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7311MED Social Determinants of Health
Creating Healthy Individuals
Bernadette Sebar
2018
Key questions for the next three weeks
• What is/are the most effective way/ways to address health priorities?
• Creating healthy individuals (Week 9)
• Creating Healthy Settings (Week 10)
• Creating Healthy Public Policy (Week 11)
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Where should the emphasis lie?
• There are two major strategy dichotomies:1. Should be we be aiming for socio-
environmental change? Or Should we focus on changing individual behaviours? And
2. Should we be addressing high risk individuals? Or should we be targeting whole populations?
Socio-environmental strategies vs. individual (1)
• Socio-environmental interpretation states that illness among disadvantaged groups is due to their social and economic disadvantage
• Strategies address the causes of the disadvantage, for example, poverty, lack of education and unemployment. That is, systems approaches (also known as ecological approaches)
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Socio-environmental strategies vs. individual (2)
• Individual interpretations state that responsibility for health lies with the individual. Health compromising behaviours such as smoking, poor diets etc. are the result of a lack of education, lack of skills or a poor attitude
• Strategies include individual behaviour change
Where should our efforts lie?
• This course looks at both levels and argues that “appropriate changes in the social environment will produce changes in the individuals, and that the support of individuals in the population is essential for implementing environmental changes” (Egger, Spark and Donovan 2013: 23)
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Second dilemma: high risk vs. low risk strategies
• Key question: should we be dealing with sick individuals or sick populations?
• The ‘prevention paradox’ states that “a large number of people at a small risk may give rise to more cases of disease than a small number who are at high risk” (Rose, 1992 in Egger, Spark and Donovan 2013: 23)
• The high risk approach seeks to protect susceptible individuals
• The population-level approach seeks to control the broader determinants and shift the distribution of exposure to a risk factor/s. The populations can be global (e.g. tobacco, HIV/AIDS), national (e.g. skin cancer) or within specific populations such as First Nation Peoples.
What should we focus on?
• Both. Strategies include:
– Prevention in populations: changing the lifestyle and environment that cause disease in populations
– Primary prevention: preventing the development of the causes of disease in low-risk populations
– Secondary prevention: identifying and helping individuals at high risk and preventing progression of disease
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This week…
• Behaviour change
– Theories
• Social marketing
• Strengths and weaknesses
• Social marketing and change
Framework for health promotion action
Downstream Upstream
Disease Prevention
Communication Strategies
Health Education and Empowerment
Community and Health Development
Infrastructure and Systems Change
Primary Healthinformation
Knowledge Engagement Policy
Secondary Behaviourchange campaigns
Understanding Community action
Legislation
Tertiary Self development
Advocacy Organisation change
Primary care Lifestyle/behaviourist Socio-ecological
approaches approaches approaches
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Develop Personal Skills
• Acknowledges the role that behaviour and lifestyles play in promoting health
• Skills are required to be able to make healthier choices• Includes information, education for health, and
enhancing life skills• Extends the skills base to community organisation,
lobbying and the ability to analyse individual problems within a structural framework
• “Changes in knowledge and beliefs will almost always form a part of a comprehensive health promotion program” (Nutbeam and Harris 2004: 13)
• Addresses the proximal determinants of health
Health Literacy: an individual determinant of health
• Access to information and education is a powerful determinant of health
• Health education aims to develop the knowledge, understanding and personal skills to allow participants to make informed decisions to enhance health
• Success is largely dependent on participants’ health literacy
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What is Health Literacy?
• Involves access and use of information• Personal skills to ask the right questions and find
appropriate answers• Making informed choices based on capacity to
integrate information with personal values and personal circumstances
• Health literacy provides options that would not otherwise be available to them
• This is an important consideration when designing health education programs
Health Literacy and Empowerment
• Health literacy increases understanding of the social, environmental, organisational and political factors impacting on health
• Health literacy empowers individuals and groups to engage in debates on local health issues
• They are enabled to collaborate with others to advocate for change
How do we improve the health literacy of individuals and populations?
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Behaviour change approach
• Origins in transition to lifestyle related diseases
• Hence - focus upon individual and behaviour
– Issue and change is at level of individual
• Focuses upon - attitudes, beliefs, motivations, values and instincts
• Based on assumed relationship between knowledge –attitudes – behaviour.
