country and over time. Almost
instinctively, health policymakers’ have chosen to tackle bad lifestyles (i.e.
eating an unhealthy diet, taking insufcient exercise, excessive drinking
and smoking) rather than bad social conditions (i.e. poor housing, unem-
ployment, inequality) as the starting point for policy interventions. Even
cherished community-based approaches, such as the former Finnish North
Karelia Program to prevent coronary heart diseases and its successors
(Puska 2008), are usually based on ‘behavioural change theories’ (Baum
2015, 509). Despite applying a comprehensive view of people’s needs and
fostering close cooperation with local stakeholders (including, in some
cases, the food industry, supermarkets and the media), those programmes
have to be carefully distinguished from broad health policies that, at least
in theory, could question ‘the power and inuence of societal sectors to
shape public policy’ (Raphael 2014, 383).
It is only recently that the public health community (i.e. its academic
and front-line pioneers) has started to analyse the reasons why the disci-
pline ‘has failed to enable, mediate and advocate for policy and political
change’ (de Leeuw and Clavier 2011, ii243). Explanations for this collec-
tive shortcoming include the rather naïve belief that scientic evidence on
the SDH inevitably translates into policy (Baum and Fisher 2014), but
also health promoters’ ‘neglect of politics, power and ideology’ (Raphael
UNDERLYING ASSUMPTIONS INHEALTH PROMOTION POLICYMAKING
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18
2014, 381) and/or their reluctance to engage in the tedious political
arguments around policymaking in health promotion (ibid.). Against this
backdrop, new policies in behavioural health promotion, most notably
based on nudges, have become increasingly prominent. The subsequent
section will turn to the question of how this ‘behavioural turn’ (Crawshaw
2013) may once again alter the underlying assumptions in policymaking
for health promotion.
nudge-BAsed heAlth promotIon: gAme chAnger or
more ofthesAme?
In the face of a steep rise in the incidence of NCDs, the need for life-
style changes can hardly be denied. Despite the tremendous impact of
health- endangering environments such as food deserts on individual
health behaviour, it is still individuals’ co-responsibility to alter their
own eating and exercise habits in order to improve their health. Due to
its direct impact on individuals’ health, which unlike the impact of
social determinants is not abstract and can be experienced directly,
‘behaviour does remain a critical determinant of health’ (Van Den
Broucke 2014, 597). At this point, behavioural public policies, mainly
equated with the popular concept of ‘nudges’ (Thaler and Sunstein
2008; see also Chap. 3 of this volume), have raised hopes of new ways
to improve public health. Essentially, nudging is both an old and a new
strategy in health promotion: on the one hand, it builds on risk percep-
tion research and risk communication (Rudisill 2012), behavioural eco-
nomics (Kahneman 2011) and social marketing (Crawshaw 2013),
which have been components of health promotion policies for a long
time. On the other hand, nudging is clearly new, in that it makes sys-
tematic use of evidence-based insights on human behaviour, which is
evaluated through randomised control trials (John 2017). The latter
provides choice architects in public policymaking with ‘politico- epistemic
authority’ (Strassheim and Korinek 2016, 121). Applying this authority
allows health nudgers, it is argued, to bypass the longstanding ideologi-
cal cleavage between behavioural-focused and SDH-related policy
approaches. In fact, at rst glance ‘nudging health’ (Cohen etal. 2016)
appears to be a reasonable middle ground that claims to innovatively
address both the behavioural and socio-environmental dimensions of
health promotion.
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19
Based on the assumption that ‘our choices are constantly at the behest
of a myriad of inuences’ (Quigley 2013, 601), nudging systematically
utilises these inuences by reshaping the interplay between the environ-
ment and individual behaviour. Society’s ‘overall health picture’ (ibid.,
605), it is assumed, consists of countless health-affecting choice architec-
tures such as the design of the built environment, how food is presented
in shops or the availability of walking paths. Because, as is repeatedly
stressed by Sunstein (e.g. 2014), choice architectures are inevitable and
exist ‘[p]rior to any new policy’ (Quigley 2013, 603), redesigning them is
a key form of leverage in health promotion. Nudges take a wide range of
forms, and relate to issues such as people’s walking routines, smoking,
drinking, eating and food-buying habits and the enhancement of public
safety (OECD 2017). However, do the underlying assumptions of nudge
policies differ from those of previous health promotion policies? And are
they able to bridge the ideologically charged division lines that separate
the various political camps in health promotion?
