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Part One
Exploring the history, theory and politics of ‘behaviour change’
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ONE
The politics of behaviour change
Michael P. Kelly
Introduction
This introductory chapter considers the things that have shaped the ways in which behaviour change is discussed and described, starting with the point that this discussion about behaviour change is never very far away from political and ideological beliefs about how people ought to be. Behaviour change is usually about making people different from how they are now. With this in mind, the chapter begins with a consideration of the politics of behaviour change and particularly the way that governments and states, indeed the powerful throughout history, have sought to get people to behave in ways that they, the powerful, want them to behave.
The political imperative
Since the time of recorded history and probably for many millennia before that, violence was the primary means used to bend others to the will of the powerful – behaviour change by force (Pinker, 2011). Hunter-gatherer societies were violent and aggressive. More settled societies were also extremely dangerous until institutions of government began to evolve and what is called state formation began. Societies, rather than being anarchic places where rival warlords vied for power, became states in which one single authority emerged that was strong enough to make other warring factions subservient and around which the institutions of the state could gradually coalesce. The power struggles in Anglo-Saxon England and its conquest by the Normans are good examples of this (Blair, 1956).
As states got stronger, societies became generally less violent (Elias, 1978). In part this was because the state acquired by force a monopoly of violence. It used this force to extract taxes, work and dues of various kinds from its subject people. But with state formation, society gradually became more peaceful and civilised. The state eventually became the monopolist of violence not so much for its own ends, but for the ends of protecting its subjects from each other and allowing trade and commerce to develop. Of course, the state retained the ultimate right to do violence to its subjects and to other states, but, by the early 19th century, state violence in Western Europe against subjects as a means of getting them to do what the state wanted them to do was becoming less and less common.
Of course, that is not to suggest that all was peace and light; it was not. War was the hallmark of European societies throughout the Middle Ages, and the French Revolution at the end of the 18th century was bloody and violent. Outside of Western Europe, states were much slower to develop and to move in a peaceful direction. However, the general trend was away from violence as the first resort to make subject peoples do what the state wanted them to do. The Western European model spread sporadically thereafter, in spite of periodic reverses for example during the rise of Nazi Germany, the Soviet Union and, more recently, Islamic State.
In modern advanced societies, states use much more subtle forms of persuasion than brute force. They use an array of behaviour change techniques to motivate, cajole, suggest, convince or inform people that certain types of behaviour are desirable and others are undesirable. The modern armoury is vast, from explicit legal and other forms of regulation, to guides like the Highway Code describing appropriate road-user behaviour (much of it backed up by the force of law), to explicit norms of etiquette promoted by public bodies, like standing only on the right of the escalator on the London Underground system. Education, advertising, marketing and propaganda are also widely used (Marteau et al, 2015).
One of the focuses of this volume is on those techniques that are applied deliberately to change a particular behaviour. These have traditionally been thought of as the province of psychology, but this is increasingly contested ground, as the next chapter will explore in depth. These activities – or interventions – are delivered at a number of levels, ranging from local, one-to-one interactions with individuals to national campaigns. It is important to remind ourselves, as the preceding historical overview about the role of the state and its use of violence has sought to do, that anything that seeks to change the behaviour of others is political and is ultimately about power and authority. So, even the apparently neutral pursuits of psychology and sociology and marketing and advertising are political. Modern western states may no longer execute their citizens for infractions of religious beliefs, nor imprison them for non-conformity, but they still seek to control behaviour for political reasons, just as states always have done.
The political nature of public health
A good example through which to explore the intrinsically political nature of behaviour change is public health. In a nutshell, a huge burden of disease is the result of the way people live their lives: what they eat, what they drink, how much exercise they take and whether or not they smoke. All these are individual choices, but the consequences in terms of the burden to the taxpayer of what many see as self-inflicted disease are enormous. On a regular basis, politicians responsible for the health service make the ‘discovery’ that the solution to the epidemics of Type 2 diabetes, obesity, liver disease, cancers and heart disease is simple: get people to change their behaviour and all will be well.
On the face of it, this is not unreasonable. After all, the major epidemics of non-communicable disease do reside in the way we live our lives. Eating, being sedentary, drinking alcohol and smoking are all behaviours. If we add to this list the misuse of drugs and the spread of sexually transmitted infections, HIV, hepatitis, healthcare-acquired infections and even Ebola, in all of which human behaviour is implicated as a major contributory factor, changes in behaviour seem an obvious means of prevention. Not surprisingly, therefore, politicians and policymakers alight on behaviour change as a solution.
