Beyond Behaviour Change: Key Issues, Interdisciplinary Approaches and Future Directions 9781447317586

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“This book shines a much-needed multidisciplinary light into the corners of the fast-emerging field of behaviour change. An important read for policymakers, business people and academics alike.” Agnes Nairn, Hult International Business School, USA

‘Behaviour change’ has become a buzz phrase of growing importance to policymakers and researchers. There is an increasing focus on exploring the relationship between social organisation and individual action, and on intervening to influence societal outcomes like population health and climate change. Researchers continue to grapple with methodologies, intervention strategies and ideologies around ‘social change’.

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Multidisciplinary in approach, this important book draws together insights from a selection of the principal thinkers in fields including public health, transport, marketing, sustainability and technology. The book explores the political and historical landscape of behaviour change, and trends in academic theory, before examining new innovations in both practice and research. It will be a valuable resource for academics, policy makers, practitioners, researchers and students wanting to locate their thinking within this rapidly evolving field.

Beyond Behaviour Change

“This excellent text provides multiple perspectives and important syntheses which should help unify ideas in the growing field of ‘wicked’ problems.” John Parkinson, Bangor University, UK

Edited by

GOVERNANCE / SOCIAL STUDIES

www.policypress.co.uk PolicyPress

BEYOND BEHAV_pb.indd 1

@policypress

Fiona Spotswood

DR FIONA SPOTSWOOD is a critical marketer based at Bristol Business School, University of the West of England. Her research uses practice theory to explore the impact of marketing on ’wicked’ problems.

Beyond Behaviour Change Key Issues, Interdisciplinary Approaches and Future Directions Edited by

Fiona Spotswood 12/02/2016 10:16

BEYOND BEHAVIOUR CHANGE Key issues, interdisciplinary approaches and future directions Edited by Fiona Spotswood

First published in Great Britain in 2016 by Policy Press North America office: University of Bristol Policy Press 1-9 Old Park Hill c/o The University of Chicago Press Bristol 1427 East 60th Street BS2 8BB Chicago, IL 60637, USA UK t: +1 773 702 7700 t: +44 (0)117 954 5940 f: +1 773-702-9756 [email protected] [email protected] www.policypress.co.uk www.press.uchicago.edu © Policy Press 2016 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book has been requested ISBN 978-1-4473-1756-2 paperback ISBN 978-1-4473-1755-5 hardcover ISBN 978-1-4473-2331-0 ePub ISBN 978-1-4473-2332-7 Mobi The right of Fiona Spotswood to be identified as editor of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988. Every reasonable effort has been made to obtain permission to reproduce copyrighted material. If, however, anyone knows of an oversight, please contact the publisher. All rights reserved: no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of Policy Press. The statements and opinions contained within this publication are solely those of the contributors and editor and not of the University of Bristol or Policy Press. The University of Bristol and Policy Press disclaim responsibility for any injury to persons or property resulting from any material published in this publication. Policy Press works to counter discrimination on grounds of gender, race, disability, age and sexuality. Cover design by Hayes Design Front cover image: Getty Printed and bound in Great Britain by CMP, Poole Policy Press uses environmentally responsible print partners

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Contents List of tables, figures and boxes vii Preface Michael P. Kelly xi Acknowledgement xii Notes on contributors xiii Introduction 1 Fiona Spotswood 9 Part One: Exploring the history, theory and politics of ‘behaviour change’ The politics of behaviour change 11 one Michael P. Kelly An introduction to theories of behaviour 27 two Tim Chatterton Intervention design and evaluation: behaviour change 49 three imperatives Sarah Denford, Charles Abraham, Jane Rebecca Smith, Sarah Morgan-Trimmer, Jenny Lloyd and Katrina Wyatt Government legislation and the restriction of personal 71 four freedoms Alan Maryon-Davis Evaluating the impact of policy: the built environment 89 five and travel behaviour Steven Melia Nudge: recent developments in behavioural science 113 six and public policy Michael Hallsworth and Michael Sanders seven Social marketing and multidisciplinary behaviour change 135 Alan Tapp and Sharyn Rundle-Thiele eight Technology and the formation of socially positive 157 behaviours Adam Joinson and Lukasz Piwek Part Two: Critique, innovation and new ideas 179 nine Stakeholder marketing and the subversion of public 181 health Gerard Hastings and Marisa de Andrade ten Participation in behaviour change: technique or tyranny? 199 Katie Collins

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eleven twelve thirteen

fourteen

Values and public expressions of concern 217 Tom Crompton Social practices and behaviour change 237 Daniel Welch The emergence of systems thinking in behaviour change: 257 a public health focus Esther Trenchard-Mabere Conclusion: what is the future of ‘behaviour change’? 283 Fiona Spotswood and Alex Marsh 299

Index

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List of tables, figures and boxes Tables 5.1 10.1 13.1

Relationship between the built environment and travel behaviour Ladder of participation Key features of reductionist approaches compared with key features of systemic approaches

90 208 260

Figures 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 3.1 4.1 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 7.1

Use of the terms ‘behaviour’ and ‘behaviour change’ 30 in English language books 1920–2008 The expectancy-value model of behaviour 33 Theory of reasoned action 34 Theory of planned behaviour 35 Theory of interpersonal behaviour 36 The determinants of health and wellbeing 38 Four dimensions of behaviour 40 Descriptions of the levels for each of the four dimensions 41 of behaviour Key functions of process evaluation and relationships 63 among them Intervention ladder 76 Modal share of all trips. Bristol suburbs surveyed 93 Percentage of trips in distance bands walked or cycled. 94 Bristol suburbs surveyed for solutions Percentage change in density of new housing and 96 in annual miles driven per person, 1994–2011 Percentage of population of England and Wales in 97 four density bands Population density and commuting by car in England 98 and Wales Gridiron street layout, Philadelphia 100 Suburban layout, Arizona 101 Filtered permeability in Malmö, Sweden 103 Bus gate in Cambridge, UK 103 Causal influences on cycling 106 The education/law continuum 140

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7.2 7.3 7.4 7.5 8.1 8.2

8.3 11.1 12.1 12.2 12.3 12.4 12.5 13.1 13.2

The social ecology model 143 A typical social marketing management process 145 Multidisciplinary behaviour change management 150 process integrating social marketing Increasing permeability between education, marketing 151 and law The extend-amplify-shape-transform (EAST) framework 159 for technology and behaviour change Examples of consumer-level smart technology that 164 enables sophisticated self-monitoring (a) Nike+ fitness tracker; (b) Basis Peak sleep and biometric smart watch; (c) Withings Smart Body Analyser Behaviour chain model 169 Individual value-level structure averaged across 220 68 countries Observable behaviour is the performance of social 239 practices The three elements model of practice 245 Recrafting practices changing the elements of practice 245 Substituting practices different practices compete for 246 time, space and resources Changing how practices interlock 248 Certainty–agreement diagram 264 The systems map of obesity 273

Boxes 1.1 1.2 1.3 1.4 2.1 3.1 3.2 3.3 3.4 4.1 4.2 4.3 4.4 4.5

Stop and think: the state knows best Stop and think: the politics of rights and freedom Stop and think: degrees of risk Stop and think: dual systems The ‘beyond the ABC’ debate Stop and think: other considerations of co-creation Stop and think: the problem with theories Stop and think: the limitations of ‘fear’ appeals Stop and think: randomised controlled trials – the gold standard Stop and think: no one escapes regulation Case study: seat belts Case study: drink driving Stop and think: powerful lobbying Case study: illicit drugs

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14 14 17 19 44 53 54 56 60 74 77 78 80 80

List of tables, figures and boxes

4.6 4.7 4.8 4.9 5.1 5.2 5.3 5.4 6.1 6.2 6.3 6.4 6.5 7.1 7.2 7.3 7.4 8.1 8.2 8.3 8.4 9.1 9.2 9.3 9.4 10.1 10.2 10.3 11.1 11.2 11.3 12.1 12.2 12.3

Case study: female genital mutilation Case study: ban on smoking in workplaces and public spaces Stop and think: the power of policy Case study: e-cigarettes Stop and think: the nature of evidence Stop and think: unintended consequences Case study: focus on the evidence around filtered permeability Stop and think: brave decisions Stop and think: are you thinking rationally? Case study: the UK government’s adoption of the behavioural sciences (post 2010) Stop and think: the importance of evaluation A comparison with social marketing Stop and think: the problem with RCTs Stop and think: the rise of behavioural economics Social marketing as the ‘middle ground’ Case study: social marketing and service delivery – redesigning breastfeeding services Case study: working across professions and redesigning interventions: ‘Wheels, Skills and Thrills’ Case study: Nike+ Case study: Google Maps Stop and think: are digital technologies for behaviour change a ‘solution in search of a problem’? Stop and think: the end of privacy? Stop and think: the fallout from CSR and CRM Stop and think: soft measures to regulate business Case study: Coca Cola’s obesity campaign Stop and think: the role of social marketing Stop and think: criticisms of participatory methods Stop and think: participation in public health Participatory methods in practice Tom Crompton’s personal journey Stop and think: your values Case study: an empirical study of values in social and environmental campaigning Stop and think: the implications of practice-as-entity Stop and think: how theories of practice make us see things differently Case study: Cool Biz

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81 82 84 84 91 99 104 107 115 116 119 119 124 138 139 144 149 164 165 166 170 184 186 186 194 206 210 210 219 221 224 240 243 244

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12.4 12.5 13.1 13.2 13.3 13.4 13.5 13.6 13.7 14.1 14.2

Stop and think: implications for evaluation Stop and think: considerations for policy Stop and think: an example of a complex system Stop and think: the role of business and marketing in the system Stop and think: an example of using boundary definitions to change the focus of activities Stop and think: widening the focus Stop and think: examples of ‘systemic’ community development and social movement approaches Stop and think: public support for regulation Stop and think: challenges and barriers to the implementation of systemic approaches in public health Stop and think: the scope of policy ‘evidence’ Stop and think: the political uses of research

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249 250 260 262 263 267 271 272 275 291 293

Preface This book provides an overview of current thinking about behaviour change, from its political and theoretical heritage to the imperatives of evidence for policymaking and various streams of emphasis for its future agenda. Given the context of non-communicable disease and environmental damage that society now faces, behaviour change is a thread running through much policymaking and academic research, and this book takes time to give key issues due consideration. The book tackles ‘behaviour change’ as a distinct cross-disciplinary field, choosing not to focus specifically on health or sustainability or transport. As such, the contributing authors have a particularly wide-ranging set of disciplinary backgrounds so that many perspectives on behaviour change are explored. Perspectives across the chapters may clash, overlap and contradict, but this merely presents a true picture of a contested field. Students, academic researchers, practitioners and policymakers alike will find it an invaluable contribution to their understanding about this demanding, engaging and politically sensitive area of modern life. Michael P. Kelly

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Acknowledgement The development of this book was originally funded by the Engineering and Physical Sciences Research Council through a Bridging the Gaps grant, entitled ‘Health, Environment and Technology at The University of the West of England’ (HEAT@UWE).

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Notes on contributors Professor Charles Abraham is Professor of Psychology Applied to Health at the University of Exeter Medical School, Exeter, UK. Charles is a practising health psychologist and a public health researcher specialising in the design, evaluation and implementation of interventions to change health behaviour patterns. He was one of seven psychologists included in a list the leading 100 practising scientists in the UK in 2014. Dr Tim Chatterton is Senior Research Fellow (Energy and Environment) at the University of the West of England, Bristol, UK. Tim has a background in both social and environmental sciences. He specialises in working at the interface of science and policy in the UK and internationally across a wide range of areas including air quality, climate change, energy use, transport and public health. Dr Katie Collins is Senior Research Fellow at the University of the West of England, Bristol, UK. Katie’s research draws on participatory, feminist and activist scholarship. Current projects exploring masculinity and institutionalisation include a critical ethnography of a self-build scheme for homeless ex-military people and exploratory work funded by the British Academy/Leverhulme Trust to understand what resources, capabilities and assets ex-offenders possess. Dr Tom Crompton is Director of the Common Cause Foundation, UK (www.commoncausefoundation.org). Tom has worked for some of the UK’s foremost charities on the role of values in motivating public commitment to social and environmental change. Dr Marisa de Andrade is Lecturer and Programme Director in Integrated Service Improvement at the School of Health in Social Science, University of Edinburgh. She completed an Impact Fellowship at the Institute for Social Marketing, University of Stirling and works on various projects in health policy, pharmaceutical regulation, critical communication, tobacco control, asset-based approaches and coproduction. Before entering academia, she worked as a broadcaster and investigative journalist.

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Dr Sarah Denford is Research Fellow in Psychology Applied to Health at the University of Exeter Medical School, Exeter, UK. Sarah’s background is in health psychology. Her previous work has attempted to identify processes that are associated with behaviour change in complex interventions. This includes systematic reviews and qualitative research. Her current research focuses on evaluation of public health interventions. Michael Hallsworth is Head of Health at the Behavioural Insights Team in London and Honorary Lecturer at Imperial College London, UK. Michael’s work focuses on applying social psychology to improve public policy. He has worked on a variety of policy issues for the Institute for Government and the RAND Corporation. Professor Gerard Hastings is Professor of Social Marketing at the University of Stirling, UK, at the Open University and at L’Ecole des Hautes Etudes en Santé Publique. He founded the Institute for Social Marketing and the UK Centre for Tobacco and Alcohol Studies. Gerard is author of The Marketing Matrix, which explores the harm being done to our health, our communities and our planet by corporate capitalism. He was awarded the OBE for services to health care in 2009. Professor Adam Joinson is Director of the Behavioural Research Lab and the Centre for the Study of Behaviour Change and Influence at the University of the West of England, Bristol, UK. Adam has published widely on the topics of psychology and technology, social media, privacy and communication, and most recently on using technology to change people’s behaviour. Professor Michael P. Kelly is Honorary Senior Visiting Fellow at the General Practice and Primary Care Research Unit, Institute of Public Health, University of Cambridge, UK. A public health researcher and academic, Michael originally trained in sociology and economics and took his PhD in a department of psychiatry. He has written extensively about health inequalities and behaviour change. From 2005 to 2014 he was Director of the Centre for Public Health at the National Institute for Health and Care Excellence (NICE). Dr Jenny Lloyd is Senior Research Fellow in Child Health at the University of Exeter Medical School, Exeter, UK. Jenny has a background in exercise and health psychology. Her research interests centre on the development and evaluation of complex interventions for

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behaviour change, particularly in relation to preventing and managing childhood obesity and the use of process evaluation to understand the effect of context on outcomes. Professor Alex Marsh is Professor of Public Policy at the School for Policy Studies, University of Bristol. Alex’s research has focused on housing and urban issues, including examining evidence in policymaking. He will soon publish his most recent book, co-authored with Dave Cowan, The battle of the bedroom tax: A study in fairness and the policy process. Professor Alan Maryon-Davis is Honorary Professor of Public Health at the Division of Health and Social Care Research, Kings College London. Alan has published widely on public health policy and has been a member of several national expert committees advising the UK central government. He is a former Chair of the Royal Society for Public Health and former President of the UK Faculty of Public Health. Dr Steven Melia is Senior Lecturer at the Centre for Transport and Society, University of the West of England, Bristol, UK. His research in the area of transport and planning has proposed the ‘paradox of intensification’ and ‘filtered permeability’. His book, Urban transport without the hot air (UIT Cambridge), was published in 2015. Dr Sarah Morgan-Trimmer is Research Fellow in Process Evaluation at the University of Exeter Medical School, Exeter, UK. Sarah’s expertise is in developing process evaluation methods for complex health behaviour interventions. Her background is in qualitative methods, evaluation research and research on social inequality. Dr Lukasz Piwek is a Research Fellow at the Behavioural Research Lab and The Centre for the Study of Behaviour Change and Influence at University of the West of England, Bristol, UK. He works on various ways to apply smart technologies in behaviour change domain, with strong interest in topics of social and cognitive psychology, behavioural economics and persuasive design. Professor Sharyn Rundle-Thiele is Professor of Marketing and Social Marketing at Griffith Menzies Health Institute, Queensland, Australia. Sharyn leads Social Marketing @ Griffith (www.griffith.edu.

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au/social-marketing) and is Editor of the Journal of Social Marketing. Sharyn’s research focuses on behaviour change. Her current projects include changing adolescent attitudes towards drinking alcohol (see http://gameon.rcs.griffith.edu.au/) and increasing healthy eating and physical activity to combat obesity. Dr Michael Sanders is Head of Research at the Behavioural Insights Team in London and Doctoral Fellow based in the Behavioural Insight Group at the Harvard Kennedy School of Government, US. Michael’s research uses field experimental methods to test insights drawn from the behavioural sciences that are applied to public policy problems, with an interest in field experimental methodology itself.  Dr Jane Rebecca Smith is Research Fellow in Psychology Applied to Health at the University of Exeter Medical School, Exeter, UK. Jane’s current research focuses primarily on the development and evaluation of evidence-based interventions to promote health-related behaviour change, mainly linked to the prevention and management of chronic diseases such as diabetes and asthma. This includes systematic reviews and randomised controlled trials with parallel economic and process evaluations. Dr Fiona Spotswood is a Senior Lecturer in Marketing at Bristol Business School, University of the West of England (UWE), Bristol, UK. Fiona is a social marketing researcher, interested in the role marketing has to play in societal problems such as materialism and obesity, and its part in identifying sustainable solutions to these problems. She is based at UWE’s Centre for the Study of Behaviour Change and Influence. Professor Alan Tapp is Professor of Marketing at the University of the West of England (UWE), Bristol, UK. Alan was founder and former Director of the Bristol Social Marketing Centre, UWE (now the Centre for the Study of Behaviour Change and Influence). He now concentrates on specific research interests centring on marketingled behaviour change work in road safety, cycling promotion, and encouraging physical activity and sport. Esther Trenchard-Mabere is Associate Director of Public Health, London Borough of Tower Hamlets, UK. Esther has worked in public health, health promotion and nutrition in the NHS, local authority, overseas, research and voluntary sectors for over 30 years. Esther led

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a local pilot on ‘whole systems’ approaches to preventing obesity and has contributed to the development of NICE guidance. Dr Daniel Welch is a Research Associate at the Sustainable Consumption Institute, University of Manchester, UK. Dan was previously a Research Associate with the Sustainable Practices Research Group. His doctoral thesis, awarded in 2013 (Sociology, University of Manchester), analysed the commercial field of sustainability communications. His research interests include theories of practice, sustainable consumption, cultural economy and socio-technical transitions. Dr Katrina Wyatt is Associate Professor in Health Research at the University of Exeter Medical School, Exeter, UK. Katrina’s background is in developing and evaluating complex interventions that can change behaviours alongside communities and stakeholders such that the intervention and the research are co-created. A central tenet of the research is understanding communities, schools, families as complex systems and trying to affect the system dynamics towards healthful behaviours.