An evaluation of health nudges against the dimensions of policymakers’
underlying assumptions concerning health promotion, as described above,
produces a mixed picture. Firstly, by seeking behavioural change—the key
rationale for health nudges—these policies are unambiguously ‘based on
an individual-level, psychological paradigm’ (Spotswood and Marsh 2016,
284). However, in order to achieve healthier behaviours, choice architects
reshape the contexts in which people are making their lifestyle choices.
Hence, encouraging the use of stairs over elevators is a common health
nudge that seeks to ‘deconvenience people’s life’ (Carter 2015, 379).
Signicantly, nudgers assume that individual health represents people’s
major interest (White 2016) and therefore justies behavioural interven-
tion, whereas other human interests such as leisure and comfort are sus-
pected of routinely undermining health’s supremacy.
With regard to the second feature—the assumed causes of disease
and, emanating from them, policymakers’ prioritisation of health pro-
motion policies—it is easier to classify nudging. Unequivocally, behav-
ioural change policies focus exclusively on lifestyle risks and personal
responsibility for presumably irrational behaviours on the part of indi-
viduals. Moreover, as Kelly (2016, 11) notes, those policies are ‘never
very far away from political and ideological beliefs about how people
ought to be’. In this sense, nudge tactics correlate with the assumption
that healthy lifestyles—strictly understood as being slim, active and
UNDERLYING ASSUMPTIONS INHEALTH PROMOTION POLICYMAKING
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20
drug-free—represent a universal ideal that is applicable to everyone and
that can be achieved through ‘prefabricated choice environments’
(Leggett 2014, 13). Classied according to Kühn’s normative aetiology,
current nudge-based polices are very likely to be selected by health poli-
cymakers because they do not fundamentally seek to challenge environ-
mental factors, social conditions or power relations, but concentrate
‘narrowly on the choices made by individuals’ (Owens and Cribb 2013,
268). Thus, far from being a game changer, today’s light-touch, low-
cost health nudges, t almost seamlessly into the existing portfolio of
health promotion policies ‘where lifestyle health interventionism is
already well established as the norm’ (Burgess 2012, 16).
Moreover, like any other policy, nudging must be assessed within the
spirit of the time and the political context in which it is applied. Steering
people gently towards healthier choices is not an apolitical or neutral prac-
tice, even if it may appear to be. It is no coincidence that the mushroom-
ing of nudge units across the globe is occurring in a social-political climate
marked ‘by citizen disillusionment with “politics as usual” and austerity’
(Farrell 2017). Viewed in this way, behavioural policymaking in health
promotion would seem to be a pragmatic ‘way of dealing with the prob-
lematic consequences of neoliberalism’ (Jones et al. 2013, 164) which
have led to ‘new social risks’ (Bonoli 2005) such as precarious living con-
ditions and scaled-back social security systems. For citizens, the underly-
ing message that emanates from policymakers’ appetite for health nudges
sounds rather familiar: there is no alternative to behavioural change. These
policies appear to be indispensable if lifestyle-driven diseases, which are
associated with substantial costs, are to be avoided on a large scale. Framed
in this manner, it is unsurprising that nudge tactics do not represent a
greater challenge to what Raphael (2014) refers to as ‘the raw politics
behind opposition to healthy public policy’, that is, the power of political
forces and corporate actors that prevent societal and systemic change.
However, while recent behavioural policies are more likely to conrm
rather than challenge the dominant assumptions in health policymaking,
this does not mean that behavioural insights cannot be used to improve
future health promotion policies. As Hallsworth et al. (2016, 12) note:
‘[I]t is clear that the full potential of a behavioral insights approach is yet
to be realised – particularly in health’. For example, integrated policies
that innovatively combine individual and societal interventions could ben-
et from behavioural insights. I will turn to this possibility in the next
section.
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21
Beyond nudgIng: Is there Arole forBehAvIourAl
InsIghts InheAlth promotIon?
