Chapter Eleven 11

Lifestyles and behaviours

Key points
• Social construction of risky behaviours and risk perception
• Tackling lifestyles and behaviours
– Smoking
– Diet
– Exercise and physical activity
– Alcohol and drug use
– Sexual health

OVERVIEW This approach aims to persuade people to change

unhealthy behaviours and adopt health-promoting
behaviours. Chapter 4 showed how neoliberal poli-
The shift in disease patterns in developed coun-
cies in many developed countries privilege individ-
tries, from communicable diseases to chronic dis-
ualist approaches and have favoured public health
eases, has highlighted the importance of lifestyles
programmes that target healthy lifestyles rather than
and behaviours as potential contributors to disease
social determinants of healthy. This chapter explores
or health. Many practitioners see their role as giv-
approaches to behaviour change and their popular-
ing information and advice about healthy lifestyles
ity and then goes on to examine in more depth five
to their clients. Behavioural lifestyle choices, such as
key areas where behaviours impact significantly on
diet, exercise and the use of recreational drugs are
people’s health – smoking, diet, exercise, drugs and
major factors in determining health status. A single
alcohol use, and sexual behaviour.
lifestyle behaviour, such as diet, can affect the like-
lihood of developing a range of conditions, includ-
ing life-threatening illnesses such as cancers of the Introduction
digestive system, severe chronic conditions such
as diabetes and many more minor conditions such Certain behaviours have become labelled as ‘risky
as irritable bowel syndrome and dental decay. It behaviours’ associated with negative health outcomes.
has therefore become a common strategy in public Such behaviours include smoking, excessive use of alco-
health and health promotion to target behaviours. hol and other recreational drugs, unsafe sex, poor diet

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(high fat and high sugar diet) and sedentary lifestyles. The lifestyles approach also assumes that people
These have all been the subject of the UK national make rational choices based on weighing up the pros
health strategies. Risky behaviours are often linked to a and cons of adopting a specific behaviour, and this
range of illnesses and conditions. For example, smoking too has been criticized for failing to take into account
is linked to lung cancer, coronary heart disease, chronic custom, habit, identity and the meaning of behav-
obstructive lung disease and asthma. Lifestyle risk iours within people’s lives. Behavioural change mod-
behaviours have been associated with most of the com- els, such as the Stages of Change model, that assume
mon chronic diseases in developed countries. These individual autonomy and choice have been seen as
conditions (e.g. diabetes, coronary heart disease and unrealistic. These critiques of the behavioural change
cancers) represent a significant disease burden and are approach are discussed in greater detail in Chapter
very costly to manage and treat. The Coronary Heart 11 of Foundations for health promotion, edn 3
Disease National Service Framework (NSF) (DH (Naidoo and Wills 2009). Empowerment strategies
2000a) highlighted the importance of tackling lifestyle that educate and enable people to take control over
behaviours as a means towards reducing the incidence their health are discussed in Chapter 8 of this book.
of coronary heart disease. Funding for smoking ces- The construction of certain behaviours as risky is,
sation groups, local exercise action pilots (LEAPS) in however, problematic. In particular, there is a gap
deprived areas, a ban on advertising tobacco, and free between epidemiological and lay perceptions of risk.
fruit for primary school children were all introduced to Epidemiological risks are scientifically calculated and
support the coronary heart disease NSF. presented as statistical probabilities. However, peo-
As discussed in Chapter 10, most research into ple interpret epidemiological risks within their own
the prevention of risk factors for disease has focused behavioural landscape, according to their own cir-
on ‘downstream’ interventions that aim to affect the cumstances and priorities (Lupton 1999). For exam-
lifestyle and behaviour of individuals, rather than ple, someone may have unsafe sex and underestimate
‘upstream’ interventions such as policies that seek to the risks of so doing, because they want sex to be
influence the broader determinants of health. This has spontaneous and not negotiated, and because it is the
led to greater evidence for individually focused inter- norm amongst their peers.
ventions than for social policy interventions. Targeting Lupton (1995, p. 9) argues that risk has replaced
lifestyles has therefore been viewed as both an effec- the notion of sin. Taking risks is attributed to lack of
tive and an efficient strategy to promote health. will power and moral weakness and as a result peo-
Targeting lifestyles has a long history: ‘The way in ple do not seek advice because they fear they will be
which people live and the lifestyles they adopt can ‘told off’. Research suggests that health risk behaviours
have profound effects on subsequent health. Health should not be perceived as ‘wrong’ lifestyle choices,
education initiatives should continue to ensure that but as rational coping strategies adopted in the context
individuals are able to exercise informed choice when of the demands of caring and the constraints of poverty
selecting the lifestyles which they adopt’ (DH 1992, (Graham 2003). People have very different construc-
p. 11). The lifestyles approach is popular because it tions of risk, and people’s personal ‘landscapes of risk’
is focused on individuals and can therefore be inte- vary according to their social situation and status. For
grated into one-to-one contacts between practitio- example, smoking is a high-risk behaviour but its risk
ners and their clients. It also reinforces the popular may be downplayed and offset against its positive role,
concept of individual freedom and autonomy in life- for example as a stress management and coping tool,
style choices. However, it has also been criticized within people’s lives. In this way, epidemiological risk
for taking behaviours out of their social context and factors such as smoking or poor diet may be overridden
ignoring the effect of structural constraints (such as by more immediate risks and more urgent problems.
income) and the regulatory context (e.g. banning The link between unhealthy lifestyles and poverty has
smoking in public places) on behavioural choices. been recognized in official government documents:

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The key lifestyle risk factors, shared by coronary • education or communication – such as one-to-one
heart disease and stroke, are smoking, poor advice, group teaching or media campaigns
nutrition, obesity, physical inactivity and high blood • technologies – such as the use of seat belts,
pressure. Excess alcohol intake is an important breathalysers or childproof containers for toxic
additional risk factor for stroke. Many of these risk products
factors are unevenly spread across society, with • resources – such as leisure centre free entry, free
poorer people often exposed to the highest risks. condoms or free nicotine replacement therapy
Dh (1999, p. 74)
(NRT).

Box 11.1 Activity

Box 11.2 Discussion point
Do you engage in any behaviour that might be
deemed to carry a risk? (If yes) How do you justify Many practitioners will suggest education as a
continuing with these behaviours? strategy to improve health. Why are educational
interventions so popular?

