In their book Behavioral Policies for Health Promotion and Disease Prevention, Benjamin Ewert and Kathrin Leor contribute to the emerging discussion of the application of behavioral public policy for health promotion. The book is an edited volume with six chapters by various authors. The chapters are generally well integrated and build on common themes, and all the chapters have ample references. Together, the chapters offer a balanced analysis of the potential contribution of behavioral health policy to health promotion efforts.
Behavioral public policy is a recent approach to policy analysis that applies theoretical and empirical insights from the behavioral sciences to public policy and governance. The interest in behavioral economics spawned the journal Behavioural Public Policy and produced a Nobel Prize for Richard Thaler. Thaler and Sunstein (Reference Thaler and Sunstein2008) introduced the concept of “nudge” to show how public and private organizations can use behavioral science to improve people’s decisions by changing the way options are presented to them. Since then, nudging has proven popular with many governments (Schmidt, Reference Schmidt2017).
Although I personally find the concept of nudge to be gimmicky, behavioral public policy does a service in challenging rational choice theory and emphasizing the “irrational” cognitive biases that often affect decision-making. Moreover, there is no doubt that the rise of behavioral sciences offers insights into human behavior that can be adapted to public health. As we come to better understand how these cognitive biases work, we can use this knowledge to fine-tune choice environments to induce people to change their lifestyles. For example, given evidence that people often go along with an option if it is presented as a default, by making desirable options the default, proponents conclude that governments can nudge us into making better personal decisions. On the other hand, critics dismiss behavioral health policies as a deceptive new form of government control (Whitehead et al., Reference Whitehead, Jones, Lilley, Pykett and Howell2018). Overall, this book provides a well-balanced analysis of behavioral health applications in health promotion.
According to the editors, Ewert and Loer, the goal of the book is to develop a fuller understanding of how policymakers choose to address public health challenges. Because noncommunicable diseases (NCDs) account for a major share of disease, policymakers must devise new strategies to reduce unhealthy individual behaviors. The book discusses the individual and societal dimensions of NCDs and the accompanying problem of social inequality, and it analyzes the trend toward behavioral policymaking. Liberal democratic societies face the dilemma of allowing people freedom of choice while, concurrently, stemming the growth of NCDs caused by their unhealthy lifestyles. While regulation has been shown to be a relatively effective policy instrument, depending on the political context and culture of a country, prohibitions or taxes on unhealthy behavior are politically risky. Therefore, new approaches are needed, especially given shrinking budgets.
In Chapter 2, Ewert explores the assumptions that underlie policymaking in health promotion and argues for the need to integrate the findings of behavioral sciences. Instead of concentrating on individuals’ unhealthy behaviors, however, health policymakers should shift their attention to social environments that entice people to make heathier choices. Health promotion nudges would include redesigning walking routines, food buying habits, and choice architecture. Ewert concludes that nudges, in themselves, are not sufficient and that behavioral policies should be combined with participatory approaches such as focus groups and citizen juries that approve nudges.
In Chapter 3, Loer continues the nudging theme, noting that all traditional policy instruments follow the neoclassical rationality paradigm and dismiss behavioral science findings. Using tobacco control as an example, she introduces an enhanced instrument typology that includes behavioral insights and builds choice architectures that promote healthier behaviors. Loer emphasizes that given the difficulty of setting limits in liberal societies, however, nudges must be designed to preserve freedom of choice and shape choices, not blame individuals.
In her review of how policymakers in various countries draw on behavioral knowledge to address health challenges, Jessica Pykett is more skeptical about nudging. It should be noted that this chapter is not a comparative analysis, but rather a discussion of examples from Singapore, the United Kingdom, and the United States. A limitation of the chapter is that it would have been useful to include other countries such as Germany, given that the authors are in Germany. Pykett’s argument is that although the World Health Organization has highlighted the inadequacy of individual behavioral change policies alone for addressing global ill health and called for policy interventions to act on the structural drivers of health outcomes, there is a tendency whereby nudge policies have been promoted to focus on individual behavior and downplay environmental factors.
In their insightful chapter, Holger Strassheim and Loer analyze how scientific expertise is produced and applied to policymaking by different actors. They contend that the scientific dimension has been captured by international expert organizations that fund and produce extensive behavioral research in public health. These private sector actors engage in advisory bodies and committees using their expertise to influence policy, while, in turn, policymakers often use the epistemic authority of industry experts to legitimize political decisions. Unfortunately, the activities of these stakeholders to bolster certain forms of expertise and transfer them into policy creates opportunities for the “hidden dominance of political and commercial interests” (p. 86) and reinforces the shift from the structural dimension of health problems to the individual level. The result, Strassheim and Loer argue, is that structural problems and social inequalities in public health are neglected in the name of evidence-based policy. Thus, if not negotiated in the public realm and politically legitimized, strategies of behavioral governance may not fit the common interest.
In the concluding chapter, the editors examine the implications of the rise of behavioral health policies for the concept of health citizenship. A “behaviorally informed health citizenship” allows us to move beyond the alleged dichotomy between citizen rights in health promotion and behavioral health governance. It entails environmental cues that empower rather than coerce people to live healthier lives and provides opportunities for citizen participation and protection against the power of private interests to nudge. Moreover, behavioral instruments in the public realm must be transparent and democratically controlled, and citizens should be able to recognize when they are being nudged. According to Ewert and Loer, the debate over the use of behavioral insights has “breathed new life into the art of policy making in health promotion” (p. 102). Ultimately, however, for Ewert and Loer, the success of behaviorally informed policies to address NCDs depends on collective actions to improve the social determinants of health and reduce health inequalities by promoting health at both the individual and structural levels.
Although this book focuses on NCDs, it has clear relevance for policymaking throughout the COVID-19 experience. The conflict between disease prevention and individual choice and the politicization of a disease have never been starker. Again, it is important to note how disparate the policy responses to COVID-19 were across countries and even among groups within specific countries. While some jurisdictions took strict regulatory measures, often they were unable to ensure even minimal compliance. Wearing masks and taking other precautions often proved unenforceable. Once vaccinations became available, exhortation by health experts, elected officials, famous athletes, and even previous U.S. presidents to “take the shot” failed to ensure high rates of acceptance. It would be interesting to analyze how behavioral public policy was implemented and whether it had any success.
One limitation of the book is the level of copy editing. This short work was published by Palgrave Pivot, which enables authors to publish up to 50,000 words with a rapid production process of about three months from acceptance of the manuscript. Although all titles are subjected to peer review, normally they do not undergo an independent copy-editing process. As a result, the final product can have issues that editors could have rectified. In this case, the book is well organized, but I found it difficult to read because of the persistent use of one- and sometimes two-page-long paragraphs.
This book should be of value for political scientists, policy analysts, public health professionals, and general readers who are interested in behavioral public policy as applied to health promotion. It offers an objective examination of the issues surrounding behavioral approaches and nudging instruments and demonstrates that it is more complex than some proponents contend. Graduate students in biopolitics, particularly those in working in public policy, might benefit from reading it as well.