It should be clear by now that policymaking in health promotion has an
‘obvious normative component’ (Klein and Marmor 2012a, 2). Health
policymakers draw from a limited reservoir of assumptions of what causes
health and illness. Accordingly, health challenges such as NCDs seem
almost exclusively to result from errant individuals ‘struggling with their
habits and willpower and self-regulation’ (Spotswood and Marsh 2016,
284). It does not require a great deal of analytical acumen to realise that
such a policy narrative is inadequate and simplistic, particularly in the face
of wicked problems such as obesity. Given the wealth of studies that have
revealed the complex interrelations between social determinants and peo-
ple’s eating behaviours (e.g. Bryant etal. 2015) and the ambitious con-
cepts designed to address this nexus (Clavier and de Leeuw 2013),
behavioural change theories appear ideologically motivated (Medvedyuk
etal. 2017). On the contrary, it is argued, in order to be effective, health
promotion policies require exactly the opposite: maximum independence
and impartiality in relation to the choice of policy approaches and instru-
ments (Van Den Broucke 2014). If they are understood as one (but not
necessarily the primary) feature within a comprehensive and integrated
approach, behavioural insights could well contribute to the overall success
of health promotion policies. According to its recentreports, this view is
increasingly shared by the UK Behavioural Insights Team (BIT)
(Hallsworth etal. 2016; Halpern 2016).
A rst step in this direction would be to widen the knowledge base that
policymakers are drawing from when designing health promotion schemes.
Such an ‘expansion in the nature of evidence’ (Spotswood and Marsh
2016, 290) is fundamental for concepts that seek to combine structural
and individual measures of health promotion. Quantied insights into
human behaviour, as produced by randomised controlled trials (RCTs),
disguise the unquantiable and contextual dimensions of unhealthy behav-
iours. Taking obesity as an example, these contextual dimensions concern
the social settings, structures and interdependencies that obese people are
conned to in their daily-lives. Evidence from RCTs, e.g. on the impact of
smarter lunchrooms (Wansink 2016), is of little value if lunchroom visitors
(e.g. students or employees) are simultaneously living in food deserts which
reinforce rather than reduce poor dietary habits. Instead, obesity preven-
tion requires a precise idea of the specic avour of local settings, for
UNDERLYING ASSUMPTIONS INHEALTH PROMOTION POLICYMAKING
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22
example, on the particularities of food supply inlocal neighbourhoods and
people’s patterns of consumption. This information, which is localised by
denition, can only be gathered through qualitative research (Spotswood
and Marsh 2016) such as interviews and focus groups. In short, policy-
makers’ assumptive worlds have to be nourished by a thick, real-world
understanding of people’s habits and lifestyles. As such, embedded social
beings rather than anonymous study participants are the appropriate refer-
ence points for policymaking.
Secondly, the application of behavioural interventions in health policy-
making must be reconceptualised. The crucial question is where (in which
cases?) and when (within the policy process) policymakers should make
use of behavioural insights. Reduced to its essence, behavioural policies
are understood as ‘interventions with a more realistic, and proven, under-
standing of human behaviour’ (OECD 2017, 48). However, probably
due to the discourse on bad lifestyles and individual responsibility for
maintaining health, behavioural policies are too often equated with errant
citizens who are prone to correction through nudging. However,
Hallsworth et al. (2016, 12) claim that, in reality, ‘behavioral insights
should be seen as an approach to policymaking as a whole’ which is appli-
cable to every group of actors and at every stage of the health policy cycle
(OECD 2017, 53). What is needed is a shift from nudging individual
health at the level of policy implementation to the application of behav-
ioural insights in the design of health promotion policies. With regard to
‘healthy public policies’ (de Leeuw and Clavier 2011), as-yet unnished
business such as cross-sectorial coordination and interprofessional coop-
eration could be re-examined through behavioural lenses. For example,
administrative transparency and pro-cooperative behaviours, such as
mutual exchange and shared decisions among stakeholders, could guide
‘departments in applying cross-government agendas’ (OECD 2017, 50).
In this sense, a pivotal behavioural insight to be researched and utilised in
policymaking concerns the determinants of stakeholders’ behaviours
which facilitate or impede collaboration in health promotion.
Thirdly, behavioural policies could be combined with participatory
approaches to health promotion (John etal. 2009). Putting this sugges-
tion into practice would elegantly circumvent a key criticism of behav-
ioural policies—that is, elitism, which provokes the question who nudges
the nudgers? Moreover, if Sunstein etal. (2017, 1–2) are right when they
say that ‘citizens generally approve of health and safety nudges’ but ‘do
not approve of nudges that are perceived as having an illicit goal’, a logical
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23
step would be to enhance the overall legitimacy of health nudges through
deliberative procedures. Citizen juries, established to co-design health
promotion strategies by applying local knowledge and experience, may
opt to use health nudges as a component within a wider approach to
health promotion. Citizen-approved nudges, for example, those that
enhance neighbourhood walkability or access to nutritious food, would
‘dispel any suspicion of manipulation or “tricking” citizens’ (OECD 2017,
55) and may lead to better policy results. If deliberatively designed, health
nudges are not restricted to the normative expectations of policymakers
on howsupposedly ordinary people should behave. On the contrary, they
are examples of ‘self-initiated efforts to improve [people’s] decision-
making’ (White 2016, 31) in health-related situations.