– Models more complex and move beyond this simplistic relationship
Knowledge Attitude Behaviour
Health Education
• Health education and health promotion - not the same – Health education is a subset of health promotion,
– Therefore one of a range of possible interventions
• Health education is a particularly valuable tool in the clinical setting where health professionals are often required to work one-on-one, or in small groups with clients (Murphy, 2004, p.188 – 9).
• However, important to recognise:– Educating individuals will not, on its own, guarantee behaviour
change
– To change population health – multiple interventions/multiple levels
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Health behaviours and behaviour change
• It is important to understand the factors that motivate people to engage in health related behaviours
• Identify factors that influence health beliefs
• Explain how theories of motivation and models of health belief can assist health promotion activities
• The role for the health educator in motivating people
Maslow’s Hierarchy of Human Needs
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Theory of Reasoned Action
• Behaviour is governed by intention
• Intention is governed by personal attitudinal and social normative factors
• Personal attitudes are made up of a belief: smoking is bad for you
• Social normative influence refers to what significant others think of the behaviour: smoking is wrong/smoking is cool
• This explains why some people do not act on their beliefs and highlights the importance of significant others
Health Belief Model (1)
• Developed to explain health-related behaviour
• Based upon belief that humans do a cost-benefit analysis when considering changing a behaviour
• Maintains that cues to behaviour change are important – e.g. health warnings on cigarette packs, Aunt Mary being diagnosed with a smoking-related chronic illness
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Health Belief Model (2)
• The model predicts that individuals will take action to protect or promote health if:– They perceive themselves to be susceptible to a
condition or problem
– They believe that it will have potentially serious consequences
– They believe that a course of action is available that will reduce their susceptibility, or minimise the consequences
– They believe that the benefits of taking action will outweigh the costs or barriers
Modifying Factors
• Personal characteristics
• Social circumstances
• The impact of cues for action: such as media publicity, personal experience
• Belief in one’s competency to take appropriate action (self efficacy)
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Health Belief Model
Demographic factorsSocio-psychological
factorsStructural variables
Perceived benefits of action -
Perceived barriers to action
Perceived susceptibility to
disease X
Perceived seriousness of
disease X
Perceived threat of disease X
Likelihood of taking recommended action
Cues to action
Individual perceptions
Modifying behaviours
Likelihood of action
Smoking and a 15 year old girl
•Jane is 15 years old•Middle class well educated family•Close friends smoke•No obvious negative physical effects of smoking
Perceived benefits of action: unsure of any
benefit; can give up any time
Perceived barriers to action: loss of social
network; social standing
Perceived susceptibility lung
cancer from smoking: Nil.
Never going to get old or die Perceived
seriousness lung cancer: Serious
Perceived threat of lung cancer: Minimal
Likelihood of taking recommended action
Minimal
Cues to action: Smoking causes cancer ads and
cigarette package warnings; Aunt Mary diagnosed with lung cancer: Minimal effect
Individual perceptions
Modifying behaviours
Likelihood of action
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Smoking and a 55 year old woman
•Joan is 55 years old•Middle class well educated family•Close friends smoke•Coughs every morning gets breathless with minimal exercise
Perceived benefits of action: will be able to
exercise; stop coughing, save money
Perceived barriers to action: withdrawal symptoms, loss of ‘smoker’ identity
Perceived susceptibility lung
cancer from smoking:
Moderate: “I could get hit by a bus
tomorrow”Perceived
seriousness lung cancer: Serious
Perceived threat of lung cancer: Moderate
Likelihood of taking recommended action
Very likely
Cues to action: Smoking causes cancer ads and
cigarette package warnings; Aunt Mary diagnosed with lung cancer: Strong effect
Individual perceptions
Modifying behaviours
Likelihood of action
Social learning theory – Bandura
• Considers the relationship and interaction between an individual and their social environment
• Bandura argues that an individual, their environment and behaviour continuously interact and influence each other (e.g. modification of social norms regarding smoking can lead to cessation among adults)
• Bandura also argues that three personal cognitive factors affect specific behaviours: – observational learning
– expectations
– self efficacy
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Observational Learning
• The capacity to learn by observing behaviour and the rewards received for a particular pattern of behaviour
• For example: Young men may observe particular behaviours (such as driving at unsafe speeds) by certain people whom they consider grown up and sophisticated.