Risk perception is also influenced by role models. Educational interventions are valued and popular
‘Candidates’ for premature death who in fact lived with practitioners because they:
to a ripe old age (e.g. ‘granddad smoked 40 a day and • empower people, enabling them to make desired
lived to 93’) and ‘victims’ who lived healthily but died changes and increase their control over their
prematurely (e.g. ‘my aunt never smoked, ate health- health
ily all her life, and then died of breast cancer aged 48’)
• involve working directly with people, enabling
are referred to as reasons for treating epidemiologi-
communication and feedback, which in turn can
cal risk assessments sceptically (Davison et al 1992).
be used to fine-tune the intervention, enhancing
In our companion book, Foundations for health pro-
its effectiveness.
motion, the sociopsychological models of behaviour
Educational and behaviour change approaches have
that explain health-related decision making are dis-
been criticized for
cussed in depth (Naidoo and Wills 2009). Lay per-
• failing to take sufficient account of the social
ceptions of risk are also affected by social and cultural
and environmental context in which behavioural
norms. If, for example, one’s peer group values a risky
choices are made
behaviour, for example binge drinking among young
women, its risk is likely to be underestimated or off- • reinforcing health inequalities because
set against other immediate benefits, such as belong- educational and motivational messages are more
ing and peer approval. Illegal behaviours are also likely likely to be acted upon by those with the most
to be assessed as much more risky than legal behav- resources, who already enjoy better health due to
iours, regardless of the evidence. For example, the their more advantaged circumstances
use of the illegal drug ecstasy is generally viewed as • being ‘victim-blaming’ – holding people
more risky than the use of alcohol, although alcohol responsible for their lifestyles when change
represents a much more significant health risk. is very difficult or even impossible to achieve
Recent guidance from the National Institute for has been viewed as unethical because it blames
Health and Clinical Excellence (NICE) states that people for circumstances beyond their control
interventions to change behaviour can be divided into • assuming a direct link between knowledge,
four main categories: attitudes and behaviour
• policy – such as legislation, workplace policies or • encouraging state intervention and interference in
voluntary agreements with industry people’s private lives.

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 pa r t t h r e e Priorities for public health and health promotion

The educational approach is discussed in more detail example smoking and excessive alcohol use, are
in Chapter 8. addictive. People may not have all the relevant facts
Practitioners will often need to discuss behavioural at hand when making behavioural choices, and access
lifestyle changes with their patients or clients. This to more information may change their choices. The
may be in the form of information, advice or a more behaviour of significant others has an impact on life-
structured and client-led examination of opportuni- styles, and advertising and marketing are also sig-
ties for change. People may reject education or advice nificant factors determining individual behavioural
because it runs counter to their intuitive understand- choices. Recognition of the persuasive effect of mass
ing, their life experience, or the example of significant media techniques has led health promoters and public
others. However, even when a message is understood health practitioners to adopt techniques such as social
and accepted, it may still not be acted upon. Being marketing to try to achieve healthy lifestyle changes
exposed to behavioural change messages that are (see Chapter 8 for further discussion of this topic).
accepted but impossible to achieve is likely to lead Individually focused educational and persuasive
to loss of self-esteem and feelings of inadequacy. The approaches have been used to try to change many
alternative is to reject or deny such messages. behaviours. In addition, many other approaches have
been used, including legislation and regulation, policy
formation and implementation (discussed in more
Box 11.3 Activity detail in Chapter 4), and community development.
The following sections examine a range of strategies
Think of a patient or client you regarded as addressing smoking, diet, exercise, alcohol and drug
‘difficult’ because they resisted or didn’t follow use, and sexual health. Within each section, the con-
your advice. Can you identify why they may have tribution of this behaviour to ill health is first out-
been like this? lined, followed by a discussion of approaches used in
practice and evidence as to their effectiveness.

Another criticism of the lifestyles approach is that

it interferes with people’s private lives. This argu- Smoking
ment holds that people freely choose their lifestyles
and behaviours, and that unless this impacts nega- Although the detrimental effects of smoking on health
tively on the quality of others’ lives, it concerns no have been known for half a century, smoking remains
one but themselves. This is an example of individu- a common habit that significantly affects the health of
alism, a highly valued concept in modern developed the population, both in the UK and worldwide.
countries, which stresses the autonomy and freedom
of individual people. The degree to which individual
Box 11.5 The prevalence of smoking

Box 11.4 Discussion point In 2006, 22% of adults aged 16 and above in
the UK (23% of men and 21% of women) were
current cigarette smokers (http://www.ic.nhs.uk/
Should practitioners encourage clients to change
pubs/smoking08).
their lifestyles?
• Cigarette smoking continues to be most
common among younger age groups (32%
of 20–24-year-olds and 31% of those aged
lifestyles impact on others is hard to determine. 25–34 were current smokers) and least likely
It is arguable whether lifestyles are a matter of choice. amongst those aged 60 and above (14%
In addition to the constraints on choice imposed by were current cigarette smokers).
the socio-economic context, some behaviours, for

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Box 11.5 The prevalence of

The evidence relating to the harmful health
smoking—cont’d effects of tobacco has been well documented for
over half a century dating back to Doll and Hill’s
• Although smoking rates are declining, the (1950) original work, published in the British
strong social class gradient in smoking Medical Journal in 1950, which demonstrated the
persists. In England in 2008, 27% of those link between smoking and lung cancer. The 1963
in manual groups were smokers, compared Report by the Royal College of Physicians, which
to 16% of those in the non-manual groups led to the setting up of the pressure group ASH
(Robinson and Bugles, 2010). (Action on Smoking and Health) and the Froggatt
Report on passive smoking published in 1988, sum-
Smoking has been identified as one of the greatest marized the available evidence and made the case
causes of the health divide between the rich and the for stronger controls on smoking in public places
poor. Due to its expense, smoking also has a signifi- and the advertising and promotion of tobacco. The
cant financial impact on low-income households, and government finally acted on this evidence base and
money spent on cigarettes may lead to shortages in in 1998 published the White Paper Smoking Kills
essential items such as food, heating and clothing. (DH 1998).

Box 11.6 Smoking and health

• Smoking tobacco is the single most smoking, approximately 20 smokers suffer

important preventable cause of ill health and from a smoking-related disease.
premature death. • In 2006/2007, it is estimated that 445,100
• Around 82,800 people in England die from adults over the age of 35 were admitted to NHS
smoking each year, accounting for around hospitals in England as a result of smoking.
one-fifth of all deaths. • Passive smoking, or exposure to the
• Almost one-third (29%) of all cancer deaths tobacco smoke of others, affects the health
are caused by smoking. of non-smokers including children.
• Eighty-eight per cent deaths from lung • Children who are passive smokers due to
cancer, 17% deaths from heart disease and parental or carers’ smoking are at increased risk
30% deaths from respiratory disease are of respiratory disease, asthma, glue ear, sudden
caused by smoking. infant death syndrome and school absences.
• One in two long-term smokers will • Second-hand smoke causes lung cancer and
die prematurely due to their smoking habit. heart disease in adult non-smokers.
• It is estimated that between 1950 and 2000, 6 • Smoking is estimated to cost the NHS
million Britons and 60 million people worldwide approximately £2.7 billion each year.
died from tobacco-related diseases.
• Smoking causes ill health and reduces the
quality of life. For every death caused by Source: http://www.ash.org.uk

Smoking is a global health issue affecting all coun- countries. The WHO recognized the global impact of
tries. The WHO global burden of disease study (Ezzati tobacco and negotiated the Framework Convention on
et al 2002) found that in developed countries tobacco Tobacco Control (WHO 2003), its first global health
is the leading cause of disability adjusted life years treaty. The Framework Convention is a legal instrument
(DALYs), and tobacco remains a significant cause of based on evidence that is intended to be incorporated
disability and a major health risk factor in developing in law and implemented in different countries.

