Improving public health is a crusade to persuade

    18 February 2016

    As January fades into the distance and new year’s resolutions fall by the wayside, many of us will have experienced first-hand the difficulties of behavioural change. Adapting your routine to incorporate exercise; walking past the biscuit tin in the kitchen; saying no to that second pint. Measures that seem so simple in theory when pronounced on 1 January seem impossible to achieve in practice. And if changing the behaviour of one individual is so difficult, how can doctors possibly hope to change the behaviour of an entire population?

    Ways to attempt this usually fall into one of two camps. There is direct intervention, where the state passes laws saying what we can and can’t do that affects our health and the health of those around us — the public smoking ban is a classic example. Or there is a softly-softly approach, where we are given information and persuaded to make our own decisions in response — such as the official guidelines on how much alcohol is safe to drink.

    But where and why the battle lines are drawn seems quite haphazard. There are many healthy changes we want the public to adopt, backed by strong scientific evidence, yet the approach is different each time. We legislate on seatbelts and smoking, yet for drinking we merely announce guidelines with no legislation on minimum pricing. The government is currently proposing a ‘sugar tax’ to reduce childhood obesity, yet childhood vaccinations — without doubt one of the most successful public health measures in medical history — are gently ‘offered’ to parents. And the approach taken has little apparent connection to the force of the science.

    One man who can explain this is Sir Liam Donaldson. When he was the UK’s chief medical officer, part of his role was to change health behaviour; the smoking ban was introduced on his watch. He says the differences in approach happen because health interventions get caught up in the politics of the day, with the public and the press protesting that the ‘nanny state’ is taking away the people’s pleasures. Governments, understandably, want to avoid this. This can explain why some measures are pushed softly while the ultimate big gun, legislation, is saved for the biggest and most worthwhile battles. Sir Liam also believes that one piece of legislation or one set of guidelines is not enough. In today’s world of multi-platform media and global influences, changing public behaviour to improve overall health requires a complex approach with many different strands woven together. So today’s policy makers need to think beyond the old alternatives of either published guidelines or new laws.

    For example, screening to detect the early stages of cervical cancer is a success. The uptake among eligible UK women is not total, but over the years a diverse series of measures have improved it. GP surgeries get incentives to invite patients in; women gets reminders to attend; posters in waiting rooms target those who are there for other reasons. This has achieved an uptake of around 80 per cent. Then from mid-2008 to mid-2009 an extra 500,000 women went for cervical screening. There had been no legislation, no new television advert and no new guidelines. This change in behaviour was entirely caused by the widely reported diagnosis, treatment and, sadly, the subsequent death of the reality TV star Jade Goody from cervical cancer. No public health body could have anticipated such an event or the response, but it reinforces the need to use of every possible channel of communication to get the health message across.

    For example, regular advice from the Department of Health about healthy eating habits is valuable, necessary and will have some impact. Backing that up by serving healthy school dinners strengthens the guidance. And when hospitals impose their own ‘sugar tax’ (as announced last month), the message will be turbo-charged because high-sugar food will intuitively be seen as having no place in a health-promoting environment like a hospital.

    Unfortunately, the converse is also true. I wonder how much of the positive health message of the 2012 London Olympics was negated by the sponsors being a fast-food chain and a soft-drinks company. The legacy of fitness and good health was surely tainted by an implicit endorsement of all that is wrong with the western diet.

    We can legislate and we can guide, but to achieve real change there needs to be much more. And with that approach the positive effects are likely to last a lot longer than the end of each January.