• Therefore: In order for them to be grown up and sophisticated, they need to engage in the same behaviours.
Expectations
• This is the capacity to anticipate and place value on the outcomes of different behaviour patterns.
• For example, if you think that smoking will help you lose weight or quitting will make you put it on AND you place value on not being overweight you are more likely to either take up smoking or not quit.
• This example highlights the importance of understanding personal beliefs and motivations underlying behaviour.
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Self Efficacy
• Emphasises the importance of belief in your own ability to successfully perform a behaviour. Self-efficacy is proposed as the most important prerequisite for behaviour change and will affect effort put into the task and outcome.
• Self-efficacy is both behaviour-specific and situation specific. For example, it is easy not to smoke when not around smokers or alcohol.
However….
• It is argued that most behaviours do not and will not change overnight
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The transtheoretical (stages of change) model – Prochaska & DiClemente
• Pre-contemplation
• Contemplation
• Action
• Maintenance
May be followed by
• Relapse
• TerminationPre-contemplation
Contemplation
Maintenance
Termination
Relapse Action
This is important because…
• Focuses on the change process
• Emphasises a range of needs for interventions in any given population
• Highlights the need for sequencing interventions to match different stages of change
• Illustrates the importance of tailoring programs to the real needs and circumstances of individuals rather than having a one solution fits all approach
» Nutbeam 2004: 19
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How do we encourage behaviour change?
• Social Marketing – broadcast and print media
• Direct behaviour change efforts:– Teaching cooking skills, weight loss programs, quit
smoking programs
• Screening– Identify asymptomatic people at risk
• Environmental Interventions– Provision of bike paths, healthy canteens at
work/school
How do we encourage behaviour change?
• Social Marketing – broadcast and print media
• Direct behaviour change efforts:– Teaching cooking skills, weight loss programs, quit
smoking programs
• Screening– Identify asymptomatic people at risk
• Environmental Interventions– Provision of bike paths, healthy canteens at
work/school
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What is social marketing?
• Involves the application of commercial marketing techniques and technologies to influence the voluntary behaviour of targetaudiences to improve personal welfare and that of society, that is to achieve a socially desirable goal
Social Marketing
• The communication of key messages designed to influence behaviour change towards socially desirable goals (Donovan 2006)
• Applies marketing techniques to social psychology theories to bring about voluntary population-wide behaviour change
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Features of Social Marketing
• Aimed at well-defined audiences who have been carefully profiled demographically and behaviourally
• Uses marketing data and stage-of-behaviour change models to define target population and behavioural theories to fit health messages to specific needs
• Has the potential to reach large numbers of people
Marketing is often seen as….
• Evil
• Capitalist
• A victim-blaming philosophy
• But it works……– How many people in the room own an SmartPhone,
an Ipad or equivalent and a computer?
– Who owns a pair of shoes/piece of clothing that you have only worn once/never?
– Who bought a new pair of running shoes to make you run faster?
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How does it differ from commercial marketing?
• Relates to the wellbeing of the community rather than the wellbeing of the marketer
Very brief history of social marketing in Australia
• 1970s: strategy to communicate messages about social issues: hygiene, family planning and attitudes towards women
• 1980s: established as an approach to educate the public and target individual behaviours: drink driving, heart disease prevention; seatbelt use
• 1990s: health related behaviours dominate: smoking, HIV/AIDs
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Fundamental goal of social marketing
• is to bring about behaviour change through:
– Self-regulation: encouraging people to change a specific behaviour on their own
– Help-seeking: encouraging people to seek professional advice where required to address a difficult problem
It does this through:
• Offering benefits people want
• Reducing barriers people face
• Using persuasion, not just information
• However, it is argued that effective social marketing include strategies that target change in social and/or physical environments, communities, social policies and legislation rather than solely relying on individuals to change their behaviour
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The Ottawa and the Bangkok Charters…
• ….recommend that contemporary social marketing campaigns invest in the social and environmental determinants of health
• “people cannot achieve their fullest health potential unless they are able to take control of those things which determine their health” (WHO 1986)
• “A social marketing campaign that targets social structures will be more likely to produce a “social good” (Donovan and Henley 2003)
Social marketing needs to be/is more than advertising
• Advertising (as a core element of social marketing) is most useful to raise awareness about an issue
• However, advertising alone is not effective in bringing about population-wide changes as one that is incorporated with a broader set of strategies that is, advertising plus community capacity building and/or the provision of practical support
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USING POSTERS AS A SOCIAL MARKETING TOOL…..