To sum up, health promotion policies ought to be enhanced with plu-
ralistic evidence, which includes but is not limited to behavioural insights,
regarding what works in different settings. The as-yet untapped potential
of behavioural insights includes the ‘early design of policies’ (OECD
2017, 53), that is, the setting up of a wide-ranging agenda for health pro-
motion. In addition, health nudges, if approved and co-designed by citi-
zens, could be a valuable component rather than a substitute for
setting-based approaches to health promotion.
some fInAl remArks
There is little doubt that behavioural insights can ‘offer new solutions to
policy problems’ (Hallsworth etal. 2016). If interpreted broadly, behav-
iourally informed policies could shake up and revitalise locked patterns in
health promotion. However, to return to the global obesity crisis described
at the beginning of the chapter, which underlying assumptions future pol-
icy interventions should be based on remains a point for debate. Is it wise
to put all our faith in behavioural insights in the face of a large-scale epi-
demic such as obesity? In this respect, the results of Victoria’s Citizens’
Jury on Obesity1 are extremely thought-provoking: established to propose
asks (i.e. policy solutions) regarding how to combat obesity in this state in
south-eastern Australia, the jury strongly emphasised the need for
regulatory government interventions (Farrell 2017). According to the
1 The around 100-member jury of ‘everyday Victorians’ was an initiative of VicHealth with
support by newDemocracy Foundation. The jury run over a period of six weeks (Halpern
2016, 48).
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24
jury, obesity prevention requires, above all, a ban on junk food and the
marketing of soft drinks to children, a 20% on sugar-sweetened beverages
and mandated discounts on healthy food for people living on lower
incomes (VicHealth 2015). Remarkably, in the jury’s nal report, the
term behaviour occurs just three times—in relation to increased govern-
ment funding for skills-based learning programmes as well as improved
access to health counselling for obese people (ibid.). Despite—or perhaps
precisely because of—the constant political focus on individual lifestyles,
the residents of Victoria seem to take an unbiased view of the range of
policy actions that could be taken to promote public health. Signicantly,
they clearly prioritise structural changes within the social environments
that shape health behaviours. Accordingly, subsidising citizens to buy
healthier food is assumed to be a more effective approach than nudging
them to eat healthily. If a citizen’s jury initiated by an agency that is col-
laborating closely with BITs (Halpern 2016) attaches so little importance
to behavioural policies, what does this tell us?
Despite people’s general sympathy with health nudges (Sunstein etal.
2017) there seem to be concerns about whether the approach is always the
most appropriate, especially if up-stream policies that regulate the health-
affecting actions of corporate actors are insufciently addressed by gov-
ernments. With regard to complex issues such as obesity, regulative policies
are necessary in order to protect people and enable them to maintain a
balanced diet. In this respect, future lessons could be learned from tobacco
prevention policies. In that area, it is considered proven that a combina-
tion of tax and price policies (Chaloupka etal. 2011) and the strict regula-
tion of advertisement has successfully reduced tobacco use, accompanied
by education, communication and public awareness strategies. A similar
policy mix is required to tackle obesity. A rst step would be, for example,
the adoption of a uniform food trafc light and intelligent calorie-labelling
system.2 Labelling food in a way that shows its effects on health combines
regulatory intervention (rating food using trafc light colours) with
behavioural insights (people’s choices are inuenced by sub-conscious
cues such as colours). Hence, a food trafc light system would represent a
classic nudge, though one that would require state regulation to put in
place. So far, within the European Union, massive resistance from food
industry lobbyists has prevented any such regulation (Dionigi 2017,
2 Accordingly, very fat or salty foods are labelled with a red trafc light, while healthy food
such as fruit and vegetables are labelled with a green trafc light.
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25
84–6). However, the current burden of NCDs is simply too heavy to rely
one-sidedly on behavioural health policies as substitutes for more funda-
mental societal interventions. Finally, it is worth pondering which policy
solutions might have been recommended by health promotion pioneers
such as Lalonde and Milio. If we may be so bold, it is hard to believe that
they would be jumping on the bandwagon and arguing that nudging
behavioural change is a silver bullet in the ght against lifestyle diseases.
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