However, getting people to change their behaviour in sufficient numbers and on the scale required turns out to be difficult. Simply telling people that what they are doing is bad for them has had only limited success (Marteau et al, 2015). Health education, advertising and social marketing have made some difference, but have not turned the tide in any of these arenas except cigarette smoking – more of which later. Behaviour change techniques may be effective, but most only seem to work in the short run. The changes required to bring about reductions in the rates of disease on the scale needed to reverse contemporary epidemics has to be sustained over a prolonged period of time. That is tough.
Anti-smoking measures were successful because education and information were combined with bans on advertising, very heavy taxation, and eventually bans on smoking in public places along with very consistent and reinforced messaging over many years. This was a massive multi-level effort on the part of the state that deliberately curtailed people’s liberties to smoke, but it has saved many hundreds of thousands of lives.
Box 1.1: Stop and think: the state knows best
Are these actions against tobacco different from a state prosecuting its citizens for religious or political non-conformity? ‘Yes, of course they are’, you might say, because the argument can be made that saving your life and protecting your health are fundamentally beneficial to you. But of course states in mediaeval times proclaimed that getting you to confess to heresy or witchcraft was good for you because it would save your soul. This is different perhaps to smoking, but the assumption that the state knew best is common to both.
The success of measures against smoking has resulted in many commentators calling for more legislation, regulation and taxation. They point not only to the success of measures against smoking but also to seat-belt legislation and drink-drive laws as having been very effective. These measures certainly have been effective in reducing road traffic accidents and deaths. Should we legislate further to prevent the misuse of alcohol, for example? There is, after all, very good evidence that minimum unit pricing would be highly effective at protecting the heaviest drinkers from the harm they are doing themselves (NICE, 2010). Should we legislate to ban smoking in cars? Clearly legislation sometimes does have very direct effects on behaviour, but we should also remember cases where legislation clearly has not worked, as in measures to mitigate against the use of mobile phones while driving and to keep so-called dangerous dogs under control.
The issue of behaviour change is political because it is about personal freedom. Unlike our prehistoric and medieval European ancestors, we do not live in a world of continued expectation of violence to be enacted against us. That is not to say that even in western democracies there is not an undercurrent of threat of random violence or domestic violence and abuse. But it is to say that the possibility of the entire social infrastructure being overthrown violently is remote. We live, at least in the west, in a political world in which certain freedoms, including freedom from random violence from the state and from neighbours, can mostly be assumed.
Box 1.2: Stop and think: the politics of rights and freedom
In the modern world, what right does the state have to make us behave in ways it chooses? What right does it have to offer guidance on or regulation of our private lives? Whether we choose to smoke, to eat as much as we want, to sleep with whomsoever we choose, or to be lazy, are personal choices. In the modern world, we tend to balance these freedoms against our right to be protected from ourselves. Does the state have a duty to protect us from ourselves? Should the state be our ‘nanny’?
There is a balance between individual liberty and the common good or the public interest and it is the subject of fierce political debate. What often win the day are arguments about harm to others. John Stuart Mill originated the idea that we are free to harm ourselves and generally speaking the state will not interfere. But at the point at which our self-harming actions also harm others, the state does have a duty to step in and protect the other person (Nuffield Council on Bioethics, 2007). It was this argument that held sway on smoking in public places and drink driving. It was about protecting innocent parties from carcinogens they had not chosen to consume, and from drivers who were a danger to other road users and pedestrians.
However, as yet no such public consensus exists on matters relating to consumption of food. On alcohol the balance is more finely struck and it was interesting to note that the UK coalition government 2010–15 swithered between arguments about health (harm to self) and public order (harm to others), before eventually doing nothing on alcohol regulation (HM Government, 2012). Behaviour changes relating to overeating and alcohol misuse seem to be less easily managed by appeals to risks to others.
Politicians, having often started with ideas about behaviour change, not infrequently find themselves ensnared in arguments about personal freedom, the rights of individuals, the rights of the state and so on, frustrating whatever ambitions they may have to improve things. As the philosopher Macintyre put it, one person’s utility (gain or pleasure) is someone else’s disutility (loss or pain) (Macintyre, 1984). And with many competing values and beliefs in a modern pluralistic society, there are very few politically easy answers. Behaviour change is always political.
The discourse of risk
Finding solutions to public problems by using behaviour change is rooted in a modern understanding of risks and their prevention. The idea is that if there is a risk it can be averted. The belief that such a thing as a hazard-free environment could exist would have been way beyond the understanding of our forebears. Throughout human existence life has been full of travails. Disease, pestilence, famine, poverty and hazards from the natural environment, not to mention one’s fellow humans, have been the lot of the species. Even our Victorian ancestors who lived in a recognisable modern environment with railways, canals, mines,...
