Health in all Policies? Rethinking Prevention
Englischsprachiges Editorial der Ausgabe #1/2022 der Deutschen Zeitschrift für Sportmedizin (DZSM). Die Autoren plädieren dafür, Prävention neu zu denken. Die Herausforderungen der COVID-19-Pandemie hätten verdeutlicht, dass erfolgreiche Vorbeugung Maßnahmen auf individueller Ebene erfordert, aber auch im unmittelbaren oder Meso-Kontext lokaler Gemeinschaften sowie auf der Ebene von Staaten oder sogar großen Regionen.
Three years ago, no-one would have imagined that a simple RNA-strand packed into a smart bioactive envelope would disrupt our public and private lives. The virus taught us that neither high-tech innovations nor high-end medicine alone suffice to ascertain well-being for all. Instead, almost all policies from economics to education were affected. What started as a term coined by the Finnish presidency of the EU in 2006 “Health in all policies” finally became a mandate. The Covid-19 prevention challenge showed us that successful prevention requires action at the individual level, the immediate or meso-context of local communities and the higher level of states or even large regions. The pandemic also revealed how individual decision making, communication, marketing, beliefs, behaviour of role models, dynamics of social media, dynamics of virus mutation, simple measures such as wearing FFP2 masks, social distancing, testing strategies and vaccination were all intertwined. Yet, each country and/ or within-country subgroups of populations followed differing individual and collective policies. The pandemic evolved as a life laboratory about prevention failures and successes involving the entire planet.
Now one being recently sick from Covid-19 or having prematurely lost loved ones would not subscribe to the saying „health is the highest asset“. Consequently, the term “prevention” sounds logical, maintaining a positive connotation. But the road to successful “prevention” remains as elusive as a simple solution to treatment of Covid-19. Scientists initially believed, once the vaccines became available in record-setting short development time, people would embrace the opportunity. Instead we observe dissent never imagined throughout our communities. The first lesson learned: if there is no universally agreed belief about the most appropriate individual decision regarding vaccination or even simply wearing FFP2 masks, how much more complicated does it become when talking about long-term lifestyle changes? Societies have to deal with an increasing number of agitated people who don‘t understand all the preventive measures against the transmission of the virus.
Humans have been fighting endless wars about the right religious beliefs – including within Christianity. We thought that, at least in Europe, we would be more enlightened by now and make our decisions based on reasoning. What we need to learn is that our brains are wired differently: we weigh information according to beliefs, sympathy, peers, role-models and other non-rational factors. No surprise that some arrive at such distrust towards science, medicine and government that they prefer to be better off not getting vaccinated being the best individual path towards long-term health.
Finally, the Covid-19-pandemia teaches us a further lesson: public infectious diseases and non-communicable lifestyle diseases are closely linked. Public, pandemic-related restrictions led to large scale changes in behaviour: on average physical activity decreased, well-being decreased, while psychosocial stress and body weight went up. But not in the entire population. Rather, again social determinants of health came into effect: those living with ample resources were less likely to be adversely affected than those living in cramped social housing. The Covid-19 pandemic highlighted the relevance of social and contextual determinants of health for prevention (11). Like a laser-beam spotlight the pandemic showed that we have not yet understood the process of effective health communication in our society. Health and healthy lifestyle are private and emotionally charged matters. Scientific arguments and facts carry different weight depending on one‘s point of view.
Decisions on Lifestyle are made by People themselves
The simple fact is that any behavioural changes or altered lifestyles occur at the individual level (13). No one can stop smoking for another person. The decision-making process to change behaviour or to alter one‘s lifestyle is also not purely knowledge-based, but emotional and goal-oriented (19, 24). This is well understood by those who apply individually targeted advertising and content placement from online-searches to social media algorithms. What we believe to be “free will” is more often subtly influenced by tailored algorithms and targeted advertising, making us longing for products or services that often adversely affecting our health in the long-term.
In this context, the environment and the people to whom people relate, in the family, at school, at work, as well as role models in public life, play an extremely important role (5, 14, 9). Therefore, when looking at human beings in a more realistic way, they will not always make the optimal decision for a healthy lifestyle. Behaviour change research has shown that most everyday decisions are made by an habitual autopilot, not requiring the scarce resource of thoughtful evaluation (19). Experimental economic research further shows that in many situations people behave differently than the theory of rational utility maximisation (23). Several theories acknowledge this myriad of non-rational influencers on habits. One of these favours „nudging“. For example, in a cafeteria, fruit and vegetables are placed at eye level to increase their consumption. And nudges as well as structuring the environment indeed show small effect sizes that may translate to relevant change at the population level (17, 22, 23).
A subclass of “nudging” are information nudges. The theory here is to offer more and tailored information to the target group so that the desired choice can be made. The pandemic teaches us that views may hugely differ across peer groups and individuals about what constitutes an “optimal” decision. When such nudging is used by the state, it is labelled „libertarian paternalism“ as the state is supporting “better” choices by many intervention options: default rules, use of social norms, disclosure of information, increase in ease and convenience, warnings and labelling, precommitment strategies (23). Change in lifestyle is unthinkable on a population level without an array of such nudges effectuated in “all policies”. For example, in urban mobility, active transport by cycling can be promoted positively by bike paths, secure bike parking, changing rooms for employees, offering of rentals, subsidies for purchases (18). While commercial advertising discloses their nudges, health promotion or prevention nudges by the state must be scientifically and rationally justified. They need to retain real free choices and “hidden agenda” or interests must be disclosed.