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Introduction Fiona Spotswood This is one of the very first books to explore behaviour change from a range of disciplinary perspectives. There is no restrictive focus in this volume, on say health or the environment. The wicked problems that society faces are complex – huge – and ‘behaviour change’ has taken on a life of its own as the thing all these problems have in common: the need for people to change their behaviour. These problems are not the fault of obscure bacteria. There is no extra-terrestrial attack. These problems – obesity, pollution, congestion, smoking-related disease and many heart diseases and cancers – are human-made. However, the phrase ‘behaviour change’, which has become so pervasive in political, academic and media commentary, is loaded with meaning, assumption and ideology. Some dislike the term because it presumes that the individuals ‘doing’ the behaving (the smokers, the drivers or the consumers of unhealthy food) should be the sole focus of intervention and that this ignores the socio-cultural structures in which all individual behaviour takes place. Alternatives, however – terms like ‘social change’ or ‘societal influence’ – are equally lambasted for the sense that ‘population control’ feels too Orwellian. In the middle comes the neoliberal view that has seen the rise of ‘nudge’ approaches – those that use behavioural economics insights to structure choices but maintain the existence of the choice. These of course have attracted their own flurry of criticism. The point is that ‘behaviour change’, used in the title of this volume for its recognisability more than for its representation of any overarching viewpoint, is rapidly becoming viewed as a ‘field’ of knowledge in its own right. There are a growing number of Masters’ and continuing professional development courses in the subject (at the Universities of Derby, Stirling and the West of England [UWE], for example), plus a growing number of specialist research centres (such as at Bath, Bristol, Cambridge, Cardiff, Stirling, University College London and UWE) that grapple with a variety of behaviour-change-related research conundrums. However, the reality, as this book demonstrates, is that the range of perspectives within ‘behaviour change’ is as considerable as the disparity between them. Until now there has been no volume that brings together the range of viewpoints, disciplines, theories, ideologies and critiques that pervade

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‘behaviour change’. Editing this book has been a challenging task; to invite contributions from the sheer breadth possible. The guiding principle has been to avoid focusing on the problems that behaviour change activity seeks to tackle, and to focus rather on the behaviour change technique, theory, ideology (and so on) itself. Naturally, there are chapters that emphasise a particular platform for the points discussed – whether urban planning for transport (Chapter Five) or public health (Chapter Thirteen); but these are ‘case studies’ for the consideration of broader behaviour change themes. Other chapters have no focus of this nature at all, and consider a particular aspect of theory or ideology in the broadest sense. A second guiding principle has been to invite contributions from authors who are intentionally diverse (and also who are established experts in their field). This has naturally led to a good deal of disagreement across chapters, where viewpoints are countered and strong criticisms offered. The resulting conflict is insightful, and stands to demonstrate the depth of knowledge within each of the areas represented, as well as the current fragmentation of the ‘field’. ‘Behaviour change’ is clearly not one field with a settled history and set of established foundational theories. It is a collection of diverse streams of research which loosely have the shared goal of societal improvement. As the conclusion discusses in more depth, it seems that a desirable shift would be for the contributing disciplines somehow to join forces and work within a transdisciplinary agenda for maximum innovation and creativity. It is hard to see how this blending will be possible (discussed at length in Chapter Twelve), but there is a growing commentary arguing that this is the move that needs to happen for ‘change’ to become more effective and sustainable. In the meantime, this book attempts to represent a range of concerns that can be grouped under the umbrella of ‘behaviour change’. There are two groupings of these, relating to the two sections of the book. The first section (Chapters One to Eight) broadly explores behaviour change from an ‘evolutionary’ perspective,1 in terms of its theoretical underpinning and development and its existing and changing applications at policy level, and in terms of technological innovations. Most of these approaches are evolutionary in that they consider behaviour change from ‘within’ existing societal structures rather than seeking to question the structures themselves (that is, from a ‘revolutionary’ perspective). As such, the book commences with a chapter on the political history of behaviour change, outlining its violent history while also drawing attention to the disciplinary dualisms – between sociological and psychological approaches – that

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Introduction

have evolved over time. Michael P. Kelly’s long-term service as Director of the National Institute for Health and Care Excellence (NICE; formerly the National Institute for Clinical Excellence) has given him the opportunity to see what has worked and failed in the past and how the field needs to evolve. His chapter is a fitting introduction. In Chapter Two, Tim Chatterton, who spent time as a visiting scholar in the UK Government’s Department of Energy and Climate Change, explores the theories that have traditionally been used to underpin behavioural understanding and intervention. Dr Chatterton examines the foundation of these traditional theories and highlights the assumptions made through use of each about the nature of ‘behaviour’. Chapter Three is a detailed overview of behaviour change intervention and design that focuses on the well-established academic field of behaviour change intervention management. The chapter, led by Sarah Denford from the University of Exeter Medical School and co-authored with, among others, Charles Abraham, one of the creators of the ‘behaviour change technique taxonomy’,2 looks specifically at mechanisms for managing intervention design that is based on sound evidence and robust, replicable evaluation. The interventions and techniques in question are specifically about individual change, which has a considerable evidence base to support its effectiveness at a population level. Then the volume moves to explore governmental applications of behaviour change approaches and introduces discussions about policies that directly or indirectly influence behaviour (Chapters Four and Five). Chapter Four was written by Alan Maryon-Davis, whose many appointments include inaugural Chair of the Royal Society for Public Health and who is a regular commentator on the role of policy in public health. After outlining the history of regulation in the fight for better public health, Professor Maryon-Davis cuts to the modern day, an age when governments are reluctant to pass laws directly curtailing the personal freedoms and behaviour of individuals despite the evidence that regulation is an essential part of the armoury of policies that governments can and should exercise to protect and promote the health and wellbeing of their populations. Chapter Five, however, considers a different take on behaviour change policies – those that are designed to change behaviour less directly, in this case via changes in the urban environment. The chapter, by an expert from the Centre for Transport and Society at the University of the West of England (UWE), Steven Melia, also focuses on the slippery nature of ‘evidence’ for these indirect measures, presenting a detailed picture of

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the problems with assuming causality. The chapter tackles two areas of travel policy: permeability and cycle paths. The next two chapters offer alternative perspectives on the government’s neoliberal agenda. Chapter Six examines the rise in favour of ‘behavioural economics’ and, in particular, the ‘nudge’ approach, which was adopted by the Conservative-led coalition government. Nudging claims to preserve freedom of choice while also containing an element of paternalism. Rather than coercing behaviour change through policy, ‘nudge’ uses insights about people’s natural tendencies and mental shortcuts to guide them towards healthier decisions. The chapter explores the rise of this approach, as well as its criticisms, and examines the work of the government’s Behavioural Insights Team, on which both authors – Michael Sanders and Michael Hallsworth – have served. In contrast, Chapter Seven explores social marketing, which has also been used as a government approach to behaviour change, although as Chapter Six points out, it has fallen out of favour and faces a range of criticisms. Alan Tapp and Sharyn Rundle-Thiele, both professors of marketing who have led social marketing research centres, tackle the criticisms head on and explain the key contributions that social marketing makes. This chapter ends with a suggestion that social marketing could form part of a multidisciplinary future for behaviour change. The final chapter in this first section of the book takes an in-depth look at technology and behaviour change, tracing a history that sees humans as historical users of tools and these tools as mechanisms for changing human behaviour. Adam Joinson and Lukasz Piwek – both at UWE’s Behavioural Science Lab – bring their analysis up to date with a detailed look at the way smart phones and social networking could be used to influence behaviour now. The insights from the authors’ collective experiences and their review of the research help paint a picture of a field ripe for the picking by behaviour change experts wanting to tackle individualist behavioural problems, but one that has yet to be fully maximised. The second section of the book takes a more ‘revolutionary’ approach in that the component chapters critique existing ways of doing behaviour change, or ways of thinking about behaviour change, and in some cases suggest radical alternatives. Chapter Nine, for example, examines so-called ‘corporate social responsibility’ (CSR) activities of organisations involved in, for example, the obesity crisis, and argues that this false-philanthropy is simply about actively seeking to avoid regulation. Although such CSR activity is beneficial on one level, it can never be allowed to replace statutory provision and regulation or

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Introduction

full corporate accountability. From his position as Special Advisor to the House of Commons Health Select Committee during its enquiries into the tobacco (2000), food (2004), pharmaceutical (2005) and alcohol industries (2010), Gerard Hastings – with Marisa de Andrade – builds a powerful case. Chapter Ten grapples with ‘co-creation’ and ‘participatory’ approaches to behaviour change, which have risen in prominence and popularity. Here, Katie Collins explores these approaches, not in a ‘how to do them’ way, but rather by discussing whether they can ever be anything but oppressive and unethical. She lays bare their history and in so doing questions the nature of interventions that do not seek to evolve ‘the system’ that creates problematic behaviour but rather the lives of people within the system. The chapter concludes with practical tips for practitioners wishing to engage with politically and practically appealing participatory approaches. Chapter Eleven is another chapter that offers innovative suggestions. Its author is Tom Crompton, founder of the Common Cause Foundation, a network of people working to help rebalance cultural values to create a more equitable, sustainable and democratic society. His chapter explores values, focusing on the idea that only ‘intrinsic values’ should be promoted and strengthened. These include concern about social and environmental problems. Focusing on extrinsic values – such as those often strengthened through commercial marketing messages – simply weakens this intrinsic concern, and with this our chances at politically led social change. The chapter develops a progressive set of contentions about values-based behaviour change strategies including that organisations tackling quite different social problems should collaborate. Chapter Twelve explores in more depth the theories of practice introduced briefly in Chapter One. These offer a theoretical view that removes the individual from being the centre of analysis, and therefore contrasts – theoretically, ideologically and politically – with the ‘individualist’ approaches on which so much behaviour change work is based and which dominate the first part of the this volume. Daniel Welch, a scholar at the Sustainable Consumption Institute, argues that by seeing practices as an ‘entity’, change may be achieved, through analysis of its various elements, its neighbouring interrelated practices and its trajectory over time. The approach provides huge potential for ‘behaviour change’ given its natural recruitment of multidisciplinary approaches and its alternative focus. It would seek to change the conditions in which behaviour is performed rather than target the performers of the behaviour directly.

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Finally, Chapter Thirteen picks up the thread of multidisciplinarity that runs through the volume and explores the growing interest in whole-systems approaches for thinking about how to achieve societal goals. Systemic approaches made the headlines when the Foresight Obesity Report developed its famous ‘spaghetti’ map of obesity, and this is explored in the chapter, along with the characteristics and complexity of the various types of system. The chapter takes a stand against reductionist models of behaviour that can only consider one or two causes and fail to fully consider the complexity and interrelatedness of social systems, including those in which obesity is embedded. Author Esther Trenchard-Mabere is Associate Director of Public Health for Tower Hamlets in London and draws on her experience of having implemented a ‘whole system’ approach to tackle obesity in the borough. The book’s conclusion seeks to answer the question ‘What should the future of ‘behaviour change’ look like?’. It argues first that the future of behaviour change must more actively include a consideration of the socio-cultural structures in which behaviour is embedded. Bourdieu’s habitus and theories of practice might help here, but whatever the theoretical basis for this perspective, the future of behaviour change must be interdisciplinary. These theoretical approaches, and the systemic approach introduced in Chapter Thirteen, naturally lead to interdisciplinarity, although true transdisciplinarity may be harder to achieve given the disparate nature of the field. In addition, the chapter explores the limited enthusiasm by policymakers for the full range of research methodologies found in behaviour change due to the preference in government for positivist evidence, often supported by randomised controlled trials. The problems with these constraints are explored in this final chapter. It concludes that the responsibility for the inclusion of a more varied range of evidence in policymaking – which would, it is contended, be a positive move – falls on both policymakers and academic researchers. There are blockages and constraints in the flows of knowledge between academic researchers and policymakers that need to be overcome. The book concludes on a largely positive note about the future of ‘behaviour change’. It is a field that contains a richness of research approaches and a wealth of valuable expertise, although with some irregularity in how this expertise is adopted and received by policymakers. The field is undoubtedly fragmented and subject to a range of forces, both internally and externally. This book illustrates many of those forces through the discussion within chapters and through the lack of complete congruence between them. It is hoped that by

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Introduction

highlighting this breadth of perspective, the book might demonstrate the power and potential of interdisciplinary behaviour change. This in turn should pave the way for further innovative discussions across the field and the setting of a firm agenda for its future. Ultimately, this is the way we will make the greatest gains and best serve those suffering the consequences of the ‘wicked problems’ our society now faces. Notes The ‘evolutionary/revolutionary’ concept is based on an idea by Dr Katie Collins (personal correspondence).

1

2

See www.ucl.ac.uk/health-psychology/bcttaxonomy

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Part One Exploring the history, theory and politics of ‘behaviour change’

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ONE

The politics of behaviour change Michael P. Kelly

Introduction This introductory chapter considers the things that have shaped the ways in which behaviour change is discussed and described, starting with the point that this discussion about behaviour change is never very far away from political and ideological beliefs about how people ought to be. Behaviour change is usually about making people different from how they are now. With this in mind, the chapter begins with a consideration of the politics of behaviour change and particularly the way that governments and states, indeed the powerful throughout history, have sought to get people to behave in ways that they, the powerful, want them to behave.

The political imperative Since the time of recorded history and probably for many millennia before that, violence was the primary means used to bend others to the will of the powerful – behaviour change by force (Pinker, 2011). Hunter-gatherer societies were violent and aggressive. More settled societies were also extremely dangerous until institutions of government began to evolve and what is called state formation began. Societies, rather than being anarchic places where rival warlords vied for power, became states in which one single authority emerged that was strong enough to make other warring factions subservient and around which the institutions of the state could gradually coalesce. The power struggles in Anglo-Saxon England and its conquest by the Normans are good examples of this (Blair, 1956). As states got stronger, societies became generally less violent (Elias, 1978). In part this was because the state acquired by force a monopoly of violence. It used this force to extract taxes, work and dues of various kinds from its subject people. But with state formation, society gradually became more peaceful and civilised. The state eventually

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became the monopolist of violence not so much for its own ends, but for the ends of protecting its subjects from each other and allowing trade and commerce to develop. Of course, the state retained the ultimate right to do violence to its subjects and to other states, but, by the early 19th century, state violence in Western Europe against subjects as a means of getting them to do what the state wanted them to do was becoming less and less common. Of course, that is not to suggest that all was peace and light; it was not. War was the hallmark of European societies throughout the Middle Ages, and the French Revolution at the end of the 18th century was bloody and violent. Outside of Western Europe, states were much slower to develop and to move in a peaceful direction. However, the general trend was away from violence as the first resort to make subject peoples do what the state wanted them to do. The Western European model spread sporadically thereafter, in spite of periodic reverses for example during the rise of Nazi Germany, the Soviet Union and, more recently, Islamic State. In modern advanced societies, states use much more subtle forms of persuasion than brute force. They use an array of behaviour change techniques to motivate, cajole, suggest, convince or inform people that certain types of behaviour are desirable and others are undesirable. The modern armoury is vast, from explicit legal and other forms of regulation, to guides like the Highway Code describing appropriate road-user behaviour (much of it backed up by the force of law), to explicit norms of etiquette promoted by public bodies, like standing only on the right of the escalator on the London Underground system. Education, advertising, marketing and propaganda are also widely used (Marteau et al, 2015). One of the focuses of this volume is on those techniques that are applied deliberately to change a particular behaviour. These have traditionally been thought of as the province of psychology, but this is increasingly contested ground, as the next chapter will explore in depth. These activities – or interventions – are delivered at a number of levels, ranging from local, one-to-one interactions with individuals to national campaigns. It is important to remind ourselves, as the preceding historical overview about the role of the state and its use of violence has sought to do, that anything that seeks to change the behaviour of others is political and is ultimately about power and authority. So, even the apparently neutral pursuits of psychology and sociology and marketing and advertising are political. Modern western states may no longer execute their citizens for infractions of religious

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beliefs, nor imprison them for non-conformity, but they still seek to control behaviour for political reasons, just as states always have done.

The political nature of public health A good example through which to explore the intrinsically political nature of behaviour change is public health. In a nutshell, a huge burden of disease is the result of the way people live their lives: what they eat, what they drink, how much exercise they take and whether or not they smoke. All these are individual choices, but the consequences in terms of the burden to the taxpayer of what many see as self-inflicted disease are enormous. On a regular basis, politicians responsible for the health service make the ‘discovery’ that the solution to the epidemics of Type 2 diabetes, obesity, liver disease, cancers and heart disease is simple: get people to change their behaviour and all will be well. On the face of it, this is not unreasonable. After all, the major epidemics of non-communicable disease do reside in the way we live our lives. Eating, being sedentary, drinking alcohol and smoking are all behaviours. If we add to this list the misuse of drugs and the spread of sexually transmitted infections, HIV, hepatitis, healthcareacquired infections and even Ebola, in all of which human behaviour is implicated as a major contributory factor, changes in behaviour seem an obvious means of prevention. Not surprisingly, therefore, politicians and policymakers alight on behaviour change as a solution. However, getting people to change their behaviour in sufficient numbers and on the scale required turns out to be difficult. Simply telling people that what they are doing is bad for them has had only limited success (Marteau et al, 2015). Health education, advertising and social marketing have made some difference, but have not turned the tide in any of these arenas except cigarette smoking – more of which later. Behaviour change techniques may be effective, but most only seem to work in the short run. The changes required to bring about reductions in the rates of disease on the scale needed to reverse contemporary epidemics has to be sustained over a prolonged period of time. That is tough. Anti-smoking measures were successful because education and information were combined with bans on advertising, very heavy taxation, and eventually bans on smoking in public places along with very consistent and reinforced messaging over many years. This was a massive multi-level effort on the part of the state that deliberately curtailed people’s liberties to smoke, but it has saved many hundreds of thousands of lives.

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Box 1.1: Stop and think: the state knows best Are these actions against tobacco different from a state prosecuting its citizens for religious or political non-conformity? ‘Yes, of course they are’, you might say, because the argument can be made that saving your life and protecting your health are fundamentally beneficial to you. But of course states in mediaeval times proclaimed that getting you to confess to heresy or witchcraft was good for you because it would save your soul. This is different perhaps to smoking, but the assumption that the state knew best is common to both.

The success of measures against smoking has resulted in many commentators calling for more legislation, regulation and taxation. They point not only to the success of measures against smoking but also to seat-belt legislation and drink-drive laws as having been very effective. These measures certainly have been effective in reducing road traffic accidents and deaths. Should we legislate further to prevent the misuse of alcohol, for example? There is, after all, very good evidence that minimum unit pricing would be highly effective at protecting the heaviest drinkers from the harm they are doing themselves (NICE, 2010). Should we legislate to ban smoking in cars? Clearly legislation sometimes does have very direct effects on behaviour, but we should also remember cases where legislation clearly has not worked, as in measures to mitigate against the use of mobile phones while driving and to keep so-called dangerous dogs under control. The issue of behaviour change is political because it is about personal freedom. Unlike our prehistoric and medieval European ancestors, we do not live in a world of continued expectation of violence to be enacted against us. That is not to say that even in western democracies there is not an undercurrent of threat of random violence or domestic violence and abuse. But it is to say that the possibility of the entire social infrastructure being overthrown violently is remote. We live, at least in the west, in a political world in which certain freedoms, including freedom from random violence from the state and from neighbours, can mostly be assumed. Box 1.2: Stop and think: the politics of rights and freedom In the modern world, what right does the state have to make us behave in ways it chooses? What right does it have to offer guidance on or regulation of our private lives? Whether we choose to smoke, to eat as much as we want, to sleep with whomsoever we choose, or to be lazy, are personal choices. In the modern world, we tend to balance these freedoms against our right to be protected from ourselves. Does the state have a duty to protect us from ourselves? Should the state be our ‘nanny’?

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There is a balance between individual liberty and the common good or the public interest and it is the subject of fierce political debate. What often win the day are arguments about harm to others. John Stuart Mill originated the idea that we are free to harm ourselves and generally speaking the state will not interfere. But at the point at which our self-harming actions also harm others, the state does have a duty to step in and protect the other person (Nuffield Council on Bioethics, 2007). It was this argument that held sway on smoking in public places and drink driving. It was about protecting innocent parties from carcinogens they had not chosen to consume, and from drivers who were a danger to other road users and pedestrians. However, as yet no such public consensus exists on matters relating to consumption of food. On alcohol the balance is more finely struck and it was interesting to note that the UK coalition government 2010–15 swithered between arguments about health (harm to self) and public order (harm to others), before eventually doing nothing on alcohol regulation (HM Government, 2012). Behaviour changes relating to overeating and alcohol misuse seem to be less easily managed by appeals to risks to others. Politicians, having often started with ideas about behaviour change, not infrequently find themselves ensnared in arguments about personal freedom, the rights of individuals, the rights of the state and so on, frustrating whatever ambitions they may have to improve things. As the philosopher Macintyre put it, one person’s utility (gain or pleasure) is someone else’s disutility (loss or pain) (Macintyre, 1984). And with many competing values and beliefs in a modern pluralistic society, there are very few politically easy answers. Behaviour change is always political.

