Health Education Research, Vol. 17, No. 6, 704-705,
December 2002
© 2002 Oxford University Press
LETTER TO THE EDITOR |
Reply to the Behavior Change Consortium researchers: the real issue is health promotion
Nuffield Institute for Health, University of Leeds, Leeds LS2 9PL, UK
In this brief reply to those Behavior Change Consortium (BCC) researchers who have entered into this useful exchange I want to do two things. First, I want to acknowledge that in my original brief critique I was not able (because of limitations of space) to adequately explain why I believed certain studies had to some extent succeeded in addressing certain important economic and contextual issues in their interventions. Although I did cite five studies as ‘partial exceptions’ to my principal criticisms (Connelly, 2002
), my view remains that the BCC programme, as a whole, has both methodological problems and missed important opportunities. My second aim, here, is to elaborate on these missed opportunities.
Professor Williams, in an elegant reply, believes that there ‘is some value in my comments’, in particular that a wider perspective in designing interventions aimed at a population’s behaviors and health is a reasonable point (Williams, 2002). He argues that there is much worth in a therapeutic relationship based on mutual respect and on non-manipulative empowerment (through, for instance, Self-Determination Theory). I agree that practitioners in individual-level health promotion would do well to adopt such an approach (Connelly, 2001), but where we differ is in what each of us understands by a ‘multi-level’ approach to intervention. Let me expand on this. I do not see individuals as pawns to be determined by economic or social conditions, hence I acknowledge agency as a fundamental and potentially transformative source of social action (Bhaskar, 1986; Connelly, 2002). At the same time, I also see social, economic and cultural regulations, rules and institutions (‘structures’) such as gender, the family, locale, material wealth and resources, social class, and ethnic and sexual identity as being as important as agency in the life-course origin, maintenance and reproduction of behaviors (Connelly, 2001). My point is that in the conceptualization of what was ‘the problem’ in the BCC studies the reality of such ‘agency/structure’ relationships in the production and reproduction of behaviors was not adequately thought through. Again, a public health perspective on this would be to do more than acknowledge the socio-economic patterning of the ‘problem behaviors’, and design interventions which tackled both agency and structural factors in their determination. For example, even the right-of-center British journal The Economist reports that in the US ‘shops in poor neighborhoods stock less fresh food (and at higher prices) while fast-food joints proliferate. Poorer people also have fewer parks and play grounds in which to exercise’ (The Economist, 2002). In addition, in the US, food labeling is misleading; political regulation of the food industry is greatly hampered by the power of lobby; schools have fast-food firms as caterers and in return for providing such things as TVs have been allowed to install snack dispensers, sited especially in poorer schools (Nestle, 2002). Surely, the BCC could have funded some studies that emphasized and tackled such ‘agency/structure’ conditions?
The response of Glasgow et al. also acknowledges that a wider perspective on behavior change is legitimate (Glasgow et al., 2002). These authors, however, maintain that together the BCC has implemented a wide variety of theories, in a wide variety of contexts, and that issues of representativeness and generalizability will be adequately examined through use of the RE-AIM policy/programme analysis heuristic. My response is to restate that individual-level ‘cognitive constructs’ were, overwhelmingly, the principal targets for both measurement and intervention (as opposed to affective, social, material or cultural factors) and contra Glasgow et al., this does not constitute a multi-level approach. I continue to predict there will be a lack of ‘understanding’ even when ‘equivalent constructs’ are compared across studies. Qualitative person-level and group-level research which attempts to elaborate narratives of behavioral ‘success’ and ‘failure’ remain an urgent necessity to allow meaning to emerge from these studies.
In sum, although no doubt constrained by the original BCC funding specification, the resulting BCC studies have not adequately engaged with structural constraints to good health and well-being. As a public health professional who previously practiced medicine and psychiatry I too value practitioner engagement in individual or ‘family’ group therapeutic alliance which adopts the biopsychosocial attitude expressed by Engel and advocated by Geoffrey Williams (Williams, 2002). My final point is that in eschewing a more thoroughgoing examination of the generative mechanisms of unhealthy behaviors the BCC (with some partial exceptions) has not sufficiently implemented the humanistic insights which such an alliance allows.
References
Bhaskar, R. (1986) Scientific Realism and Human Emancipation. Verso, London.
Connelly, J. (2001) Critical realism and health promotion: effective practice needs an effective theory. Health Education Research, 16, 115–119.
Connelly, J. (2002) Commentary. The Behavior Change Consortium studies: missed opportunities—individual focus with an inadequate engagement with personhood and socio-economic realities. Health Education Research, 17, 691–695.
The Economist (2002), Come on in: How bad is American food? And whose fault is it? August 31, 35–36.
Glasgow, R. E., Dzewaltowski, D. A., Estabrooks, P. A., Klesges, L. M. and Bull, S. S. (2002) Response to Connelly. The issue is one of impact, not world view or preferred approach. Health Education Research, 17, 696–699.
Nestle, M. (2002) Food Politics. University of California Press, Berkeley.
Williams, G. C. (2002) Response to Connelly. First at the Gates of Fire: can there be any survivors? Health Education Research, 17, 700–703.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||