One of the age-old problems for ‘public health’ has always been how to get people to adopt more healthy behaviour change. How can citizens be persuaded to vaccinate themselves, eat healthier food or avoid obvious harms such as smoking?
Of course the very concept of ‘public health’ has multiple meanings. A relatively uncontroversial starting definition is that public health is:
This definition contains the idea of collective efforts furthering the health of a population and that the improvement of health has both a moral aim and a social benefit. It also suggests that public health initiatives will inevitably be responding to health crises that are either chronic (e.g. coronary heart disease) or acute (e.g. avian flu). This crisis-led approach means that public health becomes very much issue-led. This then hints at two senses of the public: the idea of ‘the public as a social entity or target for an intervention’; and the public as ‘the mode of intervention, which requires some form of collective action’.
Taking either or both of these approaches means that public health is always ‘political’: governments commission and fund most public health functions and decisions about which harms, groups or practices to target, by which methods, are often a matter of political controversy. Governments and their agencies have an assortment of options available when attempting to reduce harm ranging from education and persuasion, through to coercion and enforcement. Modern public health is rarely (with a few notable exceptions) coercive and has normally sought to ‘educate’ or ‘persuade’ specific groups in order to influence behaviour.
Such persuasion is often based on the insights gained from scientific and expert knowledges and sometimes may be counterintuitive (e.g. the ‘back to sleep’ campaign). This raises questions about how public groups come to grips with scientific knowledges. There have been distinct phases over the last thirty years about the best ways to ‘educate’ or ‘persuade’.
Initially this raised the question of whether the ‘public’ really ‘understood’ scientific knowledge and can be traced back to Bodmer Report published by the UK’s Royal Society entitled the ‘Public Understanding of Science’. This stressed the economic, social, political and cultural benefits that an increase in citizens’ scientific literacy would bring to the nation. However, the report was heavily criticised for its implicit deficit model of citizens – where once there was a lack, ‘correct’ knowledge could be acquired by consuming science. This would then allow people to behave ‘correctly’ when making decisions and avoid making ‘bad’ choices.
The model of the ‘public’ as suffering from a ‘lack’ causing harmful behaviour underwent a shift during the BSE crisis. In 1996 the UK Government announced that there was a probable link between bovine spongiform encephalopathy (BSE) and human Creutzfeldt–Jakob disease (vCJD) and that human consumption of beef was the likely cause of vCJD. This followed years of Government and experts insisting that the consumption of British beef was safe (including a government minister feeding a beef-burger to his own daughter on live television) – something that many members of the public suspected was untrue. After this it began to be argued that rather than experts communicating ‘certainty’ about `objective facts’ there was a need for discussion involving openness, transparency and the uncertainties around scientific knowledge. The stress was now on how a ‘crisis of trust’ required a new era of dialogue between scientists, experts, policy makers and the public and the modality switched from ‘pubic understanding of’ to ‘public engagement with’ science.
A more recent approach to constitute a ‘healthy public’ has switched from ‘deficits’ or ‘engagement’ towards efforts to directly enact behavioural change. This shift is based on the ‘nudge theory’ of Richard Thaler and Cass Sunstein which argues positive reinforcements can be used to adapt behaviour by playing on ‘assets’ that people already value – assets may be existing beliefs, economic interest or simple convenience (e.g. putting fruit at eye level in self-service food outlets). The nudge concept is itself based on the somewhat contradictory idea of ‘libertarian paternalism’: people need help to live healthy lives (paternalism) but such help should be not meddlesome (libertarian). The focus is on designing social environments that make ‘good’ choices ‘easier’.
For example the recent ‘Catch it, Bin it, Kill it’ campaign during the ‘swine flu’ epidemic contained elements of ‘nudge’ as it did not seek to educate people about the dangers of viral infection in any meaningful way. It merely suggested behaviour change that most would already be entirely familiar with from the popular childhood rhyme ‘coughs and sneezes spread diseases’.
Another campaign that contained elements of ‘nudge’ was the UK’s Food Standards Agency (FSA) efforts to reduce foodborne infection from chickens. This was the ‘Don’t wash raw chicken’ initiative that started in 2014. Instead of producing educational messages, a simple communication was used to try and affect behaviour change around one activity – washing raw chicken in the domestic kitchen. While evidence is limited that ‘washing chicken’ is significantly responsible for increasing rates of infection, it is the type of activity that lends itself to modification through ‘nudge’ interventions. As the FSA website helpfully explains:
There is also a short, and somewhat condescending video, involving animated kitchen implements using ‘goofy’ voices to explain the dangers of washing a raw chicken in the kitchen. Even though there is some background explanation, the overall tone of the campaign is to ‘get people to act’ rather than educating away ‘bad’ behaviour.
‘What’s going on in your kitchen?’ (FSA 2014) Video for the ‘Don’t wash your raw chicken’ campaign
For ‘nudge theory’ the ‘public’, that needs governing in this libertarian paternalistic manner, carry out most of their everyday choices in a state of blissful unawareness. It speaks to a model of the public as benign automatons, who are mildly feckless but mostly desiring to be healthier but without exerting too much effort or experiencing any discomfort. It is therefore perfectly legitimate to ‘nudge’ them towards choices that lead to better health or to reduced harms.
This is not to say that ‘nudge’ efforts do not work, in fact despite the recent hype around their novelty, they have had a very long history of success commonly known as marketing. Supermarkets knew that putting sweets along check out aisles would increase sales long before anyone thought of putting fruit at eye level in school canteens. Some nudge efforts have undoubtedly been more creative and more effectively reached target groups for public health efforts than traditional interventions.
But criticism of nudge theory points out that ‘although persuasive, their argument rests on attacking a straw man’ as most contemporary public health uses techniques that go far beyond simple information giving. Public health already tries to mould how choices are presented and ‘unlike nudging all of these existing approaches are informed by theories… and identify the causal pathways along which they aim to operate’. At best, nudge theory is vague, has a very limited evidence base and, at worst, has the potential for doing harm. For example, the halo effect may lead to those who avoid washing their raw chickens imagining that this is the only risk of food poisoning they need to worry about.
Perhaps the reasons that nudge theory has become popular in policy circles is because it avoids unpalatable conclusions such as people regularly buying a commercial product that is so toxic that special measure are needed to prevent consequences that may be ‘fatal’. It attempts to delegate responsibility for safety from a few commercial spaces (e.g. food producers and supermarkets) to literately millions of domestic locations.
The move from attempts in the 1980s to improve ‘public understanding’ towards the ‘nudge theories’ of the 2010s could be seen as a move from naïve sociology towards naïve psychology. The ‘public understanding’ of science movement imagined that a simplistic injection of accredited expert knowledge would allow people to collectively make better decisions and this would benefit society as whole whereas ‘nudge theory’ claims to know how ‘people really think’ and can influence them to behave better through ‘choice architecture’. But it may be that both further contribute to peoples distrust and doubt about the government’s role in promoting better public health.
A more extended version of this article can be found in a forthcoming book ‘Pathological Lives: Disease, Space and Biopolitics’ due to be published in 2016 (Wiley/Royal Geographical Society Book Series: London, with co-authors Steve Hinchliffe, Nick Bingham and John Allen).