The discourse of risk Finding solutions to public problems by using behaviour change is rooted in a modern understanding of risks and their prevention. The idea is that if there is a risk it can be averted. The belief that such a thing as a hazard-free environment could exist would have been way beyond the understanding of our forebears. Throughout human existence life has been full of travails. Disease, pestilence, famine, poverty and hazards from the natural environment, not to mention one’s fellow humans, have been the lot of the species. Even our Victorian ancestors who lived in a recognisable modern environment with railways, canals, mines, gas power, industry and roads, were subject to the ravages of infectious disease on a regular basis. The cholera epidemic in London in 1854

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is one of the best known, but deaths from infection characterised the early and mid-19th century. There was little understanding of the causes of these infections. Deaths from puerperal fever in childbirth were common, and rates of infant mortality were high. Life expectancy was shorter than in the present day. And then something extraordinary overtook the Victorians in the form of the discovery of microbes and their linkage to the cause of disease (Carter, 2003). The causal pathway from exposure to a microorganism and specific types of infection was demonstrated. This was remarkable and it set in train the hunt for ways of protecting people. Aseptic procedures made surgery much safer and aseptic childbirth significantly reduced death following childbirth. Subsequently, the discovery of antimicrobials, especially antibiotics, revolutionised treatments. The risks from common infections that had been intrinsic to the human condition from time immemorial were all but eradicated by the middle of the 20th century (Davies, 2013). The idea of a preceding cause (germs and viruses) followed by a definitive outcome (interventions to fight or prevent the infection) became firmly established in the public mind. And then in the early 1950s another extraordinary discovery was made. The connection between smoking and lung cancer was established, followed by the recognition that smoking also caused stroke, heart disease, miscarriage and respiratory disease (Doll and Hill, 1952; 1964). Smoking became the first risk factor. If people could be protected from exposure to the risk, by not smoking, or by quitting smoking, then, as if by magic, their risk status would be reduced to the same level as if they had never smoked within a relatively short space of time. This was, and remains, one of the great medical advances of the 20th century and is on a par with the earlier discoveries of germs and antibiotics. However, there was an unexpected and unintended consequence. As more data became available, it became clear that as well as tobacco smoke (the exposure to which is the consequence of a human behaviour), there were other behaviours that are intrinsically risky. So being overweight, consuming too much alcohol and not taking enough physical activity were all found to be risks variously for certain cancers, heart disease and so on (Sytkowski and D’Agostino, 1996). Then in the 1980s a new infection arrived in the form of HIV. At first, the medical and political establishments had no idea what was going on, but in due course it became apparent that the virus was transmitted in body fluids principally through sex and sharing drug-injecting equipment. About 20 years after the pop group the Beatles had declared in one

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of their most famous songs ‘All you need is love’, love became ultrarisky; campaigns exhorted the population to practise safe sex, to limit the numbers of sexual partners, to use condoms and if a drug injector, to use clean needles. A truly massive effort at behaviour change was inaugurated by the state (Fowler, 2014). These efforts were very successful in the UK and the HIV epidemic was contained and never escalated in the way that had been initially feared (Fowler, 2014). But by the end of the 1980s, behavioural risks were ubiquitous. Since then, the scale and number of putative of risks has risen and now include climate change, global terrorism and threats from various other geopolitical forces. In respect of climate change and sustainability, behaviour change has been ‘discovered’ by policymakers to be one of the important weapons in the armoury of averting risk. Box 1.3: Stop and think: degrees of risk It is important to think about the scale of the risks to which well-meaning campaign groups refer. Campaign groups are sometimes less than clear about whether they mean absolute risk or relative risk. The public is left wondering about what is really dangerous. Which are more dangerous, additives in food, cigarette smoking, driving and drinking, consuming more than three glasses of wine a day, or for that matter climate change, carbon emissions, asbestos, sugar, fat, salt, sex, sunbathing or listening to loud music? All these things carry risks, but the degrees of risk are different and the individual’s likelihood of exposure to the pathogen highly variable. It may suit well-meaning campaigners to emphasise risk, but the unintended consequence of this is that, in the contemporary western world at least, risk is perceived to be everywhere.

Contemporarily, all sorts of measures are expected of the state to avert or mitigate risk. And if risks are not averted, the legislators and the courts have provided a framework within which the persons or institutions that fail to take action to avert or mitigate risk are blamed and punished in various ways. All of this is unhelpful in two senses – the public gets very confused about what is really risky and there is a danger of increased state interference in the lives of the populace and attendant distraction from the problems of broader societal injustice (Anderson, 1999). The key questions are philosophical and methodological. The emphasis on preventing risks is based on a particular way of thinking about the causes of human behaviour having predictable outcomes. In simple terms there is a preceding event (the behaviour leading to exposure to risk) – some kind of intervention to change behaviour

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– that has a predictable outcome: that is, a change in behaviour. The change in behaviour reduces or eliminates the risk. To unravel this, it is very important to distinguish between the causal action of the pathogen and the human behaviours involved. The actions of the pathogens are often highly predictable, but the human behaviour involved is not. So exposure to cholera bacterium will in some circumstances lead to disease, smoking cigarettes causes lung cancer, and having unprotected anal intercourse may lead to transmission of HIV. However, the behaviour that leads to the exposure, whether drinking contaminated water, being addicted to nicotine or having sex, are much less easy to fit into a simple and linear causal model linking behaviour and behaviour change. So although almost all smokers know that smoking causes disease, that does not stop smokers from smoking, and people still put themselves in harm’s way by virtue of their sexual behaviour and the consumption of sugarenriched, energy-dense, nutritionally poor foods. So the issue is one of disassembling the simple causal model of behaviour change and of refraining from assuming that behaviour change is as predictable as the reaction of the human body to microbes and pathogens. And, as any biologist will tell you, biological interactions aren’t simple either – it is the public discourse about risk that oversimplifies things. This point is perhaps most obvious, but least well understood, in the controversies surrounding the efficacy of health checks. The evidence is clear, if counter-intuitive, that checking people’s health and assessing their risk for the development of lifestyle-related diseases has no effect on death rates at population level for those diseases (Gøtzsche et al, 2014). And this really should be no surprise. The outcomes – that is people changing deeply embedded social habits like overeating, drinking alcohol, smoking and not exercising – cannot be inferred on the basis of the knowledge of the aetiology of heart disease or Type 2 diabetes or on the basis of levels of observable risk for those diseases. Health checking will allow for the detection of undiagnosed cases, for which treatment can begin, but as a means of bringing about sustained behaviour change to reduce population level mortality, it is a forlorn strategy. Our predictive abilities are limited both in terms of the kinds of behaviours that can be predicted and the time frame within which the outcomes are predictable. Once we get into the realm of any kind of complex behaviour in complex settings and the imperative of maintaining the behaviour once it is changed, the amount of variance in outcomes exceeds our predictive accuracy. So while reducing calorie intake is a sure fire way to lose weight, and there are various diets that

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will lead to weight loss, maintaining the healthier weight after the original weight has been lost by continued dietary discipline is really difficult. This means that trying to predict the long-term outcome of a dietary intervention or health checks more generally is fraught with uncertainty.

Towards a synthesis To a considerable extent, psychology and sociology, which are the behavioural sciences with most to say about behaviour change, are both locked into the predictive causal model of behaviour change. However, there are important ideas in each of them that, when taken out of their disciplinary silos, offer a way thinking about behaviour change that is not driven by simple causal models. The story begins in Ancient Greece. Greek mythology recognised a dualism in the human mind. This dualism is identified in the personalities of two of Zeus’s sons. Dionysus was the god of impulse, of pleasure and of the senses, especially of drunkenness. His brother Apollo was the god of reflection, calculation, order and rationality. The essential reality into which the Greek myth taps is what today psychologists call the automatic and the reflective systems. The automatic system, the heir to Dionysus, responds to immediate cues in the environment, takes all sorts of short cuts in its thinking, does not work out costs, but seeks immediate pleasurable gratification. The reflective system, the heir of Apollo, is that part of our mind that is thoughtful, calculating, rational and orderly. The reflective system is the part of mind that deals with costs and benefits, thinks about the long- and the short-term consequences and outcomes of current actions, and foregoes pleasure now, in the expectation of better rewards in the future. Box 1.4: Stop and think: dual systems Which part of your thinking are you using now? It is hopefully the reflective system as you engage with the text in this chapter, as you assess the words and sentences, the arguments and the evidence, and perhaps even disagree.

Those aspects of behaviour governed by the automatic system are quite predictable and it is perfectly possible to define with some degree of accuracy what the cues in the physical environment are to which we will respond (Hollands et al, 2013). So things like ambience and design and the placement of objects in the environment – physical things in the environment – nudge us to behave in particular ways and may

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be straightforward to describe. So for certain types of behaviour, the responses – the automatic responses – to the immediate situation or stimuli are easily delimited. So too are the mechanisms involved. As well as physical environments, there are two other dimensions that evince automatic responses. The first is subjective feeling states like pain, tiredness, fear, hunger and thirst. There is a variety of internal states that elicit automatic-type responses. The second, and more intriguing, is the social environment made up of people and groups in the immediate world of experience and also more diffuse social and cultural expectations. What sociologists have noted over the years is that we are barely aware or conscious of these things, yet they have a profound effect on our behaviour. The fact that we are barely aware is why the response to this social environment is often automatic. The social environment includes such things as the language being spoken, the proximity of other social actors, and, most importantly, rules, norms and folkways that are part of the cultural milieu and constrain behaviour through automatic or semi-automatic types of responses with very little cognitive engagement on the part of the social actors involved. Decades ago, Schutz described this taken-for-granted aspect of everyday life (Schutz, 1967). As noted, the second side of our mind is the reflective part. This is the conscious, calculating, rational part of our mind that engages with, and processes, external information in a deliberative and evaluative way and makes judgements. This is the seat of intellect and reasoning, as well as more routine and mundane thought processes. The reflective part of mind is where decisions are made and where the executive function operates to control the more impulsive and lazy part of mind. The executive function is the hypothesised mechanism, which acts as a behavioural control network. It inhibits impulsive responses, as it acts as a control on the automatic system. Intriguingly, the strength of executive functioning has been found to be directly affected by social circumstances in the early years of life, with poverty having a particularly deleterious effect (Marteau and Hall, 2013). The reflective system is not just a processor. It has consciousness. It is aware of its self. As the calculations are made within the reflective system, it is conscious of its own intellectual processing and is also conscious of itself as a social being. Nested within the reflective system is the capacity for self-awareness and the sense of self. This idea draws on a tradition that goes back to William James and George Herbert Mead (James, 1892; Mead, 1934). Both sought to explain human conduct as more than simple reactions or responses or impulses. They realised there was more to human behaviour than the automatic responses to

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stimuli. The human, they argued, has consciousness. Mead and James described what they called the self as the seat of consciousness, and this has since become a key concept in sociology. The self is the internal set of ideas that a person has about who and what they are. It involves them being able to distinguish themselves from other people, of being conscious of themselves existing across time and in different physical locations (of having an autobiography), and of being able to reason about their own internal states. The self is also a repository of performances of roles to be played in different places and at different times with an understanding about which of those roles are enduring and which are more transient. The psychological descriptions of the reflective and automatic systems, and the sociological accounts of self, all tap into the fact that humans are in part agents of their own destiny. They make choices and they do things; their actions are a force on the external world and on other people. Sociology has been particularly good in recent decades at exploring the power and importance of this human agency in shaping society or social structures (Giddens, 1979, 1982). Human agency produces social structure in the sense that the billions and billions of individual human actions produce patterns that are regular, repetitive and reproduce themselves over time at the level of society. The patterns are real things exerting real pressures on people (automatically and via interpretive, conscious, reflective processes). In other words, although shaped by human agency, social structures in turn shape human agency. Contemporary sociological thinking adds another dimension to the notion of the reflective system by noting that while social structures constrain behaviour and actions, human actors are aware of, within their reflective system, and conscious of that constraint in varying degrees. They give those constraints meaning and they interpret the social world around them before they engage in social action. It is for this reason that predictions about the outcomes of actions designed to change behaviour are prone to such variance. The intervening factor is the thinking human actor. Humans in other words are pretty smart as well as being very reactive to the world around them. This is what the Ancient Greek distinction between Dionysus and Apollo was getting at. Humans make many thousands of choices and decisions every day and they also respond to micro environments many thousands of times every day. The product of millions and millions of people doing this, billions and billions of times every hour of every day, is to produce patterns in social systems that are called social structures. Although these billions and billions of actions are the consequence of individuals’ actions, they produce supra-individual structures and always have done;

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some would say this is the defining character of the species (Cacioppo and Cacioppo, 2013). In turn, those structures constrain and set the limits to the possibilities of individual human agency. A good analogy is the billions of individual stars and galaxies in the cosmos, each with its individual location, orbit and gravitational force, but the totality of which are the patterns we can observe through telescopes and satellites. What we observe astronomically are regulated and interacting patterns and systems, each of which is interrelated. Each single planet contributes to the overall pattern, but is in itself unique. Social life is similar in that it has a patterned quality that is most easily observable at a distance, by observing groups, communities, neighbourhoods or whole societies, all the product of human agency but also the product of interactions between individuals. That patterning is sometimes referred to by sociologists as social practices (Blue et al, 2014). Chapter Twelve explores the recent developments in social practices thinking in more depth because the approach has potentially significant implications for the study of ‘behaviour’ and for the management of interventions. This short overview acts by way of a brief introduction. Social practices exist as supra-individual phenomena independently of individuals. Individuals get recruited to practices and at some point later they retire from them more or less voluntarily, or they die. The practices continue to exist even after individuals have left them. A social practice is an example of a social structure, made up of millions of automatic and reflective actions by human agents that produce patterns that constrain what can be done, what it means and what the technical possibilities are. A social practice has a reality that is produced by individual agency and is more than a collection of individuals doing stuff. Social practices include such things as smoking or eating or cooking or travelling – things that humans do. According to the most recent interpretation (Shove et al, 2012), a practice consists of three elements and new recruits have to learn and understand all three. The first are the materials, objects and things – aspects of the material world – that are related to and manipulated or used in the practice. The second are competences – the ‘know-how’ – to use the materials and to negotiate the material and social world in order to be a competent performer. The third is the meaning that people give to the practice, how they make sense of it and render it understandable – the social significance of the practice. Once in the practice, people will behave using both the automatic and the reflective systems. Their sense of self will develop inside the practice. The three elements of materials, competences and meaning are connected and have to coexist for the practice to continue. And

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practices get linked to other practices and are carried on interconnected networks of human relationships in different lifeworlds. To change behaviour in this view of things is to change the practice, and this means changing one of the three elements so that the linkages between them are broken (Blue et al, 2014). Once one of the links is broken, the practice ceases on its transit through time. That is when behaviour changes.

Conclusion So what is suggested here, and is picked up in more detail in Chapter Fourteen, is that to get a fully rounded understanding of behaviour and behaviour change we have to work towards a synthesis of psychological and sociological understandings of the phenomena. Key elements in that synthesis are laid out here and are well established within the disciplines, but tend to exist in separate disciplinary silos. The key elements are: the automatic and reflective systems, the executive function, the self having an orientation to both automatic and reflective aspects of mind, the consequent human agency producing social structure which also constrains human agency, and of practices which have materials, meanings and competences and which are intricately connected to other practices and are carried on networks of human relationships. These elements provide a framework in which the potential synergies between sociology and psychology are greater than the single disciplines can offer on their own. Taking a multidisciplinary approach is also helpful in moving us away from a view of the world in which behaviour change is seen as something imposed on people by those who purport to know what is good for them, and away from the assumption that behaviour change is easy and that the blame for failing to change lies with the individual. It takes us away from an ideology of behaviour change that relies solely on methodological individualism for its traction, and that gets itself locked into predictions about human conduct on the basis of flimsy evidence of mechanisms of causation and very wide limits of accuracy of predictions.

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End-of-chapter questions • Why is behaviour change always political? • Can you define the difference between the automatic and reflective systems? • What is meant by the concept of ‘self’? • What is a social practice? Think of an example. Why might a social practice approach offer an alternative to traditional behaviour change thinking? • What barriers might there be to tackling behaviour change in an interdisciplinary way?

References Anderson, E.S. (1999) ‘What is the point of equality?’, Ethics, 109: 287-337. Blair, P.H. (1956) An introduction to Anglo Saxon England, Cambridge: Cambridge University Press. Blue, S., Shove, E., Carmona, C. and Kelly, M.P. (2014) ‘Theories of practice and public health: understanding (un) healthy practices’, Critical Public Health, DOI: 10.1080/09581596.2014.980396, http:// dx.doi.org/10.1080/09581596.2014.980396 Cacioppo, J.T. and Cacioppo, S. (2013) ‘Social neuroscience’, Perspectives on Psychological Science, 8: 668-70. Carter, K.C. (2003) The rise of causal concepts of disease: Case histories, Aldershot: Ashgate. Davies, S.C. (2013) The drugs don’t work: A global threat, London: Penguin. Doll, R. and Hill, A.B. (1952) ‘Smoking and carcinoma of the lung’, British Medical Journal, 2: 84-92. Doll, R. and Hill, A.B. (1964) Mortality in relation to smoking: ten years’ observations of British doctors, British Medical Journal, 1, 1399-1410. Elias, N. (1978) The civilizing process: The history of manners and state formation and civilization (trans E. Jephcott), Oxford: Blackwell. Fowler, N. (2014 ) AIDS: Don’t die of prejudice, London: Birkbeck. Giddens, A. (1979) Central problems in social theory: Action, structure and contradiction in social analysis, Berkeley, CA: University of California Press. Giddens, A. (1982) Profiles and critiques in social theory, London: Macmillan. Gøtzsche, P.C., Jørgensen, K.J. and Krogsbøll, L.T. (2014) ‘General health checks don’t work: it’s time to let them go’, British Medical Journal, 348: 3680. HM Government (2012) The government’s alcohol strategy, Cm 8336, London: The Stationery Office.

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Hollands, G. J., Shemilt, I., Marteau, T.M., Jebbs, S.A., Kelly, M.P., Nakamura, R., Suhrcke, M., Ogilvie, D. (2013) ‘Altering microenvironments to change population health behaviour: towards an evidence base for choice architecture interventions’, BMC Public Health, 13: 1218, http://www.biomedcentral.com/content/ pdf/1471-2458-13-1218.pdf Hollands, G. J., Shemilt, I., Marteau, T.M., Jebb, S.A., Lewis, H.B., Wei, Y., Higgins, J.P.T. and Ogilvie, D. (2014) ‘Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco’, Available online from: http://summaries.cochrane.org/ CD011045/PUBHLTH_portion-package-or-tableware-size-forchanging-selection-and-consumption-of-food-alcohol-and-tobacco James, W. (1892) Psychology: The brief course, New York, NY: Holt, Reinhart and Winston (New York, NY: Harper, 1961). Macintyre, A. (1984) After virtue: A study in moral theory, Notre Dame, IN: University of Notre Dame Press. Marteau, T. and Hall. P.A. (2013) ‘Breadlines, brains and behaviour: targeting executive functioning and environments may loosen the links between demography and destiny’, British Medical Journal, 347: f6759. Marteau, T.M., Hollands, G.J. and Kelly, M.P. (2015) ‘Changing population behavior and reducing health disparities: exploring the potential of ‘“choice architecture” interventions’, in R.M. Kaplan, M. Spittel and D.H. David (eds) Population Health: Behavioral and Social Science Insights, AHRQ Publication No. 15-0002, Rockville, MD: Agency for Healthcare Research and Quality and Office of Behavioral and Social Sciences Research, National Institutes of Health, pp 105-26. Mead, G.H. (1934) Mind, self and society: From the standpoint of the social behaviorist, Chicago, IL: Chicago University Press. NICE (National Institute for Health and Care Excellence) (2010) Alcohol use disorders: Preventing harmful drinking, London: NICE, www.nice.org.uk/PH24 Nuffield Council on Bioethics (2007) Public health: Ethical issues, London: Nuffield Council on Bioethics. Pinker, S. (2011) The better angels of our nature, London: Allen Lane. Schutz, A. (1967) The phenomenology of the social world, (trans G. Walsh and F. Lehnert, intro by G. Walsh), Evanston, IL: North Western University Press. Shove, E., Pantzar, M. and Watson, M. (2012) The dynamics of social practice: Everyday life and how it changes, London: Sage Publications.

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Sytkowski, P.A. and D’Agostino, R.B. (1996) ‘Sex and time trends in cardiovascular disease incidence and mortality: the Framingham Heart Study, 1950-1989’, American Journal of Epidemiology, 143: 338-50.

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TWO

An introduction to theories of behaviour Tim Chatterton

Introduction Approaches to changing behaviour can be divided into theoretical approaches and practical, or applied, approaches. Practitioners often design interventions on the basis of ‘toolkits’ that involve a range of measures that have their basis in various theories about behaviour (although sometimes these toolkits have little discernible theoretical grounding). Importantly, different theoretical understandings (such as economics, psychology and sociology), overtly or tacitly, each define ‘behaviour’ in their own way. For example, social practice theory (introduced in Chapter One and considered in more depth in Chapter Twelve) avoids using the term ‘behaviour’. Instead, it focuses on abstracted behaviours as social phenomena (termed ‘practices’) rather than the specific manifestations of these by discrete individuals. This perspective differs from those that focus on the problematic ‘doing’ or ‘not doing’ of certain things, while leaving the mental, environmental and social causes, drivers and shapers for behaviour open to various interpretations, be these principally internal or external. Each perspective is grounded in a theoretical understanding and related definition of ‘behaviour’. So while it is possible to avoid theory, it can be useful in understanding the origins of many of the tools and underlying assumptions on which much ‘behaviour change’ policy is based. In the limited space available here, this chapter considers a handful of key models and theories that illustrate some common understandings of behaviour that have influenced the policy realm.1 First, an overview of the history of the various disciplines that have been involved in making sense of ‘behaviour’ is provided.

