Lifestyle drift is killing health promotion

In an earlier blog, I wrote about what health promotion is all about and what makes it distinct.  In a nutshell, health promotion is about key values (empowerment, control, choice) and approaches that enable individuals and communities to take greater control over the factors that influence their health.

Equating health promotion with trying to make populations healthier is broadly true, but how this is done is the key question.  Part of my frustration with the profession of health promotion is the obsession on individuals’ lifestyle – how they eat and exercise for instance – as though this is the answer to tackling complex problems like obesity, diabetes and hazardous alcohol consumption.  I reject this premise passionately on many levels, but mainly because it suggests that individuals live in a vacuum from social forces and that it assumes that human behaviour is simplistic and linear.  It largely assumes that
‘educating people’ (or in some cases telling people) about healthy ways of living is the answer to eradicating such perils like childhood obesity.  The social gradient of health shows that the poorer you are the younger you die and the more ill health you will have – so assuming that this body of epidemiological evidence is correct, the answer is not to address lifestyle, but to tackle poverty and everything associated with this (stigma, poor housing, marginalisation…etc) rather than addressing the issues that manifest as a result of poverty (drinking, smoking, poor diet).

Perhaps one a greater frustration for me is the issue of ‘lifestyle drift’ which I believe is killing progressive health promotion policy and practice.  In effect, ‘lifestyle drift’ is the design of policy that accepts that improving the health of individuals and communities is about tackling social determinants of health (education, housing, poverty, educational access) but only to revert back to addressing lifestyle issues, like smoking, drinking, exercise.  The policy has the right intention, but operationally it becomes difficult to execute…..but why?

Well, practically, lifestyle interventions are easier to devise than interventions that tackle ‘upstream’ issues like poverty and social disadvantage.  Next, political cycles don’t help.  For example, in order to demonstrate that things have improved as a result of a policy decision, it’s far easier to measure progress against the number of people accessing smoking cessation support than, let’s say, feel more included in society.  Moreover, in order to address social determinants it means that organisations working to address public health must work in partnership with others – something that can be difficult to do because of professional domains and territories.  Tackling poor housing, for instance, demands public health working alongside housing organisations, environmental health services, local residents, private landlords etc.

So, what’s the answer?  Well, it’s partly about highlighting the evidence about lifestyle interventions – yes, they can and, of course, do work but we need to think carefully about for whom they work for and for whom they further exclude.  Second, we need to embrace holism when we think about health.  Simply believing that education is the key is not the answer; we need to see the individual in the entire context in which they live.  Third, we need to do things that are difficult, not easy.  Tackling poverty, social exclusion and marginalisation are huge social problems that impact on people’s health.  If health promotion advocates, academics, policy-makers and practitioners shy away from this in favour of addressing smoking, drinking and exercise then lifestyle drift will kill health promotion.

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