The murky science of health promotion

Ecological models of health behavior are truly fascinating.  It could be argued, both academically and pragmatically, that we are all to varying degrees a product of our environment.  When I discuss this topic, I cannot help but be reminded of the analogous relationship of ecological models to two specific areas of interest for me personally, the nascent disciplines of epigenetics and nutrigenomics.  Certainly, we all carry a specific set of genes in our genetic makeup, some good, some not-so-good.  Our behaviors and environment affect the expression of those genes, hence epi (above) genetics.  The same principle applies to ecological models of health behavior.  Historically, there are abundant examples of individuals who were exposed to negative influences in their childhood and early adulthood, yet managed to rise above those influences by sheer strength of will, intrinsic motivations, and familial social support, such as the example of a young African American male living in the projects who is surrounded by drugs and violence, then grows up to be a congressman, or a youth in an impoverished unhealthy community who becomes an Olympic gold medalist, or a child who attended an underfunded public school in a low-income neighborhood and is now a Harvard professor, etc.

The various principles inherent to an ecological model of health education and promotion are all consistent with a framework of overlapping modalities that profoundly influence communities and individuals within those communities.  Such a model is predicated upon a “greater good” approach to health promotion that seeks to identify community-wide epidemiological risk factors and, conversely, environmental factors that influence the expression of the epidemiology, hence my allusion to epigenetics.

The first priority of effective health promotion is critical, i.e. social assessment, participatory planning, and situation analysis, because one must first accurately identify the ecological environment in which epidemiological factors can be identified within a community or society before one can design a potentially successful intervention strategy.  The first step to a solution is to identify the problem, as opposed to routine dissemination of generic dogma.  Health promotion is never a “one size fits all” proposition.  Predisposing factors, reinforcing factors, and enabling factors all influence the behavior of individuals within a community, to varying degrees depending on the individual, as posited in my previous observation about persons who have risen above their proverbial station in life.  Nonetheless, the greatest strength of ecological models of health behavior may be illustrated by the following analogy: the best way to eliminate fast food consumption in a community is to get rid of the fast food restaurants (unrealistic however).  The second-best approach would be to educate the community on the severity of health dangers associated with routine consumption of fast food, but the best solution of all is to provide a real-world motivation for people to want to stop consuming fast food and start eating healthier (a tricky proposition indeed).

Unfortunately, it is unrealistic to believe that administrative and policy initiatives enacted through government programs will significantly impact individual behaviors anywhere near as much as a simple intrinsic motivation, e.g. a young boy who decides to stop eating junk food so that he can lose some weight and make it onto his school’s football team, or a mother who packs a healthy lunch box for her child that goes to a school which serves unhealthy foods in the cafeteria.  Local, state, and federal health departments can never take the place of good old-fashioned parenting or the intrinsic motivations of individuals who just want a better quality of life and want to like what they see in the mirror.

All these arguments raise the million-dollar question (pun intended) of to what extent intrinsic factors and family/friends within an environment are influenced by the macrocosm of the environment itself?  The most salient point is that there is a huge difference between logic models of problems based on identifying causal relationships versus models of change designed to evoke actual behavioral modification within a community, resulting in measurable positive health outcomes.  We already know that most people have unhealthy habits and eat unhealthy, but what are we as a society going to do to compassionately encourage others to take a little better care of themselves?  Here’s an idea.  Lead by example!


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