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Beyond behaviour change

Interest in behaviour and behaviour change: a brief disciplinary history Controlling human behaviour, particularly putting constraints on acting on impulse driven by desire, has been a long-term preoccupation of much of humanity. Some form of moral code is the central tenet of all religions and spiritual philosophies, for example the Ten Commandments of the Christian Bible, or the Five Precepts in Buddhism. Even here, the basis of the codes differ significantly in nature, with the former being simply set out ‘by order of God’ while the latter are set within a clear logic framework that establishes them as a means to reduce suffering. The domination of religion as the key insight into human existence began to pale from the 16th century onwards with the Enlightenment and the spread of secular philosophy. The work of French mathematician and philosopher René Descartes in the 17th century proved a key turning point in the development of thinking on human behaviour. His work led to the notion of Cartesian dualism, which saw mind and matter as two separate and distinct entities. This split of the mental from the physical allowed the subject of natural philosophy to develop on its own as the philosophical study of matter, and in turn for this to grow in the 18th and 19th centuries into what we recognise today as the physical sciences. In parallel to the development of the physical sciences, with their reliance on positivism (the basing of knowledge on sensory experience and calculation), philosophy of the mind began to divide between those aspects that were based primarily on argument and speculation, and those based (like the physical sciences) on observation and experimentation. These latter developed into the social sciences, broadly consisting of anthropology, economics, political science, psychology and sociology. While all of the social sciences have something to say about behaviour, it has been psychology and micro-economics that have paid the most attention to the behaviour of individuals. This focus has allowed them to develop methodologies based on experimentation and thus position themselves as the most ‘scientific’ of the social sciences (although economics’ heavy use of equations has also contributed to this positioning). Elements of these together formed what developed to be termed the ‘behavioural sciences’. Their focus was initially to understand, rather than ‘change’ behaviour. However, the work of Sigmund Freud and others in developing psychoanalysis in the early 20th century led to the development of psychotherapy as a means for bringing about change in people’s behaviour.

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An introduction to theories of behaviour

As an indication of the increasing interest in both behaviour and behaviour change as the 20th century progressed, Figure 2.1 shows results from the Google Ngram viewer indicating the prevalence of the terms within English language books since 1800. Of main note are the increases in the use of the term ‘behaviour’ from 1920 onwards, with interest in ‘behaviour change’ following about 50 years later. There is also a decline in the use of both terms from around 1980. This tailing off may relate to the rise to prominence of neoliberal economics around this time with the Reagan and Thatcher governments in the US and the UK respectively, and the strong espousal of individualism and a laissez-faire reluctance to intervene in the lives of individuals (tackled in more detail in Chapters Four, Five and Six). One of the key take-off points for the notion of behaviour change (between 1940 and 1960) was the work of American psychologist B.F. Skinner. He saw philosophical beliefs in free will and moral autonomy as being at odds with evidence about the significant effect that the environment has on behaviour. Skinner argued that behavioural sciences to that point had focused predominantly on states of mind, feelings, traits of character and human nature, and that the role of environment had been completely underrated. Much of his work was built around how the environment could be adapted to determine people’s behaviour (‘behavioural modification’ or ‘behavioural engineering’). As he saw it, ‘Almost all major problems involve human behavior, and they cannot be solved by physical and biological technology alone. What is needed is a technology of human behavior’ (Skinner, 1971, p 24). His work was crucial in moving away from seeing people as completely free and rational individuals and opened up the study of behaviour to be much more contested ground. It is interesting to note that around this time, ‘behavioural ecology’, the study of behaviour in animals as a consequence of evolution, also began to develop rapidly. Within behavioural ecology, the actions of animals are held to be solely caused by a combination of genetic background and environmental conditioning rather than attitudes and values. Within the economic and psychological models of human behaviour described below, it is notable how far apart these place us from our ancestral heritage as animals. It is also worth considering that recent advances in technology, allowing brains to be scanned as people make decisions, show that much of what appears to be rational decision making is actually a post-hoc rationalisation of decisions that have been made at an unconscious level (see, for example, Soon et al, 2013). This suggests that what links there may sometimes be between

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Figure 2.1: Use of the terms ‘behaviour’ and ‘behaviour change’ in English language books 1920–2008

Beyond behaviour change

An introduction to theories of behaviour

attitudes and beliefs, and actual decisions and behaviour, may only be correlation rather than causation. The following section briefly describes some of the key theories that have governed views on behaviour since the 1970s. Many of these are models of decision making as much as they are models of behaviour. Interest in them has gradually changed from a desire to predict human behaviour, through to attempting to explain it (Azjen, 1991). During their development, most of the models described here were never actually designed as tools for working out how to change behaviour. Economics The dominant view of behaviour in the latter 20th century, at least in terms of its influence on policymaking, has been based on economics. The study of economics began as ‘political economy’ and developed around an idealised view of people as being fully self-interested and rational creatures who are assumed to be in the possession of perfect information. This idealised man was a practical abstraction used in the development of theories and models, allowing them to be relatively simple and comprehensible. This principle, and the type of person it imagined, was described by political economist John Stuart Mill in the 19th century, when he wrote: [Political economy] does not treat the whole of man’s nature as modified by the social state, nor of the whole conduct of man in society. It is concerned with him solely as a being who desires to possess wealth, and who is capable of judging the comparative efficacy of means for obtaining that end…. It makes entire abstraction of every other human passion or motive; except those which may be regarded as perpetually antagonising to the desire of wealth, namely aversion to labour, and desire of the present enjoyment of costly indulgences. These it takes, to a certain extent, into its calculations, because these do not merely, like other desires, occasionally conflict with the pursuit of wealth, but accompany it always as a drag, or impediment, and are therefore inseparably mixed up in the consideration of it…. [Political economy] considers mankind as occupied solely in acquiring and consuming wealth; and aims at showing what is the course of action into which mankind, living in a state of society, would be impelled, if that motive, except in the degree in which it is checked by the two perpetual

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Beyond behaviour change

counter-motives above adverted to, were absolute ruler of all their actions. (Mill, 1844, v 38) Thus this fictional creature, often referred to as ‘economic man’ or homo economicus, is not quite as simple as he is often held to be. Nor was he ever intended to be a fully realistic representation of human beings, merely a convenient and parsimonious one (Persky, 1995). However, the sway of economics over policy has meant that, along with Adam Smith’s invisible hand of the market (Kennedy, 2009), the mythic creature of economic man, characterised by pure rationality, self-interest (in terms of the accumulation of wealth), complete independence and perfect information, came to be the dominant assumption of how behaviour comes about for over a century. The example of economic man does highlight the main interest in much of economic and psychological understandings of behaviour, which is to simplify and abstract the decision-making/behavioural process. However, this move towards simplicity may itself become a problem when, in reality, we act as social creatures in a very complex world. The economic and psychological experiments that underpin these theories (for example, the classic ‘prisoner’s dilemma’2) are often undertaken in isolated and abstracted contexts where people may behave as the theories suggest. However, this is no guarantee that they will act in the same way when out and about in a social environment. Some of the problems that policy might wish to tackle may come about specifically as a result of complex social arrangements and therefore the appropriateness of simplification is often questionable. Psychology In the late 1960s, what are now seen as the classic ‘models’ of behaviour (represented by neat little flowcharts and equations) began to be developed by two social psychologists based in the US at the University of Illinois: Martin Fishbein and Icek Ajzen. Over the 1970s and early 1980s, the two academics gradually developed a progressive set of models of behaviour that are still hugely influential today. The expectancy-value model Fishbein and Ajzen’s work was grounded in motivational theory and sees people as primarily being goal orientated, and able to calculate a path to reach their goals. It can therefore be seen as being similar to J.S. Mill’s rational economic man described earlier ‘who desires

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An introduction to theories of behaviour

to possess wealth, and who is capable of judging the comparative efficacy of means for obtaining that end’. The key differences with their approach are first that wealth is not seen as the only desirable goal, and can be whatever the person in question values or believes to be valuable. Second, it is not assumed that the person has perfect information, or that if they had, that they would necessarily be able to make a decision about the optimal path for reaching their intended goal. Instead, decisions are based on the person’s understanding of the world. The simple expectancy-value model (EVM; see Figure 2.2) (Fishbein and Ajzen, 1975) sees behaviour as a function of: • the attitudes and beliefs held by a person; how they see the world and how they expect it to operate; • the value to the person of the goal that they are pursuing. These two factors generate a motivation, a reason for acting, in people which is then seen to lead to that action being carried out. The grounding of this motivation, solely in attitudes, beliefs and values in this model, frames both the means and the ends of behaviour within a very subjective context compared to that of economic man. Figure 2.2: The expectancy-value model of behaviour

Expectancy

Motivation

BEHAVIOUR

Value

Source: Fishbein and Ajzen (1975).

Theory of reasoned action Fishbein and Ajzen identified that one of the problems with the expectancy-value model, along with other attitude-behaviour work at the time, was what is referred to as the ‘value-action gap’. This is simply that it is common to see people who do not act in accordance with their stated intentions. This has become a particularly common theme

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Beyond behaviour change

in work on behaviour in the environmental sphere where it is quite common for people to express intentions towards ‘green’ behaviour but to fall short in practice. Figure 2.3 shows a schematic of the theory of reasoned action (TRA), which was developed to address the valueaction gap. Intention is central to the model: ‘Intentions are assumed to capture the motivational factors that influence a behaviour; they are indications of how hard people are willing to try, of how much effort they are planning to exert, in order to perform the behaviour’ (Azjen, 1991, p 181). In the TRA, intention is shaped by two different factors. First, ‘attitude’, which comprises the same key elements set out in the EVM (beliefs about outcomes and how to get there, and a valuation of the outcome). In addition to this is added the influence of ‘subjective norms’, which are ‘the perceived social pressure to perform or not perform the behaviour’ (Ajzen, 1991, p 188). This can be seen as being constituted of beliefs about what others think, beliefs about what experts think, and the degree to which there is a motivation to comply with other people (Ajzen and Fishbein, 1980). It is worth emphasising here that the subjective norms are seen to be completely internal and thus intention still bears no direct relationship to external factors. Figure 2.3: Theory of reasoned action Attitude towards act or behaviour Behaviourial intention

Behaviour

Subjective norm

Source: Ajzen and Fishbein (1980), reprinted by permission of Pearson Education, Inc., New York.

Theory of planned behaviour The TRA was held to operate well in circumstances where a person has complete freedom to decide whether to perform or not perform the behaviour in question. However, many behaviours are not like this and may have constraints on whether the behaviour can be carried out, such as lack of time, money, skills or the cooperation of others (Azjen, 1991). While other models of behaviour (such as Triandis’ theory of interpersonal behaviour, discussed later) consider these as

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An introduction to theories of behaviour

actual constraints, Azjen added ‘perceived behavioural control’ (emphasis added) into the model to create the theory of planned behaviour (TPB; see Figure 2.4), as he saw perception of constraints to be of ‘greater psychological interest’ (rather than importance). Figure 2.4: Theory of planned behaviour Attitude towards act or behaviour

Subjective norm

Intention

Behaviour

Perceived behaviourial control Source: Ajzen (1991).

Perceived behavioural control accounts to a small degree for actual constraints on behaviour, but only in terms of the individual’s subjective perception of these constraints. If the external odds of performing a behaviour successfully are stacked equally against two individuals, the TRB predicts that, all other things being equal, the one who perceives that they have the greatest ability to determine the outcomes will be the most likely to succeed. However, if external conditions are changed to favour one person more than the other, but in ways that they do not notice, the theory has no way of representing this difference. It places the responsibility for behavioural control firmly on the individual’s state of mind and motivation, with no clear process for assessing the impact on behaviour of external conditions other than as they are perceived by the individual. Theory of interpersonal behaviour The very individualised, and predominantly rational framing of the TPB can be highlighted by an alternative model of behaviour developed by Greek psychologist Harry Triandis in the 1970s. Triandis’ theory of interpersonal behaviour (TIB; see Figure 2.5) bears a lot of similarities to both the TRA and TPB, with most of the elements of

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Beyond behaviour change

these wrapped up in some manner within the components of attitude and social factors. Figure 2.5: Theory of interpersonal behaviour Belief about outcomes Attitude Evaluation of outcomes Facilitating conditions

Norms

Roles

Social factors

Intention

Self-concept Behaviour Emotions

Affects

Frequency of past behaviour

Habits

Source: Triandis (1989).

The name of the TIB itself is very telling. While it has been highlighted that the work of Fishbein and Azjen is very strongly focused on the individual and internal psychological processes, the TIB sets out a much more contextualised process of behaviour, albeit still centred on intention. Some key elements that are specific to the TIB are ‘roles’ (sets of behaviours that are considered appropriate for persons holding particular positions in a group) and ‘self-concept’ (how a person sees themselves – explored later by Triandis (1989) as referring to three different concepts of self – private, public and collective). These elements very much situate the rational decision-making/ intention-forming process within a context that is much wider than the individual and their beliefs and attitudes. However, Triandis also includes ‘emotion’ and ‘affect’ (the experiencing of emotion) as shapers of intention. These start to highlight the importance of non-rational elements in the behaviour process. However, what is most significant about the TIB is not what happens in the process of intention

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An introduction to theories of behaviour

formation, but what happens outside it. Here, there are two elements that are novel compared with the TRA/TPB. The TIB sees behaviour as emerging from a two-track process. In addition to intention, there is a second path to behaviour formed through habits: routine behaviours that are enacted without having to go through the conscious process of intention formation. The TIB sees these as being determined simply by the ‘frequency of past behaviour’. More recent work has identified that for behaviour to become a habit, it needs not just frequency, but also ‘automaticity’. These automatic behaviours are characterised internally by a lack of awareness of the actions; a lack conscious intent to perform them; difficulty in controlling them; and being efficient, that is allowing reasonable outcomes to be achieved without expending energy on conscious thought processes (Bargh, 1994). However, habits also require a stable context to permit them to happen. Habits cannot be continued if circumstances become significantly altered (Darnton et al, 2011). The overarching principle of habits remains the same despite these developments – sometimes people just do things without having a clearly formed intention to act in that way. This is particularly important within the context of ‘behaviour change’ as the behaviours that are of most concern are usually problematic because people do them over and over. There has been a development of a whole subject of behavioural economics based around these automatic mental processes, which has recently been popularised as ‘nudge’ – discussed at length in Chapter Six. In the description of the TPB we saw how Azjen’s model favours the internal perceived behavioural control as the way in which constraints impact on behavioural decision making. In Triandis’ TIP,, the term ‘facilitating conditions’ refers both to individuals’ resources, skills and abilities as well as ‘objective factors, “out there” in the environment, that several judges or observers can agree make an act easy [or hard] to do’ (Triandis, 1989). The recognition of facilitating conditions in this way recognises the huge influence that environmental conditions can have on shaping or preventing potential behaviours, as well as the historical development of individuals in terms of the formations of their skill sets. In one way, this can be seen as opening up the way to an acceptance and inclusion of ecological models of behaviour within psychological thinking, such as that demonstrated in models such as that proposed by Barton and Grant (2006) in Figure 2.6. Rather than presenting outcomes as a simple, straightforward line from beliefs to behaviour, Barton and Grant attempt to represent a huge complexity of influences,

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Beyond behaviour change

both on behaviour and outcomes. Although people are at the heart of the model, their health outcomes are seen as being influenced not just by their own physical characteristics and behaviour, but by a range of influences extending out as far as the global ecosystem. The model emphasises the breadth of influences, over the actual processes by which the influences manifest. Figure 2.6: The determinants of health and wellbeing

Source: Barton and Grant (2006).

An emphasis on external factors The physical-technical-economic model Following this path from the autonomous, economic man, through various models that increase the role that external circumstances (perceived or actual) play in determining behaviour can, ironically, bring us back to where we started. As emphasis on external conditions

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An introduction to theories of behaviour

is increased, individuals can become seen as acting only in response to external drivers. One example of this can be commonly found within engineering, where there is an understanding of behaviour that has become referred to as PTEM: the physical-technical-economic model, and which has become dominant in much thinking about behaviour change in the field of energy efficiency. This approach holds that the physical properties of buildings and installed technologies are the key determinants of energy use. ‘The behaviour of the human “occupants” of buildings is seen as secondary to building thermodynamics and technology efficiencies in the PTEM, which assumes “typical” consumer patterns of hardware ownership and use’ (Lutzenhiser, 1993, p 248, cited in Guy and Shove, 2000, p 58). Once the physical and technical conditions for behaviour are appropriately set, then, harking back to the notion of economic man, it is assumed that people will behave ‘appropriately’. Under this PTEM model, the role of policy is not to intervene at the level of individuals, but to merely set the conditions to determine the right behaviour in people. They are seen to behave almost as automatons, responding to their environmental programming: If technical knowledge is rigorously tested and demonstrably proven, and if market forces are not disturbed then consumption choices should be made rationally, with the right decisions being taken by millions of individual consumers, both at home and in their place of work. The role of government is clear: To set the background conditions and prices such that consumers will take decisions which are both in their own and the national interest. (Guy, 2006) Some criticisms of these approaches The psychological models described in this section, and ones like them (see Darnton, 2008 for others), have tended to dominate thinking around behaviour in terms of both how to understand it and also how to try to change it where it is seen as problematic. Admittedly, the psychological models are an advance on some of the baseline approaches that the policy world has often relied on, such as pricing and/or the provision of information. However, the section that follows considers four areas where the thinking around and derived from these models have been criticised.

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‘Behaviour’ is problematic as a catch-all term The use of the word ‘behaviour’ as a catch-all term suggests that the whole range of human activity is undertaken in the same way. Considering that the TPB was developed in the 1980s in the realisation that some behaviours differed from others in the degree to which there were (perceived) constraints, it is surprising how little work has been done subsequently to try to differentiate between types of behaviour. This may in part be due to the prevailing focus on the internal workings of individuals, and the inherent devaluing of external circumstances. In effect, this reduces all actions to being simply the consequence of mental activity. Recent work by Chatterton and Wilson (2014; see Figure 2.7 and Figure 2.8) has tried to highlight the key factors that can differ between what are often simply perceived as ‘behaviours’ with a view to helping practitioners consider the particular characteristics of the behaviour that they are seeking to change. This work essentially dismisses the idea that there is any hope of finding a one-size-fits-all model of behaviour and argues that different theories will be more or less appropriate depending on the nature of the behaviour of concern, and the reason for the analysis, that is whether to explain, to predict, or to change behaviour. In considering the models described so far, aside from the recurring actions that are represented by Triandis as habits, the models tend to emphasise all the left-hand Figure 2.7: Four dimensions of behaviour Who, or what is enacting the behaviour? Individual

Actor

Inter-personal network

Community

Segment/ group

Population

Four dimensions

What shapes or influences the behaviour? Domain

Psychological

Durability

One-off

Bodily

Technological

Institution/ social

Infrastructural/ environmental

How does the behaviour relate to time? Repeated

Dependent

Enduring

Norm-setting

How does the behaviour inter-relate with other behaviours? Scope

Discrete

Inter-related

Bundled

Five levels

Source: Chatterton and Wilson (2014).