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Box 11.7 WHO framework convention Box 11.8 Discussion point

on tobacco control (2003)
Which of the measures in Box 11.7 do you think
1. Measures relating to reducing demand for has most impacted on smoking rates?
tobacco:
• price and tax measures WHO reports that the most cost-effective option
• protection from exposure to environmental in all countries is taxation on tobacco products, fol-
tobacco smoke
lowed by comprehensive bans on advertising tobacco.
• regulation and disclosure of the contents of Together, it is calculated that these two measures
tobacco products
could reduce the global burden of tobacco by 60%. In
• packaging and labelling
countries such as the UK, where these two measures
• education, communication, training and
are already in place, additional measures such as edu-
public awareness
cation and smoking cessation interventions become
• comprehensive ban and restriction on tobacco
cost-effective.
advertising, promotion and sponsorship
• tobacco dependence and cessation
measures. Box 11.9 Example
2. Measures relating to reducing the supply of
tobacco: Evidence of effective smoking cessation
• elimination of the illicit trade of tobacco products
Effective methods of smoking cessation include
• restriction of sales to and by minors advice from doctors, structured interventions
• support for economically viable alternatives including brief interventions (see Box 11.12)
for growers. by nurses, individual and group counselling
either face-to-face or by telephone, standard
and personalized self-help materials, and
Recent years have seen a raft of smoke-free legisla- pharmacotherapies (NRT). Recent guidance
tion in the UK: from NICE (2008) provides a review of the
• 2003 Advertising of tobacco banned except evidence relating to each of these interventions
limited advertising at the point of sale and considerations involved in their provision.
• 2003 Tobacco sponsorship of domestic sporting NRT increases the rate of quitting by 50–70%,
regardless of the setting (Stead et al 2008).
events banned
The effectiveness of NRT appears to be largely
• 2005 Tobacco sponsorship of international independent of additional support, although
sporting events banned NRT combined with cessation support is
• 2007 Sale of tobacco products to under effective in increasing quit rates amongst those
18-year-olds banned who feel unable or unwilling to quit abruptly
• 2007 Smoking in virtually all enclosed public (Wang et al 2008).
places and workplaces banned
• 2008 Mandatory written and pictorial health Tobacco use is unique in that its effects are unequiv-
warnings on all tobacco products. ocally negative, both for the immediate user and for
The European Union banned all tobacco advertising others exposed to tobacco smoke. Strategies to reduce
and sponsorship in 2008. Smoke-free legislation has tobacco use are correspondingly well advanced and
been supported by an increasing percentage of the multi-pronged, including legislation to ban tobacco
population – 81% in 2008 compared to 51% in 2004 advertising and promoting access to nicotine replace-
(http://ash.org.uk/files/documents/ASH_119.pdf). ment drugs on prescription. The American social

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 Lifestyles and behaviours Chapter 11

marketing youth campaign ‘Truth’, with its mes-

• In 2004, over £30 million was spent on drugs
sage that ‘tobacco will control you’, recognizes the to treat obesity. It is estimated that treating
pervasive influence of the tobacco industry and the obesity-related conditions (ischaemic heart
addictive nature of tobacco. The WHO Framework disease, stroke, diabetes mellitus and some
Convention demonstrates the potential for global cancers) costs England over £3 billion each
strategies to change unhealthy behaviours. A range of year.
strategies is necessary because the addictive nature
of tobacco means that education and advice alone Sources: http://www.euro.who.int/obesity British
are insufficient. However, the use of complementary Heart Foundations Statistics Website The Information
strategies at different levels (individual, community, Centre 2008 http://www.heartstats.org accessed
national, global) has been shown to be effective in 13/7/09
reducing tobacco use.

In many countries, there has conversely been an

Diet epidemic rise in the incidence of obesity. Diets in
Western developed countries have changed rapidly,
Diet is a crucial factor contributing to health. alongside changes in farming, cooking habits, pro-
Malnutrition and underweight is a problem for the cessing, and the availability of prepared and packaged
developing world, and the Millennium Development food. Unhealthy diets, characterized as high fat, high
Goal 1 is to reduce by 50% the number of people who sugar and high calorie diets, are linked to the rise in
suffer from hunger. Nine hundred and forty-seven obesity, which itself is implicated in a host of dis-
million people in the developing world are undernour- eases and illnesses including diabetes, coronary heart
ished, leading to a failure to grow and thrive and an disease and some cancers.
increased likelihood of becoming ill and dying prema- Although obesity is a problem in developed
turely (Bread for the World 2009). In 2006, about 9.7 rather than developing countries, it is the poorest
million children died before the age of 5 years. Four- members of society who are most likely to be obese
fifths of deaths occurred in sub-Saharan Africa and and suffer related ill health and premature death.
South Asia, the two regions where people suffer most Substantial evidence shows how poverty affects
from hunger and malnutrition (UNICEF 2008). food choice:
• Many low-income neighbourhoods in the USA
and Canada have become ‘food deserts’, with the
Box 11.10 Obesity in the UK loss of local retailers resulting in less availability
of healthy affordable food (Cummins and
• Obesity has nearly trebled in the UK since Macintyre 2006).
1980 and is still increasing. • In 2006, only 28% of men and 32% of women,
• In 2006, 24% of adults aged 16 or above and and 19% of boys and 22% of girls aged 5–15
16% of children aged 2–15 years in England years consumed five or more portions of fruit
were classified as obese. and vegetables daily, with the proportion
• Obesity is linked to social disadvantage and doing so increasing with age and income (NHS
poverty, with higher rates for overweight Information Centre 2008).
and obesity amongst Asian groups, lower
• People living in the most deprived
social classes, and people living in Wales and
Scotland. neighbourhoods are unlikely to have access
• Obesity is responsible for 2–8% of health costs
to a car, and local shops charge more than
and 10–13% of deaths in Europe. supermarkets for basic foods including fruit and
vegetables (Lang 2005).

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 pa r t t h r e e Priorities for public health and health promotion

unfamiliar fruits and vegetables in the family diet

Box 11.11 Discussion point may not be a feasible option. To make ‘5-a-day’ a
viable option for all families, attention needs to be
Is the ‘5-a-day’ message to eat five portions of paid to the availability, accessibility and price of
fruit and vegetables a day relevant and realistic fruit and vegetables. Reducing the price of fruit, or
for families on a low income?
ensuring it is available daily in school meals, may be
more effective than educational advice on the nutri-
For low-income families whose budgets only just tional benefits of fruit, although brief counselling
cover basic food requirements, experimenting with interventions have also been shown to be effective.