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Queensland Health Ice Campaign
• “The main objective of the poster is to influence attitudes, to sell a product or service or to change behaviour patterns
• (The aim of) public health posters… (is) to alter the consciousness of the public to bring about an improvement in health practices.”
QH Young Women and Alcohol
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Campaign Objectives
• Accelerate the maturation process of young women moving them from ‘immature’ drinking to ‘mature’ drinking
• Empowering women who wish to drink less through positive recognition of their decisions
• Removing stigma associated to saying no to alcohol
• Putting drinking less into perspective
Using the stages of change model
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The Gruen Transfer’s Take on it…
• http://www.youtube.com/watch?v=DUKiOvQD2ss
SOCIAL MARKETING AND TOBACCO
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Social marketing and tobacco (1)
• The problem:– one in two long term smokers die as a result of smoking
– if current global trends continue: by 2025 there will be 1.9 billion smokers consuming 9 trillion cigarettes
• Demographics:– uptake is a paediatric problem: 90% of smokers start as
children (to look older , more sophisticated and cool)
– 94% of adult smokers want to give up, but cannot due to addiction
– 32% of lower SES smoke compared to 14% in higher SES groups; lone parents on benefits smoke in excess of 75%
Social marketing and tobacco (2)
• The tobacco industry– While tobacco advertising has been banned in most
developed nations, the marketing effort remains: product innovation, distribution, packaging and pricing strategies. These effort encourage uptake and discourage cessation
• The economics of smoking– Tobacco is a profitable business– Governments earn revenue from taxes– There are public health benefits from taxes for some
groups, but research shows that the poor will continue to smoke regardless of price.
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Anti-smoking
SOCIAL MARKETING AND ROAD SAFETY
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Speeding/Road Safety
SOCIAL MARKETING AND EXERCISE
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An example of attempting to increase physical exercise
• In Moscow a machine and an incentive was installed to:
– Increase physical activity
– To promote the 2014 Olympic Games
• http://www.viralviralvideos.com/2013/11/11/moscow-subway-ticket-machine-accepts-30-squats-as-payment/
Another example in Odenplan, Stockholm
• http://www.youtube.com/watch?v=2lXh2n0aPyw
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SOCIAL MARKETING AND TEXTING
Texting and Driving
• http://www.gizmodo.com.au/2014/06/volkswagen-just-made-the-best-ad-to-make-you-stop-texting-while-driving/
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Criticisms of Social Marketing
• Ignores the structural factors that impact on an individual’s ability to change lifestyles
• To be effective needs to be accompanied with structural changes to provide the target group with the opportunity to change
• Often competing with powerful counter messages (e.g. good nutrition vs. fast food advertising)
• Ethical questions surrounding the attempt to manipulate behaviour by appealing to particular images
• Can encourage victim blaming• No way to evaluate effectiveness
Limitations of behaviour-based programs
• Victim blaming– People are responsible for their health regardless of
social and economic circumstances
– Those who have access to society’s resources are more likely to make behaviour changes
• Behaviour change is conceptualised on reason and rational choice: “it is not good for me, so therefore I won’t do it”
• Gap in understanding between health professionals and lay people
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Questions????
Break
We have just stopped for a short break.
We will be back soon.
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TUTORIALCan social marketing influence behaviour change?
Questions
• Can you identify the tools used in these social marketing campaigns?
• Review the following ads:
– What are they trying to do?
– What change theories underpin the content?
– How effective do you think it would be?
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SOCIAL MARKETING AND BINGE DRINKING
Binge Drinking (1)
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Binge Drinking (2)
Discussion Forum Topic
• Discuss the strengths and weaknesses in using behaviour change to improve public health. Choose a social marketing or a health education campaign to support your perspective.
• Examples: HIV/AIDS; tobacco; binge drinking; domestic violence; healthy eating and exercise; road safety.
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Week 10
• Lecture: Creating Healthy Public Policy
• Tutorial: Does the nanny state know best?
Discussion Forums
• Topic A -E: Closed
• Topic F: Healthy Individuals
– OPEN from Monday 09 00 Week 10
– CLOSE: Friday 17 00 Week 11
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