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Structuring

Pervasive

An introduction to theories of behaviour Figure 2.8: Descriptions of the levels for each of the four dimensions of behaviour 

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cells of the table in Figure 2.7, focusing on individuals, psychological processes and one-off, discrete actions. If effective behaviour change interventions are to be developed, particularly at the scale necessary to achieve meaningful carbon reduction targets or to avoid public health ‘epidemics’, then more often than not much more attention will need to be paid to the cells on the right-hand side of the framework. The ‘methodological individualism’ critique Another criticism that is made of the traditional ‘behaviour change’ approaches developed from these models concerns what is termed ‘methodological individualism’; that is, through their grounding in economics and psychology, the theories are developed around models of social science that take individuals as the key unit of enquiry. This can particularly be seen in the TPB, where the individual’s perception of control/constraint appears paramount, even to the extent that actual

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Beyond behaviour change

constraints are absent from the model. This focus on the individual can be seen as useful to governments in the context of neoliberal attitudes to the (minimal) role of the state. If individuals and their intentions are held to be central to behaviour, then the blame for problems cannot be put on the state, or on how wider society operates, and responsibility can be placed solely on the individuals themselves. This issue is potentially best highlighted through recent debates on obesity. Here there are contrasting views over whether, as David Cameron put it, we should be ‘talking about people who eat too much and take too little exercise’ (Boden, 2008) or whether the problem is, at least partially, grounded in an obesogenic environment that places limitations on food choices and physical activity, as suggested by the UK government’s Foresight review on obesity (Jones et al, 2007). Taking the line that individuals are completely responsible for their behaviour and the outcomes of that behaviour has been termed in the public health sphere as ‘victim blaming’ (Holland, 2007). However, it is not simply a case of establishing the balance between an opposition of individual or environment as being the cause of problems; there are sometimes much more complex dynamics at work. The language of barriers One of the symptoms of the use of these sorts of models within ‘behaviour change’ circles is the use of the term or concept ‘barrier’, such as the Stern Report (2007), which stated that ‘The removal of barriers to behavioural change is a third essential element, one that is particularly important in encouraging the take-up of opportunities for energy efficiency’ (p xx). The language of barriers reflects the flowchart representation of behaviour (see, for example, Figures 2.2 to 2.5). This language assumes that there is a likelihood of a progression from the left of the chart, where intention is grounded in beliefs about oneself and the world, over to the right, where the behaviour desired by policymakers occurs. The absence of movement to the desired (or correct) behaviour is attributed to obstacles on this path. This thinking is essentially grounded in assumptions about individuals being rational and able to make the correct decisions (see the PTEM model described earlier). However, while there may very well be quite obvious reasons why we do not see the uptake of behaviours that we might want to be more common, it is not particularly helpful (other than through gross simplification) to see these just as barriers. For example, even where Triandis has outlined the importance of establishing a set of facilitating

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conditions, the attendant difficulties of achieving this ideal will have an impact across the entire process – affecting attitudes towards the behaviour, beliefs about outcomes, perceptions of norms and so forth. In many cases, the problem is not that barriers are preventing a move towards ‘desirable’ behaviours, but more that people are not even heading in that direction at all. In order to properly address the problem of what are perceived as barriers, a more complex understanding of the behaviour of concern will be necessary. This will need to more fully consider the contexts surrounding the behaviours away from the single point where a decision (appears) to be made. Ignoring the pervasive nature of change Lastly, these models tend to be ‘cross-sectional’; that is, they focus on single points of intention formation and decision making. They therefore tend to assume that if the same decisions are being made over and over again, then this is because the baseline conditions determining behaviour (those in the actor’s head) are the same. From this stems a conclusion that the problem is that the behaviour has become fixed, and thus that it can, or needs to, be changed. This view ignores the fact that change is occurring all the time within society, and therefore even if a behaviour appears static, its context is changing. However, the importance of context is a key element that is missing from the types of models described so far. If we want to consider how fast entire contextual landscapes around us can change, we only need to look at the smartphone, which, as we currently recognise it, came about with the launch of the first Apple iPhone in 2007. Within seven years, over 60% of people in the UK owned one (Ofcom, 2014). While this may be an extreme example of the rapidity and pervasiveness of change, there are many other factors that change in the context of decisions (both personal, societal or environmental) on timescales of hours, days, weeks, years or even longer. In ignoring the ongoing change that happens in behaviour (often referred to as ‘churn’) and in the surrounding contexts, the degree of fixity in behaviour is overestimated.

Conclusion The theories outlined in this chapter form a strange juxtaposition. On one side, there are the economic and PTEM views that see external conditions as pre-eminent and individuals as a black box that will simply behave correctly when the right buttons are pushed. On the other, we have psychological models that tend to devalue the influence of

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context and society and place the attitudes and beliefs of individuals as central. Social psychologist Paul Stern (2000) brought together a range of psychological work on behaviour within the context of ‘environmentally significant individual behaviours’. He describes this as ABC theory: that ‘behavior (B) is an interactive product of personalsphere attitudinal variables (A) and contextual factors (C)’ (p 415). This ‘alphabet model’ has more recently become the focus of critique by sociologist Elizabeth Shove, who has suggested that, in terms of climate policy at least, the ‘C’ in ABC should more appropriately stand for ‘choice’. She argues that: … in policy, if not always in psychology, the concept of choice is absolutely central. It is so in that it lies behind strategies of intervention (persuasion, pricing, advice) which presume that environmental damage is a consequence of individual action and that given better information or more appropriate incentives damaging individuals could choose to act more responsibly and could choose to adopt `pro-environmental behaviours. (Shove, 2010, p 1275)

Box 2.1: The ‘beyond the ABC’ debate The ‘ABC’ model has created fierce debate in the literature. Key papers are listed here: • Shove, E. (2010) ‘Beyond the ABC: climate change policy and theories of social change’, Environment and Planning A, 42(6): 1273. • Whitmarsh, L., O’Neill, S. and Lorenzoni, I. (2010) ‘Commentary. Climate change or social change? Debate within, amongst, and beyond disciplines’, Environment and Planning A, 43: 258-61. • Shove, E. (2011) ‘On the difference between chalk and cheese – a response to Whitmarsh et al’s comments on “Beyond the ABC: climate change policy and theories of social change”’, Environment and Planning A, 43: 262-4. • Wilson, C. and Chatterton, T. (2011) ‘Multiple models to inform climate change policy: a pragmatic response to the “beyond the ABC” debate’, Environment and Planning A, 43(12): 2781-7.

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Within the context of policy on ‘behaviour change’, it is worth noting that the behaviours in question are rarely an issue only at an individual level. They become the concern of policy when the scale of behaviour is such that it creates a problem for the state, for example due to a drain of resources on the NHS, putting strain on energy supply systems, or leading to excessive levels of greenhouse gases or air pollutants. While the consequences of behaviour-related health problems may be tragic at an individual level, this is rarely the case for behaviours that impact on the environment. Even in the instance of the former, there is now widespread acknowledgement that external factors must play a significant role in order for problems such as obesity to reach ‘epidemic’ proportions. The traditional approaches to understanding behaviour are heavily entrenched within government. Alongside the significant preponderance of economists within the civil service, it is interesting to note that the issue of behaviour in the UK’s Department of Energy and Climate Change is primarily tackled not under a social science/social research banner, but instead by the Customer Insight Team. Leaving aside the question of when it became appropriate for governments to consider citizens/subjects as customers, this example goes some way to demonstrating the extent to which policymaking has become structured around these economic and psychological models of behaviour that focus on individual decision making. End-of-chapter questions • If behavioural ecology considers the behaviour of animals to be determined by the interaction of genetics and environment, how relevant are models of human behaviour that only account for attitudes, beliefs and perceptions? • To what extent do we ever exert complete free will? Or are our choices always facilitated and constrained and shaped by external conditions? • With societal problems such as over-consumption of goods, or greenhouse gas emissions, does a focus on individual behaviour change make sense, or do we need to change the way society operates? Does this change if you consider health-related behaviours such as smoking, drink driving, or sexual health?

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Notes In order to get an appreciation of the full diversity of models available, the reader is advised to look at Darnton’s ‘Overview of behaviour change models and their uses’, written for the Government Social Research service, and which describes over 50 different models and theories (Darnton, 2008). 1

2 The ‘prisoner’s dilemma’ is a classic Game Theory examplar, in which two criminals are locked in solitary confinement and need to calculate whether it is better to remain silent or to betray their fellow gang member with the hope of a lesser sentence. Their sentencing outcome is dependent on the actions of their partner.

References Ajzen, I. (1991) ‘The theory of planned behavior’,  Organizational Behavior and Human Decision Processes, 50(2): 179-211. Ajzen, I. and Fishbein, M. (1980) Understanding attitudes and predicting social behaviour (1st edn), New York, NY: Pearson Education. Bargh, J.A. (1994) ‘The four horsemen of automaticity: awareness, intention, efficiency, and control in social cognition’, in R.S. Wyer and T.K. Srull (eds) Handbook of social cognition, vol. 1, Hillsdale, NJ: Erlbaum, pp 1-40. Barton, H. and Grant, M. (2006) ‘A health map for the local human habitat’, The Journal for the Royal Society for the Promotion of Health, 126(6): 252-3. Boden, N. (2008) ‘Fat or poor? It’s probably your own fault, Cameron declares’, Daily Mail, 8 July, www.dailymail.co.uk/news/ article-1032703/Fat-poor-Its-probably-fault-Cameron-declares.html Chatterton, T. (2011) An introduction to thinking about energy behaviour: a multi-model approach, London: Department for Energy and Climate Change. Chatterton, T. and Wilson, C. (2014) ‘The “Four Dimensions of Behaviour” framework: a tool for characterising behaviours to help design better interventions’,  Transportation Planning and Technology, 37(1): 38-61. Darnton, A. (2008) Reference report: An overview of behaviour change models and their uses, GSR Behaviour Change Knowledge Review, London: University of Westminster, www.civilservice.gov.uk/wp-ontent/ uploads/2011/09/Behaviour_change_reference_report_tcm6-9697. pdf

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Darnton, A., Verplanken, B., White, P. and Whitmarsh, L. (2011) Habits, routines and sustainable lifestyles: A summary report to the Department of Environment, Food and Rural Affairs, AD Research and Analysis for Defra. Available from http://randd.defra.gov.uk/Default. aspx?Menu=Menu&Module=More&Location=None&Completed= 0&ProjectID=16189#RelatedDocuments Fishbein, M. and Ajzen, I. (1975) Belief, attitude, intention, and behavior: An introduction to theory and research, Reading, MA: Addison-Wesley. Google (2014) Google Books Ngram viewer: ‘Behaviour Change’. Guy, S. (2006) ‘Designing urban knowledge: competing perspectives on energy and buildings’, Environment and Planning C, 24(5): 645. Guy, S. and Shove, E. (2000) The sociology of energy, buildings and the environment: Constructing knowledge, designing practice, vol.5, New York: Psychology Press. Holland, S. (2007) Public health ethics, London: Polity. Jones, A., Bentham, G., Foster, C., Hillsdon, M. and Panter, J. (2007) Tackling obesities: Future choices–obesogenic environments–evidence review, London: Government Office for Science. Kennedy, G. (2009) ‘Adam Smith and the invisible hand: From metaphor to myth’, Econ Journal Watch, 6(2): 239-63. Lutzenhiser, L. (1993) ‘Social and behavioural aspects of energy use’, Annual Review of Energy and Environment, 18: 247-89. Mill, J.S. (1844) On the definition of political economy; and on the method of investigation proper to It. Essays on some unsettled questions of political economy, essay V, London: Longmans, Green, Reader, and Dyer. Ofcom (2014) Facts and figures, independent regulator and competition authority for the UK communications industries, http://media.ofcom. org.uk/facts Persky, J. (1995) ‘Retrospectives: the ethology of homo economicus’,  Journal of Economic Perspectives, 9(2): 221-31. Shove, E. (2010) ‘Beyond the ABC: climate change policy and theories of social change’, Environment and Planning A, 42(6): 1273. Shove, E. (2011) ‘On the difference between chalk and cheese – a response to Whitmarsh et al’s comments on “Beyond the ABC: climate change policy and theories of social change”’, Environment and Planning A, 43: 262-4. Skinner, B.F. (1971) Beyond freedom and dignity, New York, NY: Bantam Books. Soon, C.S., He, A.H., Bode, S. and Haynes, J.-D. (2013) ‘Predicting free choices for abstract intentions’, Proceedings from the National Academic of Science USA, 18 March, www.pnas.org/cgi/doi/10.1073/ pnas.1212218110

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Stern, P.C. (2000) ‘New environmental theories: toward a coherent theory of environmentally significant behavior’,  Journal of Social Issues, 56(3): 407-24. Triandis, H.C. (1989) ‘The self and social behavior in differing cultural contexts’, Psychological Review, 96(3): 506. Whitmarsh, L., O’Neill, S. and Lorenzoni, I. (2010) ‘Commentary. Climate change or social change? Debate within, amongst, and beyond disciplines’, Environment and Planning A, 43: 258-61. Wilson, C. and Chatterton, T. (2011) ‘Multiple models to inform climate change policy: a pragmatic response to the “beyond the ABC debate”’, Environment and Planning A, 43(12): 2781-7.

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THREE

Intervention design and evaluation: behaviour change imperatives Sarah Denford, Charles Abraham, Jane Rebecca Smith, Sarah Morgan-Trimmer, Jenny Lloyd and Katrina Wyatt

Introduction Our behaviour has a substantial impact on our health. In this chapter, we focus on how behaviour patterns can be changed to prevent and manage illness and promote wellbeing and on how we can identify effective and useful behaviour change interventions. Behaviour patterns that influence health and wellbeing have become topical as evidence accumulates regarding the impact of smoking, alcohol consumption, overeating and sedentary lifestyles on population health and the cost of health services. For example, in England, 64% of the population is overweight or obese, with 25% classified as obese (Public Health England, 2012). By 2050 60% of men, 50% of women and 25% of children are predicted to be obese, having a substantial impact on people’s physical and psychological wellbeing (Kushner and Foster, 2000), as well as costing an additional £45.5 billion per year (Butland et al, 2007). Unsurprisingly then, a review of the UK NHS (Wanless, 2002) concluded that national health services would only remain affordable if the population became more engaged in their own healthcare. These concerns have also raised the issue of rationing public health services on the grounds that some interventions may only be effective for those leading ‘healthy’ lifestyles. For example, are hip replacements less effective for obese people? Despite a lack of evidence that this may be the case (Judge et al, 2014) such concerns are having an impact on health services. Nonetheless, there is clear evidence that key behaviour patterns damage health and decrease longevity. More than 40 years ago, the Alameda County study of health-related behaviour patterns followed 7,000 people over 10 years and showed that amount of sleep, exercise patterns, alcohol consumption, and eating habits predicted mortality

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(Belloc and Breslow, 1972). Similarly, following 4,886 individuals, Kvaavik et al (2010) found that those who smoked, consumed less than three portions of fruit and vegetables daily, did less than two hours physical activity per week and consumed more than 14 units of alcohol had an all-cause mortality risk equivalent to being 12 years older than those that did none of the above. Fortunately, interventions to change behaviour can be effective. Reductions in smoking and unsafe sexual behaviour, increases in physical activity, healthy diets, self-care and health screening have all been observed following particular interventions (for example, Greaves et al, 2011; Denford et al, 2013). The UK’s National Institute for Health and Care Excellence (NICE) commissioned a review of reviews that included data on 103 systematic reviews of interventions targeting one of six behaviours (cigarette smoking, alcohol consumption, physical activity, healthy eating, drug use and sexual risk taking) and, although the degree of effectiveness varied between populations and intervention characteristics, overall, interventions were found to be successful in changing behaviour patterns (Jepson et al, 2010 and see too Johnson et al, 2010). Influences on health behaviours are numerous, and operate at different levels. Whitehead and Dahlgren’s (1991) model provides a useful depiction of the multiple layers of influence on the health of the population. The model recognises that, in addition to personal lifestyle, the physical and social environment, and wider socioeconomic conditions, affect population health. Interventions may operate at any of these levels. Consider, for example, an intervention targeting obesity. At an individual level, the intervention could target intrapersonal regulatory processes or psychological ‘determinants’ of physical activity and eating behaviour. If effective and widely applied, such individual change could have population-wide effects (Laatikainen et al, 2007). Opening community health and fitness centres, improving access to green spaces, healthy eating campaigns in workplaces and communitybased education are all examples of interventions targeting the physical and social environment. Restricting advertisements for fattening foods or providing financial support for purchase of healthy food are examples of policy intervention that target the wider socioeconomic environment. Throughout this chapter, we focus on interventions evaluated in terms of individual change that have proved to be effective and have the potential to affect population health. However, we recognise – as have other authors throughout this volume – that often the most effective interventions target multiple layers of influence. For example, changes

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in policy and the built environment are often important (Barton and Grant, 2006), and policy changes such as banning health-damaging ingredients from food or drug processing may be prerequisite to individual-level change (Fichtenberg and Glantz, 2002).

Designing behaviour change interventions Developing, implementing, and evaluating effective behaviour change interventions can be complex and challenging. A number of frameworks have been developed with the aim of supporting the process, some of which are discussed later. In this section, we outline the steps involved in one approach to intervention development: intervention mapping (IM; Bartholomew et al, 2011; www.interventionmapping.com). To exemplify the process of intervention mapping, we use the example of the Healthy Lifestyles Programme (HeLP), which is a school-based intervention, designed in accordance with the principles of IM to prevent weight gain among nine- to ten-year-olds (Lloyd et al, 2012; Wyatt et al, 2011; 2013). Intervention mapping Intervention mapping involves six design stages. First, a needs assessment determines what (if anything) needs to be changed. Second, primary and secondary intervention objectives are defined. This involves specifying precisely the behaviour changes participants are expected to make over what time period. Third, identification of underlying mechanisms that maintain current (unwanted) behaviour patterns, and those that would promote behaviour changes, leads to selection of change techniques that have been found to alter those mechanisms. Fourth, having identified evidence-based change techniques relevant to the intervention’s objectives, practical ways of delivering these techniques are developed. Fifth, implementation planning involves anticipating how the intervention will be used or delivered in everyday contexts. For example, is the intervention attractive, practical and sustainable? The final stage is evaluation. Does the intervention change the specified behaviours in context? Step 1 occurs before plans for an intervention are developed. A needs assessment involves identifying the health problem, behaviours exacerbating that problem, and the determinants of that behaviour for the specific population. This is achieved through reviews of the relevant literature, and crucially, discussions with stakeholders. The product of the needs assessment is a description of the health problem,

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its impact on the target population, behavioural and environmental causes and determinants of the behaviour. In some situations, a needs assessment may reveal that an intervention is not necessary or feasible, or that the appropriate intervention should target changes in policy or legislation, rather than individual behaviour. A thorough needs assessment can avoid wasting time and resources in unnecessary or ineffectual intervention development. Using this process, the Director of Public Health, working with the creators of HeLP, identified school children’s weight gain to be a considerable problem (Lloyd et al, 2011). Behaviours and regulatory mechanisms are specified during stage 2 – in other words, what needs to change. The primary objective for HeLP was prevention of excessive weight gain for primary school children. Reviews of the literature suggested that this was best achieved though reducing intake of fizzy drinks, reducing the amount of daily screen time, and increasing consumption of healthy snacks over unhealthy snacks. Underpinning the development was the commitment to build relationships at the level of the school, child and family, and create opportunities to bring parents into the school and for children to take the messages home to create supportive school and family environments. Regulatory processes included pro-physical activity norms (Ajzen, 1985) and self-efficacy (Bandura, 1999; Lloyd et al, 2011). The mapping of regulatory processes onto appropriate change techniques occurs during stage 3, and during stage 4 practical ways of delivering these techniques are considered. The choice of change techniques should be dependent on identification of regulatory processes or mechanisms underpinning the targeted behaviour pattern. For example, if participants lack confidence in relation to adoption or maintenance of new behaviour patterns, then techniques to enhance skills and confidence in those skills are needed. Finally, where possible the selection of change techniques should be based on evidence that a particular technique or combination of techniques has been found to change underlying mechanisms and behaviour patterns in previous research (Abraham and Kools, 2012). Processes regulating behaviour patterns can be changed using a variety of techniques that may be delivered in different ways and particular techniques may be more or less effective in different delivery contexts; thus the mode of delivery should also be considered when change techniques are selected. Behaviour change interventions may be ineffective if they are implemented without input from those who will deliver and receive them. Co-creation with recipients and those who will deliver the intervention not only facilitates ownership of the programme but also

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highlights any practical challenges that need to be overcome during the design phases to maximise adoption and fidelity of implementation. The creators of HeLP had regular discussions with key stakeholders, including children, teachers and parents. This ensured that the delivery methods chosen were feasible and acceptable and crucially could engage schools, children and their families to ‘buy into’ the programme. The final HeLP intervention involved a combination of different approaches including drama workshops where children co-created scenes with the actors, who played the characters Active Amy, Disorganised Duncan, Football Freddie and Snacky Sam. A technique used during these sessions was Forum Theatre, where actors acted out a family scene and children focused on the behaviours of one character. If they noticed the character not adhering to the healthy lifestyle messages, the children shouted ‘stop’ and suggested the change the character could make to improve the outcomes. The child then entered the scene, taking on the role of the character, and the scene was rerun with the suggested change. Following a week of drama activities children set goals with their parents and the HeLP coordinator around changing or maintaining their dietary and physical activity behaviours. Each intervention component within the four-phase programme delivers a range of change techniques that are mapped out in the HeLP manual (Lloyd et al, 2011). Once developed, interventions should be piloted. Pilot studies can clarify whether or not an intervention is feasible and sustainable and ensure that the planned evaluation is practical. An exploratory trial of the HeLP intervention tested the acceptability of the materials and delivery methods as well as the feasibility of evaluating HeLP using a randomised controlled trial methodology (Lloyd et al, 2012). Data collected through interviews and focus groups with children, parents and teachers refined the intervention, and information on the recruitment and retention of schools and children allowed an understanding of whether the planned trial format was feasible and acceptable (Wyatt et al, 2013). Box 3.1: Stop and think: other considerations of co-creation We have here presented a picture of co-creation without discussing any of the potential limitation or problems this approach might encounter. For different stakeholder groups, such as children, single parents, black and minority ethic (BME) adults or disabled teenagers, consider what additional support might be needed to involve them in taking a ‘co-creation’ approach. You might like to refer to Chapter Ten at this point.

