THE PRESUMPTIONS OF COMMUNITY-BASED HEALTH PROMOTION INITIATIVES

The importance of empirical evidence-based interventions for community health promotion cannot be overstated.  Analysis and reporting of data are critical for the development of effective programs because they need to be founded on real-world needs within a specific community or population.  As always, I emphasize the point that communities are comprised of individual members of the community taken as a whole, an excellent starting point but hardly a “destination” in effective health interventions.  Public health programs, including those involving financial incentives, would likely be more effective if designed based not on how perfectly rational people ought to make health decisions but on how real people actually make them.  Clearly, any potentially efficacious health promotion program based on an assessment of community needs and program evaluations must be grounded on pragmatism to be truly successful. Academic constructs such as ‘Expected Utility Theory’, ‘Prospect Theory’, and ‘Nonlinear Probability Weighting’, all reflect to varying degrees individuals’ response to health promotion efforts within specific communities, most often via traditional asymmetric paternalistic approaches to public health policy on a micro and macro level.  Perhaps the most erroneous of these constructs is ‘Expected Utility Maximization’, i.e. the presumption that humans are always rational and driven primarily by “self-interest”, which is not only an unrealistic expectation but also a double-edged sword.  I would propose a not unusual scenario in which an individual’s personal definition of “self-interest” is to be extremely inebriated as often as possible while still holding down a job they hate and continuing to endure a loveless marriage for practical reasons, whereas another individual’s definition of “self-interest” might involve staying as fit and healthy as possible while maximizing their longevity.  We all have to have priorities, right?

So, what we have essentially is two or more target audiences for any grandiose health promotion campaign within a community.  How then do we judiciously apply needs assessments and program evaluations to a community composed of both similar and dissimilar individuals?  Do we just shrug and commit the sin of generalization, patting ourselves on our shoulders for our well-meaning intentions and meddling interventions?  Further complicating health promotion efforts is the hot topic of ‘Nonlinear Probability Weighting’, which strongly influences individual health choices, such as when reference dependence leads to getting drunk at a bar with co-workers every evening after work, a behavioral component not likely to be altered by health promotion programs warning of the dangers of excessive alcohol consumption.  It’s great to have some sort of well-designed health education program in place as a starting point for broad interventions but, in the final analysis, what people really need is not health education (they know full well what they’re doing to their bodies) but rather realistic motivations for change, based on the same emotional impulses that lead them to pursue an unhealthful lifestyle habit, since we already know that rational thinking is not what drives most unhealthful behaviors.  The precipitating impulse for an unhealthful behavior is usually just a selfish desire for immediate pleasure and satisfaction, further framed within the context of camaraderie and social norms, a desire to be loved and accepted, to simply “fit in”, none of which have anything to do with healthful practices, unless of course one makes the superhuman effort to change one’s environment and circle of friends.

Health education and health promotion are indeed complex, intellectually challenging propositions, further hampered by budgetary and legislative limitations, especially when it comes to government-sponsored programs.  I have nothing but the highest admiration and respect for anyone who chooses this difficult line of work as their vocation!

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