Box 11.12 Example

Fruit and vegetable project for adults on shown to be effective in increasing the consumption
low incomes of fruit and vegetables among adults with low
The most common techniques of health incomes. The intervention consisted of nutrition
promotion (providing information and facilitating or behavioural counselling involving two 15 min
goal-setting) may be helpful for low-income consultations a fortnight apart supplemented by
groups. Personalized information, combined with written information. A randomized trial has shown
professional consultation or advice, can improve that the most effective intervention is behavioural
knowledge and recall. Disadvantaged populations counselling based on social learning theory and
benefit from this approach more than other groups, the Stages of Change model, although nutritional
possibly because their knowledge base is less, and counselling is also effective.
so they have more to gain from health information
(King’s Fund 2008). For example, brief counselling Source: Steptoe et al 2003 cited in Press and
interventions by primary care nurses have been Mwatsama (2004)

Figure 11.1 shows how diet is determined by a number panion volume, Foundations for health promotion
of different interweaving factors. Simply improving [Naidoo and Wills 2009].) The 5-a-day programme
knowledge about healthy foods does not necessar- has taken these factors into consideration. Included
ily lead to changes in consumption. Such foods need in the programme is a national school fruit and
to be accessible and available and people need the vegetable scheme, which, following a positive evalua-
skills and confidence to prepare these foods. The UK tion of several pilot schemes, has now been rolled out
government has recognized the negative impact of throughout England. The school fruit and vegetable
fast food outlets on the nation’s diet, and in a recent scheme offers a free piece of fruit or vegetable to all
strategy document stipulates that local authorities 4–6-year-olds at nursery and school. Nearly 2 mil-
can and should use existing planning powers to con- lion children in more than 16,000 schools are now
trol the number and location of fast food outlets in involved in the scheme (http://www.dh.gov.uk).
their local areas, especially in relation to parks and The reintroduction in 2006 of nutritional standards
schools (HM Government 2008). for school meals states that fresh fruit and vegeta-
The environments in which people work or live bles should be available each day as part of the school
can promote or inhibit healthy behaviours. (For a meal. Catering outlets also need to be targeted, as
more detailed discussion of the policy context see 10% of people’s total food intake is now eaten out-
Chapter 4 and the section on settings in our com- side the home (Office for National Statistics 2000).

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 Lifestyles and behaviours Chapter 11

Figure 11.1 • Determinants of food and

ACCESS
nutrition consumption. Source: Dh (1996, p. 4).
• Food prices
• Relative cost of healthier food
• Money for food
• Shopping capacity: time, transport,
physical ability, child care
Household Food
• Domestic storage capacity
Security
MACRO-LEVEL
POLICIES FOODS
Agriculture, AVAILABILITY HOUSEHOLDS
Economics, • Foods stocked in shops CAN BUY
Housing, used: range, quality
Employment, • Shop siting
Transport,
Retailing,
Health, INFORMATION
Town Planning etc.
• Food labelling
• Advertising and marketing
FOODS HOUSEHOLDS
• Nutrition education; leaflets, contact with
AND INDIVIDUALS
health professionals, formal education
CHOOSE TO BUY

CHOICE Nutrition
Security
• Taste, preference EATING
• Family acceptability AND MEAL
• Social/cultural norms PATTERNS FOODS
• Nutritional knowledge CONSUMED BY
• Motivation to consider health INDIVIDUAL
• Influence of promotions – advertising etc.

FOOD PREPARATION PRACTICES

INTRA-HOUSEHOLD
• Cooking skills DISTRIBUTION
• Ability and confidence to prepare healthier foods
• Family food hierarchy
• Cooking facilities

Box 11.13 Example

Social marketing to address obesity active lifestyles to families with children aged up to
Romp and Chomp is an initiative of the Sentinel Site 5 years. The Romp and Chomp family provides a
for Obesity Prevention, a WHO collaborating centre role model to encourage daily physical activity and
within Deakin University. The Romp and Chomp healthy eating. Once families identify with the Romp
project, based in Geelong, Australia, is a community- and Chomp family, support messages (e.g. how
based intervention addressing obesity. About 20% to increase active play opportunities for children
of Australian children are obese, and lack of physical under 5) can be delivered. Romp and Chomp works
activity and poor eating habits amongst the under with a variety of partners including day care facilities,
fives sets a pattern for later life that is difficult to families and physical activity providers.
remedy. Staff taking care of early childhood needs
lack the knowledge, confidence and skills to initiate Sources: Riethmuller et al 2009; http://www.deakin.
physical activity programmes. Romp and Chomp edu.au/hmnbs/who-obesity/about-us/publications/
uses social marketing techniques to promote healthy flyers/romp-chomp-brochure-dec-2005.pdf

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 pa r t t h r e e Priorities for public health and health promotion

The rise of fast food, takeout meals and the loss of such programmes through the provision of dietary
practical food preparation skills in schools’ curricula education and advice. In addition, practitioners can
has led to a focus on providing cooking skills. Cooking take a lead in implementing appropriate interven-
skills programmes seek to encourage people to prac- tions within the healthcare service setting and refer-
tise food preparation in a safe environment and stim- ring clients to local programmes.
ulate home cooking using fresh foods.

Box 11.14 Example Physical activity

Cookery classes for homeless people Physical activity is associated with positive health
Centrepoint, a registered charity and housing benefits as well as reducing the risk of coronary heart
association for young homeless people in Greater disease:
London, has launched a comprehensive project
The public health importance of physical
to improve the diet of the young people with
activity is clear, as adults who are physically
whom it works. The project was initiated following
research in 2002 that flagged up the problem of active have 20–30% reduced risk of premature
food poverty and poor diets amongst its clients. death, and up to 50% reduced risk of developing
In addition to improving the nutritional quality and the major chronic diseases such as coronary
variety of the food it provides and ensuring that its heart disease, stroke, diabetes and cancers.
kitchen and dining facilities are of a high standard, CMO (2004, p. 1)
Centrepoint has initiated a free programme that
includes cooking workshops run by a chef who
The British Heart Foundation (2003) estimates that
focuses on how to cook nutritious meals using
cheap available ingredients. The workshops are 37% of deaths from coronary heart disease could be
run every week and young people can attend as attributed to inactivity. The degree of risk of inac-
often as they like. Workshops on ‘budgeting for tivity is comparable to the relative risk associated
food’, which support young people to use their with the three main risk factors for coronary heart
limited money most effectively when shopping disease, i.e. smoking, high blood pressure and high
for food, and food hygiene sessions have also cholesterol. Inactivity is the biggest risk factor for
been instigated. Attendance at the cooking and the population as a whole and has one of the largest
shopping workshops has been high and feedback potentials for improvement. In common with debates
from young people has been very positive. over dietary recommendations regarding the desired
quantity of daily fruit and vegetables, recommenda-
Source: http://www.foodvision.gov.uk/pages/ tions relating to levels of physical activity have var-
cookery-courses-for-the-homeless accessed 8/7/09
ied. Current advice is a recommended minimum of
30 minutes of moderate exercise five times a week,
Integrated programmes that adopt a variety of strate- but there is flexibility in how this is achieved. For
gies including individually based education and per- example, incorporating exercise into everyday life in
suasion and community-based structural programmes 10 min blocks can be equally effective. Children and
focusing on access and availability are most effective. young people should undertake a range of moderate
Interventions may also target providers further up the to vigorous activities for at least 60 min every day.
food chain, for example the sourcing of locally grown At least twice a week this should include weight-
produce sold in farmers’ markets, or food labelling bearing activities that produce high physical stress to
to ensure that consumers can easily compare fat and improve bone health, muscle strength and flexibility
sugar contents of processed foods. Practitioners can (NICE 2009). Recent research shows that the major-
play an important role in supporting and reinforcing ity of the population is not taking adequate exercise.