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Changing regulatory processes Behavioural patterns involve both reflective processes (involving beliefs, values, intentions and plans) and automatic processes (or impulses) (Strack and Deutsch, 2004; Kahneman, 2011). Choices made reflectively involve consideration of values and conscious reasoning. In contrast, actions regulated by the impulsive system have low levels of conscious monitoring and high levels of automaticity (Bargh, 1994). These behaviours are said to be habitual. Continuing with the example of weight loss, counterproductive behaviour, such as unhealthy snacking, may be largely controlled by the impulsive system. Furthermore, such behaviour is also likely to be highly rewarded. This means it may be difficult to change - even when a person is highly motivated (Kessler, 2009). We might plan to eat a salad for lunch, but the smell of fried bacon overrides our intentions and we act in accordance with our desires. It is important to target the appropriate system when attempting to change behaviour. For example, motivating people to lose weight may be ineffective if the behaviour change required is primarily habitual, that is, regulated by the impulsive system. Changing reflective processes As Chapter Two explored in depth, theory plays a key role in behaviour change and the development of behaviour change interventions. Theory can direct intervention developers toward both mechanisms underpinning particular behaviours, and techniques that may facilitate change. Accordingly, it is widely recommended that interventions are based on theory (Kok et al, 2004; Craig et al, 2008). A plethora of theories of behaviour change exist, each with numerous constructs that may or may not be unique (Abraham et al, 1998). However, single theories tend to be narrow in their focus, specifying key cognitive processes, but failing to consider wider influences on behaviour patterns (Spicer and Chamberlain, 1996; Crossley, 2001). Identifying the behavioural determinants underpinning a selected behaviour is arguably more useful than relying on one specific psychological theory (Kok et al, 2004). Box 3.2: Stop and think: the problem with theories Chapter Two explored a range of limitations to theories traditionally used to underpin behaviour change thinking. Combined with critique in this chapter, this adds up to quite a list. What do you think the benefits are to using theory to explain and understand problem behaviours and how to tackle them?

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The information-motivation-behavioural skills model (Fisher and Fisher, 1992) proposes that reflective behaviour change occurs when individuals are well informed, highly motivated, and have the skills necessary to perform the behaviour. It is important to work out which of these regulatory processes need to be changed for behaviour change to occur, and to design the change processes included in the intervention appropriately. Provision of information is unlikely to change behaviour unless individuals lack knowledge. For example, to lose weight, individuals may benefit from information about the number of calories in everyday foods and drinks, and the amount and type of exercise needed to burn off the calories consumed. Knowledge alone will frequently fail to change behaviour because often those who understand the consequences of their actions do not change. Motivation refers to how strongly we intend, or want to, undertake an action or sustain a pattern of new behaviour over time. Based on an integration of a number of theories of motivation, Fishbein et al (2001) proposed that motivation is influenced by an individual’s beliefs about the advantages of changing their behaviour outweighing the disadvantages; the anticipation that changing behaviour will lead to a positive emotional reaction; the extent to which they believe that others want them to change their behaviour; the extent to which the behaviour is consistent with their own self-image; and the extent to which they feel capable of changing their behaviour (self-efficacy). Techniques to change motivation may therefore focus on persuasion; for example, using fear-arousal messages. They may focus on normative influences, informing individuals that others around them are behaving similarly. They may also focus on building self-efficacy. We are unlikely to exert much effort on goals we believe we cannot achieve. Those who believe they can succeed (that is, have high self-efficacy) set themselves more challenging goals, exert more effort, use more flexible problem-solving strategies and are more persistent (Bandura 1999). Bandura (1999) argues that self-efficacy can be enhanced through mastery experiences in which the individual successfully performs the behaviour; vicarious experience in which the individual observes others successfully achieving the behaviour; verbal persuasion; and perception of physiological and affective states (that is, recognising and managing emotional arousal). However, sometimes well-informed, motivated individuals fail to take appropriate action because they lack the skills to undertake an action or the skills needed to change impulsive regulation of an unwanted behaviour pattern. In such situations, motivation-building techniques will not succeed and may even be counterproductive.

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For example, anti-smoking campaigns that induce fear will often fail because individuals do not feel capable of quitting. Instead, they will attempt to minimise the negative emotions that the campaign evokes by denying all personal relevance (Milne et al, 2000). Similarly, when trying to lose weight, individuals may struggle because they do not have the necessary skills. Losing weight may require the ability to cook, use exercise equipment, or, crucially, manage social situations that involve food (that is, refusing a slice of cake a friend has baked or avoiding Saturday night take-away with friends). The development of behavioural skills requires instruction, practice and feedback. This not only ensures proficiency, but also enhances self-efficacy. Box 3.3: Stop and think: the limitations of ‘fear’ appeals Much has been written about the limitations of fear appeals in health promotion and social marketing campaigns. See Hastings and Webb (2004) for an overview of arguments. What do you think the potential downsides are to using ‘fear’, both in terms of effectiveness and ethics?

Changing automatic processes In some situations, individuals may fail to act on intentions because the behaviour in question occurs habitually, with little conscious thought (Ouellette and Wood, 1998). Habits are behavioural patterns that are elicited automatically when in particular contexts. They require very little conscious monitoring (Verplanken and Aarts, 1999; Gardner et al, 2012). For a number of reasons, eating is one such behaviour that is highly susceptible to becoming habitual. People are largely unaware of the majority of food-related decisions they are making multiple times a day (Wansink, 2007), and our food choices are greatly influenced by environmental factors that we are not aware of. For example, people will eat more popcorn when it is served in a large container, regardless of how much they like or dislike it (Wansink and Kim, 2005). Over time, habits strengthen if contexts are consistently encountered and a strong habit will override motivational determinants of behaviour. So, if an individual is highly motivated to lose weight, but the intention conflicts with an existing, strong habit, the individual will usually act in accordance with the habit (Gardner et al, 2011). This means that interventions need to focus on breaking the habit before behaviour change is likely to occur (Danner et al, 2008). In order to break such a habit, the individual must consciously recognise the situations that trigger the behaviour and either avoid the trigger, or, if this is not possible, rehearse new responses to these triggers. This requires

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the individual to prepare and practise new cognitive, emotional and behavioural responses to contexts that trigger unhealthy behaviours. One simple strategy to break habits involves asking people to make ‘if then’ plans. This simply involves specifying contextual cues and desired responses (Gollwitzer and Sheeran, 2006). For example, if it is Monday at 2pm, then I will go to the gym. Such simple plans can have substantial effects if people are already motivated (Luszczynska et al, 2007). Thus, through a process of identifying triggers, planning and practising new thought patterns and behavioural responses, we can change habits. However, this requires considerable cognitive and emotional effort, and this is not sustainable in the long term (Baumeister et al, 1998). Replacing one habit with another habit means that new behaviour patterns become prompted automatically by everyday environmental cues, and thus require less conscious monitoring. This means that they are more likely to be maintained (Verplanken, 2006; Rothman et al, 2009). Selecting change techniques to include in behaviour change interventions Deciding on which change techniques to include in behaviour change interventions requires an understanding of the underlying process or mechanisms regulating the targeted behaviour (Abraham and Michie, 2008; Abraham and Kools, 2012). For example, Luszczynska et al (2007) did not attempt to change beliefs or attitudes towards eating in order to motivate their participants to lose weight. These women were motivated, but their efforts to change their behaviour patterns were being undermined by situations in which impulsively regulated, habitual behaviours were prompted, despite their good intentions. So the regulatory mechanism of importance was the prompting of habitual responses in specified situations. Helping individuals identify such situations in advance and specify alternative, manageable responses in those situations has been found to overcome habitual responding (Adriaanse et al, 2011a; 2011b). Consequently, this intervention focused on supporting individuals to make ‘if then’ plans that identified their risk situations and linked them to particular, desired responses. This simple, relatively inexpensive intervention was based on an analysis of the key regulatory processes and on evidence that a particular change technique had been found to be effective in changing those processes, evidence that has been further bolstered since publication of the intervention evaluation.

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IM recommends that behaviour change intervention design begin with an analysis of underlying regulatory mechanisms and an investigation of what evidence exists in relation to the effectiveness of particular techniques in changing those mechanisms. Without this, the content of the intervention may be misdirected. For example, even if a ‘fear arousal’ or ‘attitude change’ intervention had succeeded in bolstering the motivation of the women (in Luszczynska et al’s 2007 study), it is likely that this would not have helped them lose weight because a lack of motivation was not the underlying problem. It is also crucial to the advancement of a science of behaviour change that intervention designers record their analyses of regulatory mechanisms and how these shaped the selection of the change techniques that formed their intervention content (see, for example, Tortolero et al, 2005). As we have noted, the effectiveness of a technique is also critically dependent on how it is delivered. For example, if an intervention is delivered in such a way that it fails to capture recipients’ attention or they fail to understand, then even if included techniques have been found to be effective in previous interventions they may fail to change behaviour for these recipients. In this case, the failure is not due to the analysis of underlying regulatory mechanisms or the selection of appropriate change techniques (that is, during the third stage of IM). The failure lies in the translation of potentially effective techniques into materials that constitute the intervention content (in stage 4 of the IM process). For example, in developing HeLP, it was recognised that children could be prompted to identify situations and cues that might prompt them to eat unhealthy snacks and piloting suggested that a good way of engaging the children in this process was by creating ‘temptation T-shirts’ that depicted snacks that might derail their good intentions. In this case, the task of identifying cues that might require new ‘if then’ plans was adapted so that the children would find it engaging, memorable and useful to think about after the exercise. This fashioning of intervention components to include evidencebased change techniques in engaging and helpful components depends critically on co-creation with recipients and early piloting. Again it is crucial to the development of a science of behaviour change that developers record these stage-four decisions.

Evaluating interventions Intervention evaluation involves comparing outcomes for those who receive and do not receive the intervention. Such outcome evaluations

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tell us how effective the intervention was. A process evaluation (Moore et al, 2014) involves investigating how the intervention was delivered (for example, was it delivered as planned?), how it operated to produce outcomes (for example, did it change the identified regulatory processes?) and how it was affected by context or recipient group (for example, did it work better in particular types of schools or work better for older or younger people?). This is a more recent development in public health intervention evaluation compared with outcome or economic evaluation; comprehensive guidance on this area has only recently been published by the Medical Research Council. Since this is a more novel area, it is discussed in some detail below. In addition, a cost-effectiveness evaluation may be conducted to assess the costs and effects of delivering the intervention relative to a comparative course of action. This type of evaluation is especially important to commissioners who must decide between alternative interventions within limited budgets. Outcomes evaluation A rigorous outcome evaluation may involve a no-intervention control group or another intervention group (as is the case when an intervention is compared with routine care) – or both. Typically, postintervention levels of outcome measures are compared, controlling for any pre-intervention levels. Ideally, we do not expect difference between intervention and control groups before the intervention but in practise these may occur. Randomisation to intervention and control groups minimises differences between the two comparison groups. For example, HeLP schools were randomised to the intervention or a non-intervention control group. Where randomisation is impossible, matched groups need to be carefully scrutinised to ensure that differences other than exposure to the intervention are not responsible for observed differences in outcome. Outcome evaluations usually calculate an effect size (such as Cohen’s ‘d’ value) to indicate how effective the intervention was (Cohen, 1992). Anticipating the likely effect size in advance is important to ensure that enough participants are included to detect change. Attrition rates, that is, the number of people who drop out of the study, are also important. For example, if an intervention requires persistence and 50% of those in the intervention group drop out, then, even if the intervention is very successful among the remaining 50% (compared witho no-intervention controls), the overall impact of this intervention may be limited.

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Validated measures of behaviour are, of course, required to evaluate behaviour change interventions, but as well as key behavioural outcomes (such as exercise levels or eating behaviour) various other outcomes may be measured before and after the intervention. These include intermediary outcomes such as social and psychological determinants and characteristics assumed to be involved in the change process on which the design is based, or able to influence outcomes. Finally, health outcome measures (such as weight loss or STI rates) are valuable to check the hypothesised link between behaviour change and health. For example, behaviour change interventions focusing on increasing physical activity or promoting a healthy diet may weigh participants in intervention and control groups before and after the intervention (see, for example, Proper et al, 2003; Luszczynska et al, 2007). Process evaluation Randomised controlled trials have traditionally examined the outcomes of interventions. Process evaluations investigate how an intervention was delivered, how it operated to produce outcomes, and what contextual factors influenced this. Whether an intervention is effective or not, it is important to know whether it was delivered, implemented and received as intended (for example, classes took place and were taught as described in the manual, and participants engaged with the intervention) and whether it generated the predicted changes in regulatory mechanisms (for example, changes in cognitions and other psychological processes). These factors are critical to explaining why an intervention does or does not work, and for indicating how to improve an intervention if it is ineffective. It is also important to explore what contextual factors influence the implementation and effectiveness of an intervention, particularly if the intervention is to be offered in other settings or to other groups of people. Box 3.4: Stop and think: randomised controlled trials – the gold standard Randomised controlled trials (RCTs) are held as the gold standard of evidence by many, including policymakers. They are a rigorous mechanism, but do they have their downsides? What kind of interventions or research do you think could not be measured by RCT and what are the implications of this?

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Process evaluations informed by a range of frameworks and theories A key starting point for any evaluation (and replication) is the availability of an accurate, detailed description of the intervention. Consequently, it is important that intervention manuals are prepared and available (Abraham and Michie, 2008). It is also important to articulate the underlying ‘theory of change’ of how the intervention is anticipated to produce outcomes in order to direct the evaluation towards key implementation processes, mechanisms and contextual factors of interest. When an IM approach is used in developing an intervention, change targets, mechanisms, techniques and associated delivery structures and contexts, plus the links between these and the intended intermediary and final outcomes of the intervention, are explicitly specified in advance. This can be represented diagrammatically in the form of a ‘logic model’ (W.K. Kellogg Foundation, 2004), which can be based on a specific psychological or other academic theory, or on implementer and stakeholder theories, regarding how an intervention is postulated to achieve anticipated outcomes. A logic model is a simple way to represent assumptions about how change will be produced via the resources and structures available for delivery and implementation, and the underpinning causal mechanisms linking intervention components to outcomes. It may also include contextual factors identified as influencing implementation and outcomes. In recent UK guidance on process evaluation (Moore et al, 2014) that builds on a previous framework for developing and evaluating complex interventions (Campbell et al, 2008), such logic models are recommended as the basis of comprehensive process evaluations. Although the emphases of process evaluations have traditionally varied, and will depend on the research priorities for each study, it is suggested that comprehensive process evaluations should focus on three aspects of interventions (see Figure 3.1). These are: • Implementation, covering how delivery is achieved via intervention structures, resources and processes and what is delivered, including the fidelity of this to what was planned and considering issues such as the quality/integrity, quantity or dose of the intervention delivered and received, reach, adaptations and adoption (Steckler et al, 2002). A recently developed Oxford Implementation Index (Montgomery et al, 2013) for extracting data on implementation in systematic reviews also points towards implementation issues that should be considered in designing and evaluating interventions. Assessing how all of these influence the effectiveness of an intervention is a

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key function of process evaluation, and should be articulated prior to a process evaluation through intervention mapping or a logic model developed for the intervention. The evaluator may want to draw on theories, such as diffusion of innovations (Rogers, 2010), when examining processes of delivery and implementation. Process evaluations during feasibility and pilot trials can be particularly useful in identifying and helping resolve implementation problems before research reaches the definitive trial stage. • Causal mechanisms of intervention impact, which explain how the intervention produced change for those receiving the intervention. A process evaluation can investigate these causal mechanisms, which can be evaluated quantitatively by testing mediators, or qualitatively, through interviews for example, to examine in detail the processes that occur in the intervention and what the causal chains of events are that produce the outcomes. To guide research questions and analyses, these should be clearly specified a priori in logic models and the behaviour change theory employed in the intervention mapping, although assumptions about these may need to alter if process analyses reveal that postulated mechanisms are not supported, or unanticipated effects are identified. This again emphasises the iterative nature of work on developing and evaluating interventions. Exploration of causal mechanisms via process evaluation is a key way in which research can contribute to the development of wider behaviour change theory. • Contextual factors that are external to the intervention but can influence all of the above in positive or negative ways, such as by affecting implementation or causal mechanisms and acting as moderators of outcomes. Assessment of contextual factors is critical to explaining why interventions are successfully or unsuccessfully implemented, and why they do or do not work in some settings, and what might happen if an intervention is implemented in a different setting or population group. Contexts may include institutions (such as schools), localities or cultures. It is also worth noting that contexts might be changed as a result of implementing an intervention. By examining implementation, causal mechanisms and context in some detail and in relation to each other, process evaluations can provide an account of how interventions work – through programme design, behaviour change techniques and theorised regulatory mechanisms, for example – and thus an explanation for how health behaviour interventions produce outcomes.

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Intervention design and evaluation Figure 3.1: Key functions of process evaluation and relationships among them Context Contextual factors which shape theories of how the intervention works Contextual factors which affect (and may be affected by) implementation mechanisms and outcomes Causal mechanisms present within the context which act to sustain thye status quo, or enhance effects

Description of intervention and its causal assumptions Logic model Theory of action/ change

Implementation How delivery is acheived (training, resources etc...) What is delivered  Fidelity  Dose  Adaptations  Reach

Mechanisms of impact  Participation responses to, and interventions with, the intervention  Mediators  Unanticipated pathways and consequences

Outcomes

Note: Grey boxes represent components of process evaluation, which are informed by the causal assumptions of the intervention, and inform the interpretation of outcomes. Source: Moore et al (2014, p 10).

Mediation and moderation analyses, which are statistical procedures used to examine causal mechanisms and the influence of contextual factors respectively, have a long history of application in behaviour change research (Baron and Kenny, 1986). Similarly, the interaction between contexts, mechanisms and outcomes is recognised as an important topic for qualitative investigation alongside complex interventions, including via realist approaches that have ‘context-mechanism-outcome configurations’ at their core for understanding ‘what works, for whom, and under what circumstances’ (Pawson, 2013). Much of process evaluation is therefore not new, but recent guidance (Moore et al, 2014) and frameworks (Grant et al, 2013) for how they should be conducted bring some of these differing perspectives together and highlight that comprehensive process evaluations necessitate mixed-methods research. In the context of health research, this is often within a randomised controlled trial, where one aspect of the mixed-methods approach will be to explain quantitative outcomes data often using qualitative and quantitative process evaluation data. For example, guided by clear process evaluation research questions derived from the underpinning intervention logic model, when linked to outcome data, quantitative data (such as from questionnaires, structured observations and routine data sources) can be used alongside and iteratively with qualitative data (such as from interviews, focus groups, observations and examination of intervention materials) to further understanding of how and why

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interventions work or fail. They can also be designed to address gaps in the literature by testing and developing theories of behaviour change. As for evaluations generally, consideration must be given in planning process evaluations to practical issues, including: • timing and sampling (such as when and from whom data should be collected); • potential Hawthorne effects (collection of data becoming an intervention in itself); • possible vested interests of intervention designers, implementers and outcome evaluators in findings and how to manage these; • the order of analysis and reporting of process and outcomes data; • how process evaluators work together with outcomes evaluators in a study team; • resources, staffing and expertise (process evaluations can generate large quantities of data that require complex quantitative and qualitative analyses and synthesis). However, with increasing guidance becoming available, during different phases of the research, process evaluations can make a valuable contribution to developing, refining, testing and ensuring effective implementation and uptake of behaviour change interventions.

Key recommendations Throughout this chapter, we have made a number of recommendations, summarised here. Intervention designers should: • follow the principles of intervention mapping; • ensure that an intervention is needed and necessary before spending time and resources on its development; • identify and clearly specify the target recipient/s of the intervention, the behaviour that is to be changed and the behavioural determinants; • use relevant theories to identify mechanisms of behaviour regulation that need to be altered, including consideration of reflective and impulsive control processes; • choose and describe the techniques and the mode of delivery that are to be used to change the behaviour; • ensure a match between the intervention techniques and mode of delivery and behavioural determinants;

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• consider the context and environment in which the intervention is to be implemented, and think about the availability of resources in this environment; • ensure that the behaviour change techniques and the mode of delivery are suitable for the context in which the intervention is to be implemented; • co-create interventions with intended users and implementers to maximise their use and sustainability; • ensure that those delivering the intervention have appropriate training to ensure fidelity of delivery; • pilot all intervention materials before use; • evaluate rigorously, exploring both processes/mechanisms and outcomes; • ensure all the factors above are considered from the outset.

Conclusion Throughout this chapter, we have argued that effective behaviour change interventions depend on an understanding of the mechanisms underpinning change, change techniques, how to design interventions, and how to conduct robust evaluations (as suggested in IM). When designing interventions, it is necessary to consider the role of reflective and automatic processes. Successful implementation of interventions requires collaboration between developers and stakeholders, and consideration of the context, environment and resources available. Interventions need to be subject to rigorous evaluations of both outcomes and processes. End-of-chapter questions • Why is a rigorous process of intervention planning so important? • Why do you think intervention evaluation is so rare? What problems does this cause? • How do you think it could be made easier for intervention managers to evaluate their interventions more systematically?

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Greaves, C., Sheppard, K., Abraham, C., Hardeman, W., Roden, M., Evans, P., Schwarz, P. and the IMAGE Study Group (2011) ‘Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions’, BMC Public Health, 11(1): 119. Hastings, G. and Webb, J. (2004) ‘Fear appeals in social marketing: strategic and ethical reasons for concern’, Psychology and Marketing, 21(11): 961-86. Jepson, R.G., Harris, F.M., Platt, S. and Tannahill, C. (2010) ‘The effectiveness of interventions to change six health behaviours: a review of reviews’, BMC Public Health, 10. Johnson, B.T., Scott-Sheldon, L.A. and Carey, M.P. (2010) ‘Metasynthesis of health behaviour change meta-analyses’, American Journal of Public Health, 100: 11. Judge, A., Batra, R.N., Thomas, G.E., Beard, D., Javaid, M.K., Murray, D.W., Dieppe, P.A., Dreinhoefer, K.E., Peter-Guenther, K., Field, R., Cooper, C. and Arden, N.K. (2014) ‘Body mass index is not a clinically meaningful predictor of patient reported outcomes of primary hip replacement surgery: prospective cohort study’, Osteoarthritis Cartilage, 22: 431-9. Kahneman, D. (2011) Thinking, fast and slow, London: Macmillan. Kessler, D.A. (2009) The end of overeating: Taking control of the insatiable American appetite, New York, NY: Rodale Books. Kok, G., Schaalma, H., Ruiter, R.A., van, E.P. and Brug, J. (2004) ‘Intervention mapping: protocol for applying health psychology theory to prevention programmes’, Journal of Health Psychology, 9: 85-98. Kushner, R.F. and Foster, G.D. (2000) ‘Obesity and quality of life’, Nutrition, 16: 947-52. Kvaavik, E., Batty, G.D., Ursin, G., Huxley, R. and Gale, C.R. (2010) ‘Influence of individual and combined health behaviors on total and cause-specific mortality in men and women: the United Kingdom health and lifestyle survey’, Archives of Internal Medicine, 170(8), 71118. Laatikainen, T., Dunbar, J., Chapman, A., Kilkkinen, A., Vartiainen, E., Heistaro, S., Philpot, B., Absetz, P., Bunker, S., O’Neil, A., Reddy, P., Best, J. and Janus, E.D. (2007) ‘Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting: Greater Green Triangle (GGT) Diabetes Prevention Project’, BMC Public Health, 7: 249.

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FOUR

Government legislation and the restriction of personal freedoms Alan Maryon-Davis

Introduction The health of the people is the highest law. (Cicero, De Legibus, circa 40bc) As Jane Austen might have observed, it is a truth universally acknowledged that a government in pursuit of its role will seek to influence the behaviour of its populace. She might have added that this includes behaviours affecting the safety, health and wellbeing of individuals, communities, workforces and society at large. Governments exercise their influence in a variety of ways: through regulation by passing laws; persuasion using social marketing campaigns; incentivisation using fiduciary instruments and other financial inducements; education providing knowledge and skills; the provision of services; ecological changes to the physical, social and economic environments; and many others. Some of these levers are applied at national or international level, others at regional and local level. Many are discussed – and often criticised and questioned – during the various chapters of this book. This chapter explores some of the ways in which governments use legislation to directly regulate individual behaviour in order to safeguard and promote the health of the people. We consider how the public responds to this approach, and we weigh up some of its benefits and pitfalls.

An historical perspective Public health and regulation targeted at individuals are familiar bedfellows. They share a long history. Enforced restrictions on personal freedoms have historically been seen as a relatively quick

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and simple way to ensure changes in behaviour to protect the health and wellbeing of individuals and communities. The earliest examples were almost entirely concerned with health protection, personal and community safety, avoidance of environmental hazards and the prevention and control of communicable disease. In ancient times, religious rites about hand and foot washing and disposal of the dead through burial, embalming or funeral pyre had spin-off benefits for hygiene and health. In ancient Babylon, religious rules forbade the digging of wells near burial grounds and midden heaps. Throughout the Middle East and Europe, lepers were forcibly confined to closed colonies from the earliest times. During the Black Death that swept Europe in the 14th century, bubonic plague sufferers were compelled to stay in their homes, as indeed they were even more forcibly during the Great Plague that ravaged Europe two centuries later. With increasing industrialisation in the late 18th and 19th centuries, concerns were raised about the welfare of workers in the textile industries, initially the cotton mills and later the wool trade. In the UK, most of the resulting rules and regulations were aimed at employers in a series of Factory Acts, notably the 1833 Factory Act, intended primarily to regulate child labour in the Lancashire cotton mills. Employers were forbidden to employ children under the age of nine and were compelled to restrict nine- to 13-year-olds to no more than eight hours a day. In 1847, the Ten Hour Act did the same for adults and heralded a series of mandatory improvements to working conditions (Parliament.uk, 2015). In the wider community, triggered largely by a series of cholera epidemics and the pioneering work of anaesthetist and epidemiologist John Snow in London’s Soho district in the early 19th century, attention was focused on avoiding environmental ‘nuisances’ through the provision of clean water and the proper disposal of sewage – the so-called ‘Victorian sanitary revolution’. Legislation comprised a series of Public Health Acts, notably the ground-breaking 1848 Public Health Act for England and Wales, which brought in sweeping changes including the establishment of local boards of health and the post of medical officer of health (Hamlin and Sidley, 1998). London’s Great Smog of 1952, leading to an estimated 12,000 excess deaths from respiratory and heart disorders in the ensuing months, prompted an enquiry that culminated in the Clean Air Act of 1956 (www.legislation.gov.uk/ukpga/Eliz2/4-5/52), introducing ‘smoke control areas’ in towns and cities. In these areas, people were debarred from burning coal or wood and only permitted to burn smokeless fuel. This had a dramatic effect on levels of air pollution, particularly with

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reduced levels of sulphur dioxide, hydrocarbons and soot, and led to a shift towards more use of gas and electricity and more central heating. In the world of work, despite some previous legislation, the great majority of workers had no legal safety protection until the passage of the Health and Safety at Work Act 1974. This legislation provided the legal framework to enforce high standards of health and safety and promote the protection of employees and the public from a wide range of activities connected with work. As well as employers, employees themselves also had a duty to comply, as did those who provided goods and services for the employment and workplace. On the roads, a series of Road Traffic Acts and accompanying regulations governed who could drive (including age thresholds for different types of vehicle), driving tests, disabilities, speed limits, roadworthiness of vehicles, drink driving and many other aspects of road use. Crash helmets became compulsory for motorcyclists in 1973, the wearing of front seat belts in cars in 1983, and rear seat belts in 1991. In the last decades of the 20th century, the attention of successive governments in the UK and elsewhere turned increasingly towards the pressing issue of ‘long-term conditions’ (chronic disease) and the burden these imposed on healthcare services and the wider economy. Many reports, national and international, called for a shift towards prevention and a more ‘upstream’ approach to tackling the wider determinants of health. Much of the focus of the World Health Organization’s (WHO’s) aspirational and all-encompassing Global strategy for health for all by the year 2000 initiative (WHO, 1981) and its subsequent Ottawa charter for health promotion (WHO, 1986) was on ‘healthy public policy’ to secure the basic prerequisites for health and wellbeing, namely peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity. In the UK at the dawn of the new millennium, the government was deeply concerned about the ever-increasing demands and costs of the NHS, and asked the banker Derek Wanless to review the situation and make recommendations. His first report, Securing our future health: Taking a long-term view (2002), dealt mainly with the resource considerations of the NHS and promulgated the notion of what he called ‘the fully engaged scenario’ with all elements contributing in a coordinated way. In his second report, Securing good health for the whole population (2004), Wanless extended the concept of the fully engaged scenario to embrace the wider determinants of health. While acknowledging the importance of individual choice in terms of behaviour, Wanless recognised a number of social, economic and environmental ‘failures’ that play a part, and outlined how these could be tackled by wide-

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ranging action across all sectors, including government – national and local. In particular, he maintained that shifting social norms was a legitimate activity for government in achieving behaviour change and that it might need to be appropriately underpinned by regulation. In all countries of the UK, a vast and complex tapestry of legislation has been woven, proscribing individual behaviour in a myriad of ways, governing almost every facet of modern life – how we live, love, work and play – from sexual relations to road traffic; from food safety to offensive weapons; from drugs and alcohol to disposal of rubbish; from child protection to smoking in public. This chapter now considers a number of general issues that arise out of this regulatory approach to individual behaviour, including the main benefits and pitfalls, and it outlines a few examples as case studies to illustrate some of these points. Box 4.1: Stop and think: no one escapes regulation Think for a second about how many laws affect your daily life. Your journey to work or university, for example, was controlled by several. Did you think about these at the time, when you put on your seat belt or waited on the left-hand side of the road for the bus? Regulation and social norms are inextricably linked.

Ethical considerations Chapter Two examined some of the theory behind behaviour change, and some of the many ‘isms’ that have been postulated to help us understand why people ‘behave’ in the way they do, what governs their choices and how these choices can be influenced to help promote or protect the individual’s, community’s and society’s health and wellbeing. What is of interest here is the trade-off between the state’s authority to act for the public good (paternalism) and an individual’s right to personal autonomy and liberty (libertarianism). This tension has led to a continuing highly polarised debate between those who hold that the state has a responsibility to create conditions that safeguard and promote the health of the people, especially vulnerable groups, and those who maintain that individual freedom is paramount (Nuffield Council on Bioethics, 2007). Chapter Six examines the concept of behavioural economics – an approach that has gained much traction in the current climate of neoliberalism and the tendency to abhor anything that smacks of the ‘nanny state’. Today’s mostly liberal governments tend to resist calls for regulatory approaches to health behaviour. They are averse to regulating industries such as the tobacco, alcohol and food industries for fear

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of interfering with companies’ rights to sell their legal products and their legal obligation to shareholders to maximise profits. They tend to be even more reluctant to pass laws directly curtailing the personal freedoms and behaviour of individuals. Yet, as Wanless and others have recognised, regulation is an essential part of the armoury of policies that governments can and should exercise to protect and promote health and wellbeing of their populations. Governments have a responsibility to provide the conditions that help protect their citizens and help them lead healthy lives. But a balance has to be struck between respect for individual freedom, autonomy and personal responsibility and the role of the state as responsible guardian of its citizens’ safety and wellbeing. To assist in this, the Nuffield Council on Bioethics has described what it calls the ‘stewardship model’, recognising a hierarchy or ‘ladder’ of interventions (see Figure 4.1) – the higher up the ladder, the greater the coercion or intrusion and the greater the need for justification. Highly coercive or intrusive interventions infringing personal liberty require greater justification in terms of significantly preventing serious harm to the community – the so-called ‘harm principle’ first espoused by philosopher John Stuart Mill. Considerations include the burden of the threat being tackled; the effectiveness and cost-effectiveness of the intervention; the acceptability by the population affected; and the overall balance of risks and benefits to the people of implementing (or not implementing) the intervention. All too often, a government’s decision is dictated more by commercial pressures or the effect the measure will have on votes. As the ethical considerations have highlighted, the key to justification for the more coercive or intrusive interventions is that the wider benefits should outweigh the risks of restricting personal freedom. Other principles to be weighed up in the mix can be summed up by the following: • • • • • • •

evidence-based; effective and cost-effective; equitable; acceptable; culturally sensitive; practical to implement; and politically expedient (this being not so much a principle as realpolitik).

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Beyond behaviour change Figure 4.1: Intervention ladder

Eliminate choice

Restrict choice Guide choice: impose disincentives Guide choice: provide incentives

Guide choice: change the default

Increasing coe rcion or intrusion

Enable choice

Provide information

Do nothing

eg. enforce quarantine for close contacts or cases of a highly infectious disease such as Ebola eg. prohibit the sale of alcohol to people under the age of 18 eg. impose high rates of duty/tax on the purchase of cigarettes eg. reduce road tax for electric cars to cut carbon emissions and reduce air pollution eg. serve tap water as standard in restaurants eg. provide supervised exercise facilities in local leisure centres, or safe cycle lanes eg. online advice on home safety, or campaigns on healthy lifestyles eg. no active intervention, perhaps just monitoring the situation

Source: Nuffield Council of Bioethics (2007).

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Benefits and pitfalls of regulation of individual behaviour Direct regulation of individual behaviour clearly has advantages and disadvantages compared with regulation of commercial and environmental interests that shape individual behaviour (discussed in Chapter Nine) and other approaches that seek voluntary behaviour change (discussed in Chapters Six and Seven). Benefits When considering the benefits of regulation, a key principle is the extent to which the regulation will achieve the desired behaviour change, and the latter will lead to the intended health outcomes – in other words, the strength of the evidence base for regulation. In terms of effectiveness in achieving the desired behaviour change, regulatory approaches have generally proved superior to ‘softer’ approaches such as information provision, social marketing, ‘nudge’ and incentivisation. Compliance rates are generally higher when there is regulation. The threat of being prosecuted for doing the wrong thing is generally more persuasive in changing behaviour than fear of the health consequences, whether immediate or longer term. Regulation avoids many of the barriers associated with simply raising awareness, giving people information or incentives and hoping they will voluntarily change their behaviour. The history of public health is littered with voluntary schemes that have failed. An obvious example is the government’s repeated attempts to persuade people to voluntarily wear the seat belts fitted to all new cars, as the following case study explores. Box 4.2: Case study: seat belts On the basis of powerful evidence involving human dummies in scientifically controlled car crashes, front seat belts were legally required to be fitted in new cars in the UK in 1965. But their use by drivers and passengers was voluntary and uptake was disappointingly low despite national campaigns to improve compliance, famously using the slogan ‘clunk click every trip’. Pressure mounted on successive governments to bring in mandatory wearing of front seat belts, and eventually, in 1983, this resulted in a new law enforcing their use. Compliance leapt from 38% before its introduction to 93% afterwards (Jochelson, 2006). A similar but smaller increase in compliance was seen with the mandatory wearing of rear seat belts in 1991 (Jochelson, 2006).

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Beyond behaviour change Although initially many drivers were resistant to the change, complaining about the nanny state and infringement of their liberty, it soon became second nature for most drivers to ‘belt up’, and today compliance remains at about 95% (AA/Populus, 2013). In the 20 years following the compulsory wearing of front seat belts, deaths on Britain’s roads were reduced by an estimated 50,000 (RoSPA, 2003).

Imparting and translating knowledge and life-skills into motivation to voluntarily change behaviour can be impeded by many factors: social, economic, cultural and environmental as well as more intrinsic factors such as intelligence and a sense of responsibility to others. It can be argued that compulsion is likely not only to be more effective than seeking voluntary compliance, but also more equitable in that it applies across the board to the relevant target group whatever their background and circumstances. A good example of this principle is drink-driving legislation, explored in the following case study. Box 4.3: Case study: drink driving In the UK, laws to tackle the problem of driving under the influence of alcohol date as far back as 1872, when the Licensing Act made it an offence to be drunk in charge of horses, carriages and steam vehicles. The 1925 Criminal Justice Act extended this to include being drunk in charge of any mechanically propelled vehicle on any highway or other public place. With the 1930 Road Traffic Act it became an offence to drive, attempt to drive or be in charge of a motor vehicle on a road or any other public place while being ‘under the influence of drink or a drug to such an extent as to be incapable of having proper control of the vehicle’. Not until the Road Traffic Act of 1962 was provision made to include blood and urine testing for alcohol as part of the assessment of fitness to drive, though not compulsory. Finally, the Road Safety Act of 1967 introduced the first legal blood-alcohol limit in the UK, set at 80mg/100ml blood. As well as being an offence to drive, attempt to drive or be in charge of a motor vehicle with a blood-alcohol concentration that exceeded the maximum prescribed legal limit, the 1967 Act also made it an offence to fail to provide a blood or urine specimen for a laboratory test without reasonable excuse. Enforcement of the new drink-drive limit was accompanied by the use of roadside ‘breathalysers’ as a convenient way of screening drivers suspected of being over the limit. These changes were brought in alongside a series of government anti-drinkdriving public awareness campaigns starting in November 1964 and timed to coincide with the festive season. Slogans ranged from the early ‘Drinking and

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Government legislation and the restriction of personal freedoms driving can be dangerous’ to the more recent ‘Think before you drink before you drive’ and even punchier ‘Think! Don’t drink drive’ alongside graphic and shocking TV and print images. Public attitudes have changed markedly in the half-century since hard-hitting campaigns and firm legislation combined to put drink driving firmly on the map. According to opinion polls carried out for the Department for Transport in 2014, 91% of respondents agreed that drink driving was unacceptable and 92% said they would feel ashamed if they were caught drinking and driving (DfT, 2014). These results compare favourably with findings from a similar poll in 1979, which found that over half of male drivers and nearly two thirds of young male drivers admitted to drink driving on a weekly basis (DfT, 2014). Changes in attitudes seem to have been reflected in a marked change in drinking/driving behaviour and its consequences: the number of deaths linked to drink driving fell from 1,640 in 1964 to 230 in 2012 (BBC, 2014). Compared with 50 years ago, drink driving is now a minority behaviour in the UK as in most developed countries. Change has been brought about through firm laws, highly visible enforcement and a major shift in public attitudes. Drink driving has come to be regarded as completely unacceptable by the most people (DfT, 2014). In December 2014, Scotland became the first country in the UK to reduce its statutory drink-drive limit to 50mg alcohol per 100ml blood. The change in the law was accompanied by a comprehensive public awareness campaign.

Pitfalls There are also many downsides to using the ‘big stick’ of individual regulation. We have seen in these case studies how restrictions on personal freedoms may lead to accusations of ‘nanny-statism’ or ‘health fascism’ against the government. Politicians are acutely aware of this risk and the constant fear that it might translate into a loss of votes at the next election. Also, commercial interests might be threatened by legislation aimed at the individual. This may occur if the individual’s choice is circumscribed, for example, by restricting their purchasing of cigarettes or alcohol. Often one of the biggest barriers to bringing in changes to the law is pressure on legislators from powerful commercial interests such as ‘big tobacco’. The Clean Air Act in the mid-1950s virtually

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wiped out the domestic solid fuel business overnight as people switched from coal to gas and electricity for their heating. Box 4.4: Stop and think: powerful lobbying Commercial interests and politics are closely related. Major corporations pay a lot of tax and have huge influence on policymakers and policy, depending on how organised their lobbying tactics are. What influence do you think corporations have on the policy landscape? How easy do you think it is for politicians to pass laws that ultimately protect our health – but that might also impinge on commercial trading of one kind or another? See Chapter Nine for further discussion.

Finally, the law is often flouted. For example, speed restrictions on the roads are widely ignored – although the use of speed cameras has helped to increase compliance. Young people tend to be more influenced by peer pressure and a thrill-seeking, risk-taking youth culture than by laws and regulations that limit their personal liberty – witness the high usage of illicit recreational drugs in this age group, the subject of the next case study. Box 4.5: Case study: illicit drugs Throughout the world, the use of illicit or ’controlled’ drugs is one of the most tightly regulated personal behaviours, being extensively and stringently circumscribed by laws that vary greatly from country to country. Drug prohibition of one form or another is universal, and, as well as national legislation, is subject to firmly enforced international treaties, the first being the International Opium Convention (The Hague Convention) of 1912. In the UK, the main legislation is the Misuse of Drugs Act 1971, which designates a classified list of controlled drugs, specifically excluding alcohol and tobacco. The Act, among a range of statutes, covers possession and supply of controlled drugs, and the use of premises for production and supply. Under the 1971 Act (and its amending regulations and orders), controlled substances are classified into three categories – A, B and C – according to the perceived personal dangers and risks to society, with different penalties for each category. The Home Secretary has powers to add new substances or de-list others, or change the category a substance comes into, and it is this classification of illicit drugs that has come in for considerable criticism in recent years, with particular controversy over the place of cannabis, ecstasy and a number of hitherto ‘legal highs’ (Nutt et al, 2007).

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Government legislation and the restriction of personal freedoms The concern among those who are seeking to change this classification is that much of it is based more on political ideology and expediency than scientific evidence of personal or social harms. With regard to cannabis for example, critics argue not only that its recent reclassification from C to B overrepresents the risks to the individual and society, but that the resulting penalty in terms of a criminal record does more harm than good. They also argue that the ‘get tough on drugs’ policy drives users more firmly into the arms of criminals and, on balance, simply does not work, and that a softer, more supportive and educational approach shows better results (Nutt et al, 2007).