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 Lifestyles and behaviours Chapter 11

Box 11.15 Example

Levels of physical activity in England • 4.2 million people (10.5%) go to the gym
in 2006 • More men (23.7%) regularly take part in
The Active People Survey is conducted by Sport sports than women (18.5%)
England, with the first survey taking place in • Over 2.7 million people put some voluntary
2005/2006. time into sport – with an estimated 1.8 million
• 21% of adults take part in at least three hours unpaid support every week of the
moderate intensity 30 min sessions of sport year. This equates to over 54,000 full-time
and physical activity every week equivalent jobs
• Walking was the most popular recreational • 4.7% of the adult population (1.9 million)
activity for people in England. Over 8 million contributes at least 1 hour a week
adults aged 16 and above (20%) had walked volunteering to sport
for at least 30 min during the previous 4 weeks
• 5.6 million people (13.8%) swim at least once Source: http://www.sportengland.org/research/
a month active_people_survey/

Box 11.16 Example

Approaches towards promoting physical no evidence has been found in the review from
activity amongst adults NICE (2007a) to suggest that exercise referral
The promotion of physical activity amongst adults schemes are effective in increasing physical activity
through primary care has included subsidized levels in the longer term (over more than 12 weeks)
access to leisure facilities, the use of pedometers or over a very long time frame (over more than 1
and walking or cycling schemes, and on-going year). Their guidance suggests that new exercise
support and advice to inactive people from referral schemes should not be established other
practitioners. than as part of such an evaluation programme or
other relevant evaluative study.
‘Exercise on prescription’ or exercise referral
schemes have been widely established. However,

However, brief interventions from primary care effective (Grandes et al 2009). Although the overall
practitioners have been shown to be effective (NICE clinical effect was small it would have a significant
2007a). Lawton et al (2008) found that a brief impact if rolled out across the population.
intervention by the practice nurse with a 6-month Although both the Health Survey for England
follow-up visit and monthly telephone support over (NHS Information Centre 2008) and the Active
9 months was effective in increasing physical activ- People Survey (http://www.sportengland.org) have
ity and quality of life for women aged 40–74 over a found that the proportion of men and women achiev-
2-year period (although there were also more falls ing recommended exercise levels has been increasing
and injuries). A cluster randomized trial of a primary steadily, only 6% of men and 9% of women knew
care intervention that involved physicians provid- what the recommended level is, with around one
ing advice and prescribing physical activity during an quarter thinking it was greater than it is and most
additional appointment found this intervention to be people either unaware of the recommendation, or

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 pa r t t h r e e Priorities for public health and health promotion

thinking it was less than it is. The most commonly iour and cardiovascular risk factors have their origins
cited barriers to doing more physical activity were in childhood. Positive changes within a school set-
work commitments (cited by 45% men), lack of lei- ting are associated with the following characteristics
sure time (cited by 37% women), and caring for chil- (HDA 2001; Canadian Cancer Society 2008; NICE
dren or older people (cited by 25% women). Around 2009):
15% of people cited lack of money, and around 12% • appropriately designed, delivered and supported
cited poor health, as barriers. physical activity curriculum
Children are a particular target group for increased • access to suitable and accessible facilities and
physical activity. The rise in passive hobbies and lei- opportunities for physical activity
sure pursuits, such as using the computer or watch- • involvement of young people in planning
ing TV, together with fears about road safety and the programmes
loss of sports activities in school (driven out partly • self-management programmes
by the demands of the national curriculum) have all
• complementary classroom curricula focusing on
combined to reduce the physical activity patterns of
physical activity
a whole generation. Behavioural patterns established
in childhood exert an influence on later adult behav-
• family involvement programmes.

Box 11.17 Example

Walk to school the Department for Transport, Transport for London,

Walking to school provides not only valuable Living Streets, and various local partners.
exercise but also the opportunity for social contact
and bonding between children and their parents http://www.livingstreets.org.uk/
and peer groups. More active transport methods
are also good for the environment. During national There is evidence that walking buses (volunteer-
walk-to-school weeks the number of pupils walking led walking groups supported by parents and
to school increases by about a third. Over 6,380 teachers plus the involvement of the local
schools, involving 1,719,558 pupils, currently highways or transport authority) led to increases
take part in walk-to-school schemes, which are in self-reported walking among 5–11 year olds,
promoted by 2 out of 3 local authorities. and reduced car use for children’s journeys to and
from school. However, the provision of a walking
Walk to school on one day a week (WoW), first bus may in itself not be sufficient to stem a more
launched in Gloucestershire in 1999 and later general decline in walking to and from school.
adopted by six London boroughs in 2004, aims to Retaining volunteers to act as coordinators for
achieve a permanent shift in commuting patterns. these schemes appears to be a key factor in the
WoW is supported by a variety of partners including sustainability of walking buses (NICE 2009).

Health promotion and public health interventions use of open spaces are being proposed. More often a
have focused on targeted interventions that reduce settings approach is used, as in the school setting in
barriers to exercise rather than promoting physical the example above, and increasingly a targeted focus
activity. However, more integrated approaches that on a particular group (e.g. young women) in a par-
are multi-level and include local travel plans and the ticular setting is adopted.

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 Lifestyles and behaviours Chapter 11

Alcohol and drugs Box 11.19 Discussion point

Alcohol and drug use is associated with many health and In 2009, the Chief Medical Officer called for a
social problems including violence, burglary, hazardous minimum pricing policy for alcohol of 50 pence
driving and public disorder in addition to physical and per unit of alcohol. What might be the objections
mental health problems. The links with criminal justice to such a policy?
tend to receive a higher profile than the health issues.
This is illustrated by the public focus on drugs, espe-
There is considerable ambivalence in the UK about
cially illegal drugs, rather than alcohol, although alcohol
tackling alcohol. On the one hand, there is evidence
poses a more serious risk to the public health.
of alcohol abuse and a recognition that reducing con-
sumption is a legitimate policy aim. On the other hand,
Box 11.18 the UK alcohol industry employs more than one mil-
lion people and is the fourth largest producer of spirits
Alcohol consumption in the UK and the sixth largest producer of beer in the world.
• Current recommendations are that men Alcohol constitutes over 3% of total tax revenue.
should not regularly drink more than 3–4 Health messages relating to alcohol may be ambig-
units per day and women should not uous and confusing because a limited intake of alco-
regularly drink more than 2–3 units per day. hol is associated with reduced risk of coronary heart
A unit of alcohol is equivalent to half a pint of disease. However, excessive use of alcohol is linked
beer, a glass of wine or a measure of spirits.
to a variety of health and social problems. The rise
• The General Household Survey shows that
in alcohol-related health and social problems has
in 2007, 37% exceeded the recommended
been fuelled by increases in alcohol consumption,
level and 20% of adults consumed more
than double the benchmark at least once especially amongst young people and women.
during the preceding week.
• Men drink more than women (41% of men Box 11.20 Discussion point
exceeded the daily limit at least once during
the previous week compared to 34% of What are the benefits and disbenefits of alcohol
women). consumption to:
• People in ‘managerial and professional’ a. society at large
households are more likely than those in b. communities
‘routine and manual’ households to have
c. trade and industry
exceeded the daily limit at least once
during the preceding week (43% and 31%, d. health and social care services
respectively). e. individuals and families.
• People are most likely to be drinking at
home on the days they drink the most.
• Over four-fifths of people (86%) had heard Box 11.21 Alcohol and health
of alcohol units but only about two-fifths
of people knew the correct recommended In 2006, in England there were over 6500 deaths
daily maximum for men and women (38% directly linked to alcohol, of which two-thirds
men and 44% women). were men.

Source: http://www.statistics.gov.uk/StatBase/ In 2006/2007, there were 207,788 hospital

Product.asp?vink=5756 admissions with a primary or secondary diagnosis

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pa r t t h r e e Priorities for public health and health promotion

Box 11.21 Alcohol and health—cont’d Commentary

Current research and policy supports a multi-
related to alcohol, with 9% of these involving partner and multi-factorial approach to alcohol
patients under 18 years. misuse and related harm. The current approach
seeks to preserve individual freedom and choice
Excessive use of alcohol is linked to many health whilst promoting self-regulation. Many countries
problems including raised blood pressure, certain focus on limiting intoxicated behaviour and the
types of cancers, strokes, fertility problems, criminalization of some drinkers (e.g. those in
gastritis, pancreatitis, liver disease, mental health public places). Demand reduction is anticipated
problems, accidents and suicides. following a health education programme of
recommended sensible drinking levels. Yet
Excessive use of alcohol is also linked to social there is a persistent credibility gap between
problems such as violence and crime. messages such as ‘safe, sensible and social’
and contemporary alcohol-related attitudes and
In 2006/2007, just over a half of violent attackers behaviours. In relation to supply, government
were believed to be under the influence of alcohol seeks a more responsible approach to
at the time of the attack. marketing and promotion by the drinks industry,
notwithstanding the liberalization of licensing
In 2004, alcohol misuse was estimated to cost the laws. Alcohol impacts on local communities,
health service between £1.4 and £1.7 billion per year. crime and disorder, and health and social
care, so tackling alcohol misuse and its effects
Recent estimates put the total cost of alcohol- requires close partnership working across a
related harm at around £20 billion per year. variety of agencies and services to promote a
safe night-time economy through the promotion
and enforcement of responsible retailing and
NHS Information Centre for Health and Social Care 2008. enhanced public protection measures. There
Cabinet Office 2004. is a role for many different strategies including
legislation, mass media campaigns, community
action and individually tailored education
Box 11.22 Practitioner talking and advice. This is illustrated in the following
example of England’s alcohol harm reduction
strategy.
It is so depressing being on the weekend night
shift at hospital and each week seeing the
same avoidable injuries, accidents and deaths,
all caused by alcohol. Last week was freshers’
week at the university and was even worse
A national alcohol harm reduction strategy for
than usual. We were stretched to the limit,
and then on top of it all you have drunken England, announced in 2004, identified the follow-
young people causing disruption in hospital ing approaches (ibid):
and being offensive to the people trying to • Better education and communication, for
help them. If they’re bright enough to go to example the ‘Know Your Limits’ binge-drinking
university, surely they’re bright enough to campaign and the ‘THINK’ drink-driving
know about sensible drinking limits? Although campaign.
a lot of it is down to irresponsible marketing • Improving health and treatment services.
and promotion by the drinks industry. All
• Combating alcohol-related crime and disorder
around town and the university, there are
notices offering cheap drinks and happy
through the use of new enforcement powers in
hours, and these students think it’s great. the Licensing Act 2003 and the Violent Crime
Reduction Act 2006.

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 Lifestyles and behaviours Chapter 11

• Working with the alcohol industry to promote be adopted. Interventions should include address-
sensible drinking and curb irresponsible ing alcohol education in the curriculum, policy
advertising and marketing of alcohol. development and the school environment, and staff
In 2007, this strategy was reviewed by several gov- training. Children and young people thought to be
ernment departments (DH, Home Office, DES and at risk of alcohol misuse should be offered one-to-
DCMS 2007), who announced the next steps in the one advice or be referred to an appropriate exter-
national alcohol strategy: nal service. Legislation continues to be one of the
• Sharpened criminal justice for drunken most effective strategies in combating alcohol mis-
behaviour. use. A combination of alcohol taxes, restrictions in
• A review of NHS alcohol spending. availability, and drink-driving countermeasures is
• More help for people who want to drink less. effective in reducing alcohol misuse and its effects
(Room et al 2005).
• Tougher enforcement of underage sales.
• Trusted guidance for parents and young people.
• Public information campaigns to promote a new
‘sensible drinking’ culture. Drugs
• Public consultation on alcohol pricing and The numbers of problematic drug users is hard to
promotion.
estimate but is in the region of 200,000 in England
• Local alcohol strategies. and Wales. Problematic drug use is therefore a low
prevalence risk behaviour but it is associated with
many health and social problems and high levels of
Box 11.23 Discussion point mortality. For example, the standardized mortal-
ity ratio for Scottish drug users is 12 times as high
Do you think that the current policy employs an as for the general population and the higher preva-
effective mix of legislation, media advocacy and
lence of problematic drug use in Scotland compared
education?
to England accounts for a third of Scotland’s excess
mortality over England (Bloor et al 2008). The new
National Drug Strategy (COI 2008) focuses on six
The BMA (2008) concluded that education and key areas:
health promotion had only a limited effect on 1. target drug-misusing offenders who are the
drinking behaviour, and advocated instead more source of crime in communities and take away
emphasis on the early intervention and treatment their proceeds
of alcohol misuse within primary care and hospi-
tal settings. At present, there is no routine screen- 2. focus on people at the top of the drug supply
ing for alcohol misuse, although alcohol misuse networks
questionnaires are an efficient and cost-effective 3. ensure that the police listen and respond to
means of detecting alcohol misuse. Brief interven- community concerns
tions delivered in healthcare settings are effec- 4. offer more support to families, especially
tive for people who are not dependent on alcohol. where there are parents misusing drugs
For alcohol-dependent people, specialized alcohol
treatment services are vital and need to be pro- 5. provide better information to parents and
vided and adequately funded throughout the UK young people, with compulsory drug education
(BMA 2008). in schools and local information campaigns
NICE (2007b) guidance on school-based inter- 6. provide better drug treatment services that
ventions on alcohol concluded that a whole school help drug users stay drug-free and reintegrate
approach involving a range of local partners should into society.

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 pa r t t h r e e Priorities for public health and health promotion

500 arrests and almost 300 people being referred to

Box 11.24 Example drug treatment services. The area has become safer
and a more pleasant environment (HM Government
The FRANK campaign 2009, p. 8).
Caught between media hysteria, adult denial,
and anecdotal stories from peers, young people
can find it hard to be informed about drugs. In Box 11.25 Activity
2008/2009, £6.6 million was allocated to the
FRANK campaign, using TV, radio and online How easy and ethical is it for practitioners to
advertising to reach young people. The social adopt a harm reduction approach?
marketing campaign was developed from
young people’s concepts of risk to develop
clear information. The website offers free and Treatment is a crucial part of the overall strategy.
impartial information and advice about drugs, Treatment is both effective and cost-effective – for
and individual queries can be e-mailed. A every £1 spent, an estimated £3 is saved in crimi-
number of sources of help are signposted from nal justice costs alone (Home Office 2002). The
this website. The FRANK campaign is jointly National Treatment Agency oversees treatment ser-
funded by the Home Office and the Department vices that are locally coordinated and provided by
of Health, working closely with the Department Drug Action Teams. Services range from in-patient
for Education and Skills. The recent FRANK detoxification and prescribing to structured counsel-
campaigns on cannabis and cocaine have been
ling and residential rehabilitation. The aim is to pro-
hailed as a success, with the cocaine campaign
vide a positive route out of addiction and crime for
featuring Pablo, a dog used to traffic the drug,
being viewed more than 700,000 times on the drug users.
YouTube website. Research shows that 89% of Harm reduction is another important aspect of
young people recognized the campaign and over strategy. There are many definitions and approaches
half the young people interviewed (53%) would to harm reduction but essentially it is a package of
turn to FRANK for information about drugs. measures and approaches that enable people to
reduce their risks. Some practitioners may find such
Source: http://www.talktofrank.com HM Government an approach difficult because it acknowledges peo-
(2009) ple’s right to make unhealthy or illegal decisions. It
also does not presume a goal of abstinence. For some,
this may be an unethical stance and one they cannot
Local communities bear the brunt of drug-related endorse. For others, using such an approach can pro-
disorder and crime. Coordinated action between vide a useful way to contribute effectively to reduc-
local people and agencies and local police can have a ing risks without having to adopt an unrealistic ‘all or
dramatic effect on the local availability of drugs and nothing’ approach.
associated problems. Drug arrest referral schemes, in
which users are offered early interventions and sup-
port through local police stations, self-referral, and Box 11.26 Discussion point
the courts, have been widely adopted. Following
Why do you think there are separate national
consultation with local people living in the London
strategies for alcohol, tobacco and drugs?
Road area of the city, Sussex Police and Brighton and
Hove City Council launched Operation Reduction in
2005. Operation Reduction targeted drug dealing and Alcohol and drug use presents law and order chal-
aimed to cut demand by getting drug users into treat- lenges as well as health problems. The most effective
ment. The campaign has been a success, with nearly approaches combine the use of different strategies

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 Lifestyles and behaviours Chapter 11

targeting different aspects of the problem. The use good sexual health are equitable relationships
of legislation, regulation and the criminal justice sys- and sexual fulfilment with access to information
tem is an important adjunct to the individual health and services to avoid the risk of unintended
screening, education, advice and medication provided pregnancy, illness or disease.
by practitioners. The evidence demonstrates that Dh (2001b, p. 7)

specific targeted interventions by health practition-

ers are effective and contribute to the reduction of Gender is an important factor affecting sexual health.
the disease burden caused by alcohol and drug use. ‘The differential power of men and women is evident
in most sexual intercourse as it is in the wider con-
text of male–female relations’ (Doyal, 1995, p. 62).
Sexual health Women’s capacity to enjoy and express their sexual-
ity is limited by the fundamentally unequal relation-
The term sexual health has many contrasting defini- ship between men and women. Women may have
tions that are influenced by beliefs about concepts to negotiate their concerns about fertility and safer
such as health and sex. Definitions may range from a sex and may be threatened with violence, harass-
focus on the clinical causes of ill health, such as infec- ment or abuse from their partners. A survey of young
tions, to a celebration of pleasure. women’s sexual attitudes concludes that for ‘a young
woman to insist on the use of a condom for her own
safety requires resisting the constraints and oppos-
Box 11.27 Activity ing the construction of intercourse as a man’s natural
pleasure and a woman’s natural duty’ (Thomson and
How would you define sexual health? Does your Holland 1994, p. 24). Homosexuality remains a less
definition impact equally on men and women? On socially valued and more discriminated against sex-
heterosexual and homosexual people?
ual identity compared to heterosexuality. Activities
that heterosexuals take for granted, such as public
Sexual health has been defined in various ways. recognition and acceptance of their sexual partners,
Whilst there is often a focus in service provision on can be problematic for homosexuals. The rights of
sexual ill health and disease, most definitions refer homosexuals are prescribed by law, for example the
to a holistic positive concept of sexual health. For age of consent for homosexuals is 18 compared to 16
example, the World Health Organization refers to for heterosexuals.
‘the integration of the physical, emotional, intellec- The element of sexual health that is defined as
tual and social aspects of sexual being, in ways that being free from sexually transmitted infections
are enriching and that enhance personality, commu- (STIs) has declined in recent years. All STIs have
nication and love. Fundamental to this concept are increased in the past decade (1998–2007), espe-
the right to sexual information and the right to plea- cially gonorrhoea (42% increase), chlamydia (150%
sure’ (WHO 1975). The Department of Health rein- increase) and syphilis (increased by a factor of 19)
forces the holistic concept of sexual health whilst (http://www.avert.org/stdstatisticuk.htm). The inci-
acknowledging the need to avoid unintended conse- dence of STIs is linked to ethnicity (in 2005 Black
quences of sexual activity including disease. Caribbeans accounted for 18% gonorrhoea diagnoses)
and homosexuality (in 2007 55% syphilis cases were
Sexual health is an important part of physical acquired through sex between men) (ibid). The inci-
and mental health. It is a key part of our identity dence of HIV/AIDS has also increased significantly;
as human beings together with the fundamental for further details see Chapter 10.
human rights to privacy, a family life and living The UK has the highest rate of teenage pregnan-
free from discrimination. Essential elements of cies in Western Europe. Teenage pregnancy is linked

223
 pa r t t h r e e Priorities for public health and health promotion

to poverty and disadvantage, and is more common also been criticized for adopting a moralistic stance
in lower socio-economic families living in deprived and treating young people as immature and lacking in
areas. It is also more common amongst some ethnic autonomy. Sex education programmes in the UK are
groups (e.g. Caribbean, Pakistani and Bangladeshi supporting young people to delay sexual activity.
young women), young people with below aver- A review of the government’s 10-year sexual
age educational achievement, young people who health strategy, launched in 2001, pinpointed five
have been in care, socially excluded from school, or key strategic areas where priority action was needed
involved in crime, and children of teenage mothers. (MedFASH 2008):
Teenage pregnancy is linked to a number of negative • Prioritizing sexual health as a key public health
outcomes (health problems for babies, lower educa- issue and sustaining high-level leadership at local,
tional attainment and employment rates of mothers, regional and national levels.
lone parenthood and social isolation), and is one of • Building strategic partnerships with health
the mechanisms which perpetuates cycles of depriva- services, local authorities and the third sector
tion throughout generations (Swann et al 2003). (voluntary sector).
England launched a Teenage Pregnancy Strategy • Commissioning for improved sexual health.
in 1999 with an ambitious target to halve teenage • Investing more in prevention through
pregnancies by 2010. Since 1998 there has been a commissioning and resourcing sexual health
13.3% reduction in conceptions amongst under 18 promotion, making personal social and health
year olds, with reductions in more than 120 local education in schools statutory, and improving
authorities. More than 20% of local authorities have dissemination of effective interventions.
had decreases of at least 25% in teenage pregnancy
• Delivering modern sexual health services.
rates. A new strategy “Teenage Pregnancy Strategy:
Beyond 2010” has been launched. (http:www.dcsf.
gov.uk/everychildmatters/healthand wellbeing/
teenagepregnancy) A review of evidence found the Box 11.28 Activity
following interventions to be effective (Swann et al
2003): Why do sexual health services remain
• sex education in schools, particularly when linked the Cinderella of the NHS – underfunded,
to contraceptive services understaffed and relatively invisible?

• community-based education, development and

contraceptive services
Health promotion and public health interventions
• youth development programmes focusing aimed at changing sexual behaviour face particular
on personal and vocational development and challenges due to the sensitive nature of the subject
education and the power of gender and sexual orientation in
• family outreach involving parents of young people. shaping people’s perceptions and attitudes. Sexual
Responsive local services that are accessible and health is also a complex area and includes both fer-
staffed by trained and committed staff are also vital. tility and STIs. The focus of the national strategy is
Peer education, ensuring age-appropriate interven- on increasing access, availability and acceptability of
tions tailored to young people with clear messages NHS sexual health services. This may involve prac-
and partnership working are all factors flagged up as titioners developing more client-centred, flexible
contributing to effective interventions. Abstinence- approaches to service delivery. The priorities remain,
based interventions (which advocate no sexual activ- however, more focused on sexual ill health – to
ity before marriage) have been widely supported in reduce STIs and HIV, and also to reduce the teenage
the USA but are shown to be ineffective, and have pregnancy rate.

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 Lifestyles and behaviours Chapter 11

individual clients, and also with groups and local

Conclusion communities if the opportunity arises. These tech-
niques seek to change people’s behaviour voluntarily
Lifestyles and individual behavioural choices have a as a result of education, information, support and
long history of being targeted for change by health advice. An evidence base of effective techniques to
promoters. The significance of behaviours such as use in educational and motivational interventions is
diet, exercise, smoking, alcohol and drug use, and growing. A combination of different strategies that
sexual activity in affecting or even determining health includes legislation and regulation is the most effec-
outcomes is widely accepted. What is disputed is tive means of achieving behavioural changes.
the effectiveness of different kinds of approaches
to changing lifestyles and whether they are ethi-
cally defensible. Lifestyles are generally viewed as Further discussion
an individual choice that should be respected unless
they directly infringe on someone else’s freedom to
• Identify the opportunities and barriers to
choose. The impact on others is generally easier to
working with individual clients to change one of
appreciate when it involves aspects such as safety and
the behaviours discussed in this chapter.
crime (linked to alcohol and drug use) rather than
aspects such as health (linked to smoking). However, • What criteria would you use to determine
the counter case may be made – that the government whether or not individual behaviours (such as
has a duty to protect people from known health risks, smoking and alcohol and drug use) should be
especially when these are socially patterned and the subject of legislation and regulation?
linked to socio-economic inequalities. When behav-
• Discuss the relative contribution of individual
iours directly impact on others, it is much easier to
education and advice, mass media campaigns
get support for legislation and regulation to control
and legislation in achieving behavioural change.
such behaviours. When the effects are more diffuse,
the case for legislation is correspondingly more dif-
ficult. This can be demonstrated by comparing the Recommended reading
existence of laws regulating drunkenness in pub-
• Ewles L, Simnett I: Promoting health: a practical
lic places and whilst in charge of vehicles with the
guide, edn 5, Edinburgh, 2003, Baillière Tindall.
long battle to ban the advertising and promotion of
This popular book includes sections on how
tobacco products. Whilst smoking causes ill health
practitioners can assess needs and help their
and distress to passive smokers as well as to smokers,
clients change their behaviour and lifestyles.
it is not associated with visible anti-social behaviour.
The campaign to ban tobacco advertising therefore • NICE: Behaviour change at population,
took a long time to build the evidence and win sup- individual and community levels, 2007, at
port, and a ban on smoking in virtually all public http://www.nice.org.uk/Guidance/PH6.
places and workplaces was only introduced in 2007. This guidance identifies how to plan and
Whilst legislation and regulation may be the most run relevant initiatives based on evidence
effective means of changing lifestyles, in many cases from different theoretical perspectives and
they are seen as inappropriate because of the right research.
to individual freedom and liberty. In these cases, Summaries of evidence of effective
education and persuasion through the use of mass interventions to tackle a range of public
media campaigns may be the appropriate strategy. health issues are available on the NICE web-
Health practitioners have an important role to play site http://www.nice.org.uk and currently
in using educational and motivational strategies with include:

225