While there is increasing public support for statutory measures to curtail behaviours that threaten other people’s health (such as passive smoking and drink driving), support is less firm with regard to lifestyle factors that primarily threaten only the individual concerned, like unhealthy eating or lack of exercise. On the matter of healthy eating, as one journalist summed it up: ‘The state can offer advice and can lean heavily on the food manufacturers, but it has no right to interfere in the diet of adults, unless they are cannibals’ (Gillian Bowditch, cited in Weekend Australian, 2004). As we have seen, any attempt to directly regulate personal behaviour through the introduction of a new law, or firmer enforcement of an existing one, has to pass the test of public acceptability. This includes the need for cultural sensitivity in its application and implementation. Difficulties might arise where prohibition of a particular behaviour or practice runs counter to religious teaching or a deep-rooted cultural norm. We now consider the topic of female genital mutilation. Box 4.6: Case study: female genital mutilation The practice of female genital mutilation (FGM) has been illegal in the UK since 1985, carrying a maximum sentence of 14 years in prison. It is also illegal to take a British national or permanent resident abroad for FGM or to help someone trying to do this (gov.uk, 2014). Despite this, FGM is quite widespread among certain sections of the Muslim community in the UK. A study published in 2014 found that an estimated 137,000 women and girls in England and Wales, mostly of West, Central and East African origin, are living with the consequences of FGM (gov.uk, 2014). And yet, to date, very few people have been prosecuted – the main barrier being the extreme religio-cultural sensitivities that surround this issue, the resulting veil of secrecy and a reluctance on the part of health and social care personnel to get involved, partly for fear of being accused of racism (Topping et al, 2014).

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Another potential pitfall is the possible infringement of human rights. Regulation infringing individual liberty is challengeable on the grounds of curtailing or denying human rights. But this must be set against the individual or societal risk of not imposing the restriction. Inevitably it comes down to proportionality. Only where the individual can demonstrate that the burden of restriction is disproportionate to the risk to the wider population is their challenge likely to have grounds. An example of this is when the restriction infringes a cultural or religious taboo to the extent that it creates a personal stigma or burden that outweighs the risks to third parties or society at large (Martin, 2007). On the principle of practicality, a number of questions arise: How can the measure be implemented? How will it be ‘policed’? What are the costs (direct costs and opportunity costs) in terms of deployment of personnel, training, equipment, infrastructure, and so on? For example, a powerful argument against the ban on smoking in cars with a child on board is that enforcing such a ban is likely to be difficult and will divert police away from traffic-related duties. Finally, there is the realpolitik pseudo-principle of political expediency. Governments have an innate tendency to act largely in their own self-interest along party-political lines. Ideology all too often trumps evidence. Politicians are generally thick-skinned, but very sensitive to media headlines and public opinion. This can be exploited by activists who wish to see legislation passed to restrict personal behaviours. A classic example is the media advocacy campaign mounted by a coalition of health interests looking for a ban on smoking in workplaces and public spaces in England, considered in the following case study. Box 4.7: Case study: ban on smoking in workplaces and public spaces Evidence of the dangers to non-smokers of breathing second-hand smoke had been mounting for some time before authoritative reports began to appear calling for restrictions of smoking in enclosed spaces such as workplaces. Most notable of these was the government White Paper, Smoking kills (gov.uk, 1998), which included a recommendation that a voluntary code of practice be adopted by the hospitality trade, particularly pubs. However, government progress in working with the trade to make this happen through a Public Places Charter was slow and patchy, with poor compliance across the country, despite a funding injection by the tobacco industry (Arnott et al, 2007). In 2002 the British Medical Association called for a ban on smoking in enclosed public places, stating that voluntary measures had failed (BMA, 2002). The pressure group Action on Smoking and Health (ASH) set up an advocacy

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Government legislation and the restriction of personal freedoms campaign through a new partnership, the Smokefree Action Coalition, to lobby for comprehensive legislation on the premise that everyone has a right to a smoke-free workplace (Arnott et al, 2007). The key elements of the campaign strategy were: • promoting evidence-based arguments; • gaining proactive and reactive media coverage; • building positive public opinion; • developing local action by working with local authorities; • pursuing intersectoral action, working with employers and lawyers; • cultivating political support in both Houses of Parliament. The media plan involved heavily promoting the evidence around the risks of passive smoking, particularly for bar workers, together with authoritative reports, repeated opinion polls and profile-raising events. Pieces of research were fasttracked to counter false claims made by opponents of a ban. Media coverage was impressive, with news items reaching about 4.5 million people a week between 2004 and February 2006 when the Bill was passed (Arnott et al, 2007). Public opinion was crucial to the campaign’s success and was the factor that swung most of the wavering politicians behind the Bill. In this respect, opinion polls played a very large part in demonstrating that the majority of voters were in favour of protecting workers from second-hand smoke by banning smoking in enclosed workplaces. In one of the earliest examples of online petitioning to gather public support for a health issue, the London Health Commission instigated ‘the Big Smoke Debate’ and along with six other regions had amassed over 125,000 participants within a year, 79% of whom declared support for mandatory smoke-free workplaces (Arnott et al, 2007). Alongside this multi-pronged movement, ASH worked with the Chartered Institute of Environmental Health and others to encourage more than 50 local authorities to express an interest in developing local policies to ban smoking in workplaces, and Liverpool and London drafted Bills to put through Parliament giving them local powers. Threatened with employee legal action on health and safety grounds, the hospitality industry started to accept that smoking legislation was ‘inevitable’. Soon after, and in the face of the latest poll showing 80% public support for a total ban, the reluctant Health Secretary, John Reid, was forced to concede to legislation, albeit exempting pubs that did not serve food and private clubs. The Smokefree Action Coalition then focused all its efforts on pushing for a total ban. It provided crucial evidence to the Parliamentary Health Select Committee,

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Beyond behaviour change which pronounced the exemptions ‘unfair, unjust, inefficient and unworkable’. Intense lobbying by sympathetic MPs led to the government caving in and allowing a free vote, unfettered by party whips. This triggered the Action Coalition to orchestrate massive ‘grass-roots’ pressure on MPs to vote according to their constituents’ wishes, as evidenced by a deluge of emails and letters and even more persuasive opinion polls. Finally, on 14 February 2006, the House of Commons voted by a majority of 200 for comprehensive smoke-free legislation in England, which came into force on 1 July 2007. It was a great victory for a coordinated, sustained and energetic advocacy campaign over a period of several years.

Box 4.8: Stop and think: the power of policy How effective do you think legislation would be on its own? The populace has to adhere to legislation for it to be effective. What is the magic combination, in your view, between soft measures like social marketing and hard coercive measures like regulation? Perhaps on their own, neither soft measures nor harder measures are the answer. Perhaps combined they are stronger than the sum of their parts.

The arguments around the curtailment of personal freedom have recently been brought into sharp focus by the rapid rise in popularity of e-cigarettes: devices for inhaling electronically vaporised nicotine solution, known as ‘vaping’. Setting aside the merits or de-merits of these devices as an aid to giving up smoking, or concerns about the risks of recruiting non-smokers to the nicotine habit (known as the ‘gateway’ effect), the question of whether people should be banned from vaping in enclosed public places and workplaces in the same way as tobacco smoking has divided policymakers around the world. The following case study explores the issue further: Box 4.9: Case study: e-cigarettes WHO has recommended that vapers be ‘legally requested’ not to use e-cigarettes indoors, especially where tobacco smoking is banned, until such times as the exhaled vapour is shown to be non-harmful and vaping is shown not to undermine the enforcement of smoke-free policies (WHO, 2014). The American Heart Association has adopted a similar but more nuanced stance, supporting the inclusion of e-cigarettes in new smoke-free laws, but only amending existing laws if there is no risk of these being undermined (Bhatnagar et al, 2014). In the UK, the British Medical Association has called for an outright ban on the use of e-cigarettes in public places (BMA, 2014), while the Royal College of

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Government legislation and the restriction of personal freedoms Physicians has advocated ‘proportionate regulation’ to maximise public health benefits, including regulation to ensure that the use of e-cigarettes in public places does not ‘undermine smoking prevention policies’ (RCP, 2014). The fear expressed by some health advocates is that vaping, by mimicking smoking, threatens to re-normalise the culture of smoking in public and thus undermine decades of progress in achieving a broadly shared expectation of smoke-free public environments. It also creates enforcement issues for employers in these places. On the other hand, advocates of e-cigarettes claim, with some justification, that the vapour is virtually odourless, disappearing without trace almost instantly, and that there can be no reasonable grounds for banning their use in pubs, bars, restaurants and other public places. They accuse the health lobby of a knee-jerk antipathy, not borne out by the known facts, which threatens to restrict vapers’ access to a much safer alternative to tobacco smoking. For legislators this highlights a real dilemma that will only be settled with further research on the balance of benefits to risks.

Conclusion There is a long history of governments using regulation to directly influence the personal behaviours of individuals with regard to health and wellbeing. The priorities for this approach have always been the prevention of infectious diseases (like sanitation), the avoidance of hazards (such as safety at work) and the reduction of environmental threats to longer-term health (such as smoking bans). A balance has to be struck between the freedom and autonomy of the individual and the ‘stewardship’ role of the state or governing authority. Any intrusion or coercion needs to be justifiable in terms of the balance of benefits to risks for society as a whole. Such measures can be effective and cost-effective (such as the use of seat belts); relatively easy to implement (such as speed limits); broadly acceptable (such as smoking bans); and equitable (such as the drink-driving ban). More recently there has been increasing pressure to extend this approach to the promotion of healthy lifestyles, but most libertarian governments have shied away from direct regulation of individuals to ‘be healthy’ and instead have preferred to pursue alternative approaches that persuade or encourage individuals to change their behaviour voluntarily, such as through social marketing or ‘nudge approaches’ – topics explored in Chapters Six and Seven. There is also the option for governments to regulate the industries responsible for purveying ‘unhealthy’ products such as tobacco, alcohol

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and junk food, and although this is done to some extent (such as the ban on tobacco advertising), there are debates to be had about the government’s willingness to restrict the activities of ‘big business’. This is considered in more detail in Chapter Nine. ‘The health of the people is really the foundation upon which all their happiness and all their powers as a state depend.’ (Benjamin Disraeli)

End-of-chapter questions • What are the main arguments for and against laws that restrict personal freedoms? • What role does evidence of effectiveness play in shaping legislation that restricts personal freedoms? • How can interdisciplinary research help to inform government policies seeking to influence personal behaviours and lifestyle choices?

References AA/Populus (2013) ‘30th anniversary of front seat belt law’, www. theaa.com/newsroom/news-2013/seat-belt-law-30th-anniversary. htmlAlcohol Health Alliance UK (2012) ‘Policy positions’, www. rcplondon.ac.uk/projects/policy-positionsArnott, D., Dockrell, M., Sandford, A. and Willmore, I. (2007) ‘Comprehensive smoke-free legislation in England: how advocacy won the day’, Tobacco Control, 16(6): 423-8. BBC (2014) ‘How have anti-drink driving adverts changed in 50 years?’, www.bbc.co.uk/news/uk-29936901 Bhatnagar, A., Whitsel, L.P., Ribisl, K.M., Bullen, C., Chaloupka, F., Piano, M.R., Robertson, R.M., McAuley, T., Goff, D. and Benowitz, N. (2014) ‘Electronic cigarettes: a policy statement from the American Heart Association’, Circulation, 130: 1418-36. BMA (British Medical Association) (2002) Towards smoke-free public places, London: BMA, pp 18-19. BMA (2014) ‘E-cigarettes’, http://bma.org.uk/working-for-change/ improving-and-protecting-health/tobacco/e-cigarettes DfT (Department for Transport) (2014) ‘92% of people feel ashamed to drink and drive as 50th anniversary THINK! campaign is launched’, https://www.gov.uk/government/news/92-of-people-feel-ashamedto-drink-and-drive-as-50th-anniversary-think-campaign-islaunchedGov.uk (1998) ‘Smoking kills’, www.gov.uk/government/ publications/a-white-paper-on-tobacco

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Gov.uk (2014) ‘Female genital mutilation’, www.gov.uk/femalegenital-mutilation Hamlin, C. and Sidley, P. (1998) ‘Revolutions in public health: 1848, and 1998?’, British Medical Journal, 317: 58. Jochelson, K. (2006) ‘Nanny or steward? The role of government in public health’, Public Health, 120: 1149-55. Martin, R. (2007) ‘Law as a tool in promoting and protecting public health: always in our best interests?’, Public Health, 121: 846-53. Nuffield Council on Bioethics (2007) Public health: Ethical issues, London: Nuffield Council on Bioethics. Nutt, D., King, L.A., Saulsbury, W. and Blakemore, C. (2007) ‘Development of a rational scale to assess the harm of drugs of potential misuse’, The Lancet, 369(9566): 1047-53. Parliament.uk (2015) ‘Early f actor y leg islation’, www. parliament.uk/about/living-her itage/transfor mingsociety/ livinglearning/19thcentury/overview/earlyfactorylegislation RCP (Royal College of Physicians) (2014) ‘RCP statement on e-cigarettes’, www.rcplondon.ac.uk/press-releases/rcp-statemente-cigarettes RoSPA (Royal Society for the Prevention of Accidents) (2003) ‘RoSPA road safety information sheet’, www.rospa.com/roadsafety/ adviceandinformation/vehiclesafety/in-carsafetycrash-worthiness/ seat-belt-history.aspx Topping, A., Laville, S. and Mason, R. (2014) ‘Parents who allow female genital mutilation will be prosecuted’, The Guardian, 22 July, www.theguardian.com/society/2014/jul/22/parents-allow-femalegenital-mutilation-prosecuted-cameron-law Wanless, D. (2002) Securing our future health: Taking a long-term view, London: HM Treasury. Wanless, D. (2004) Securing good health for the whole population, London: HM Treasury. Weekend Australian (2004) ‘Battle of the Bulge in “choccie wars”’, 5-6 June. WHO (World Health Organization) (1981) ‘Global strategy for health for all by the year 2000’, http://whqlibdoc.who.int/ publications/9241800038.pdf WHO (1986) ‘The Ottawa Charter for Health Promotion’, www.who. int/healthpromotion/conferences/previous/ottawa/en WHO (2014) ‘Conference of the parties to the WHO Framework Convention on Tobacco Control, sixth session, Moscow, Russian Federation, 13-18 October, provisional agenda item 4.4.2 FCTC/ COP/6/10 21’, www.who.int/fctc/cop/sessions/cop6/en

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FIVE

Evaluating the impact of policy: the built environment and travel behaviour Steven Melia

Introduction As Chapter Four explored, policies that aim to change behaviour may directly target the behaviour, through persuasion or enforcement, but policies may also use indirect methods to change the context in which individuals make decisions. These two approaches may be viewed as opposite ends of a continuum rather than distinct categories: many behaviour change initiatives and policies combine elements of both. The subject of this chapter is policies that lie at the ‘indirect’ end of that continuum: those that change the physical characteristics of the built environment in order to change behaviour. Such policies are often controversial: changes to the built environment are long-lasting and may affect many aspects of life, introducing many possibilities for unintended consequences. The impacts of such policies often take time to emerge and are impossible to isolate from other causes, creating uncertainty over measurement and controversy over their effectiveness. This chapter explores the impact of policies that change the built environment in order to influence travel behaviour. It will begin by reviewing the long-running debate around spatial planning and travel behaviour focusing on city-wide urban intensification: does it reduce the volume of car driving, as many claim, and does it cause unintended consequences? Two more specific measures where research has struggled to establish causal relationships will then be examined. Do more permeable street networks lead to more walking and cycling, and do more cycle paths lead to more cycling? Both of these claims have been made many times in the literature but the evidence base, examined in this chapter, is ambiguous and contested. The chapter will conclude with a discussion of the pressures from policymakers for economic evaluation of individual measures and

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the use of ‘evidence hierarchies’, which attach greater weight to experimental findings. Do these approaches offer any solution to the unresolved questions around the effectiveness of interventions in the built environment?

The built environment and travel behaviour: a causal relationship? The relationship between the built environment and travel behaviour has generated a vast quantity of research and writing over recent decades. Litman and Steele (2013) surveyed a wide range of that literature, mainly relating to North America. Some of the principal relationships they found are summarised in Table 5.1. Table 5.1: Relationship between the built environment and travel behaviour Built environment factor

Associated with (behavioural outcomes)

Population density

Lower vehicle ownership and vehicle miles travelled (VMT) and use of alternative modes

Proximity to a regional urban centre

Lower VMT

Land-use mix

Lower VMT and increased use of alternative modes, particularly walking

Concentration of activity in centres

Increased use of alternatives to the car for commuting

Connectivity (or ‘permeability’) of road networks and walkways

Increased roadway connectivity can reduce vehicle travel; improved walkway connectivity increases non-motorised travel

Quantity, quality and security of pavements and cycle paths/lanes

Increased non-motorised travel and reduced car travel

Source: Litman and Steele (2013).

The list in Table 5.1 is not exhaustive; several other factors could be added (Litman and Steele also include some more specific transport measures such as parking constraints) and some of these claims have been contested, which will be discussed later. Studies of other developed countries have identified similar relationships and several other relevant built environment factors. Hickman and Banister (2008), for example, studied cross-sectional data for Surrey in England. They found similar associations with density, connectivity, accessibility to public transport and proximity to central London. They used jobs/ housing balance within the settlement as a measure of land-use mix

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(negatively associated with energy-weighted vehicle miles travelled – VMT). Several studies of the Netherlands have found significant associations between composite measures of urbanisation and different measures of travel behaviour, similar to those described (such as Schwanen et al, 2004; Susilo and Maat, 2007). Litman and Steele (2013) present their summary of the evidence to support a policy of ‘smarter growth’, which seeks to increase all of the factors in Table 5.1, in order to change the behavioural outcomes shown (among a range of advantages claimed for smarter growth). This recommendation assumes that the factors cause the behavioural outcomes shown. Most of the studies reviewed by Litman and Steele controlled for socioeconomic factors in reaching the conclusions shown in the table. A few also incorporated measures of attitudes or preferences. The vast majority of the literature in this area relies on cross-sectional studies; however, causality can not necessarily be inferred from these. If the built environment factors do not cause the behavioural outcomes in the second column of Table 5.1, then it cannot be assumed that promoting those factors will produce behaviour change. Box 5.1: Stop and think: the nature of evidence Policymakers may rely on evidence, or at least should do, when they design interventions for behaviour change. The quality of that evidence and the claims based on it are critical. To be of use to policymakers, research findings need conclusions about what causes what. But establishing causality is very difficult – in practice, very few research projects are able to prove a cause and effect. Some element of judgement is usually required. The pressures on policymakers to make quick and informed decisions are huge, but there is also a responsibility for researchers to be open – in simple and effective terms – about the claims they can make from their findings. There are clearly important considerations in ‘behaviour change’ work about the nature of communication between researchers and policymakers, something the conclusion to this book explores in more detail.

Across the developed world, cross-sectional data shows that residents of suburbs generally drive more than residents of inner cities (because of the density and proximity factors outlined in Table 5.1). A recent largescale panel study from across England also found that household moves to more urban locations are associated with reductions in household car ownership (Clark et al, in press) and commuting by car (Clark et al, 2014). These observations generally remain true after controlling for socioeconomic factors such as income and household structure. Controlling for socioeconomic factors is a necessary but not sufficient condition for establishing causality; attitudes may also be important. A

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major strand of the literature concerns the question of ‘self-selection’: the tendency of people to choose where to live based on their personal preferences for particular modes of travel, as well as neighbourhood characteristics. Suburban residents might drive more out of personal preference, and choose to live in suburbs partly because it is easier to drive there than it is in inner cities. If the difference between urban and suburban travel behaviour were entirely due to self-selection, intensifying suburbs would create dissatisfied residents but make no change to travel behaviour. Reviewing 38 studies, Cao and colleagues (2009) found several different methods used to analyse or control for self-selection in the relationship between travel and the built environment. Nearly all of them found significant relationships after controlling for attitudinal factors including self-selection. Ten of the 38 studies used longitudinal methods, from which stronger causal inferences could be made. They also showed significant relationships between measures of the built environment and travel behaviour, but none of these tried to measure attitudes over time, so could make only limited observations on the influence of self-selection. Some studies using qualitative interviews (such as Næss, 2009 and Melia et al, 2011) have found evidence of self-selection among residents of suburbs or dense urban areas but also evidence of changes in attitudes and behaviour occurring after a move to different type of area, partly influenced by the characteristics of the area. Several of the factors in Table 5.1 act as proxy measures for other factors that exert a more direct influence on travel behaviour. For example, the distances between individual households and the nearest local shops would be affected by population density, mixture of land use and the connectivity of street or path networks in each neighbourhood. If people in dense mixed-use permeable neighbourhoods are observed to walk more, or to drive shorter distances than people in sprawling impermeable housing estates, then the three factors would be acting (at least in part) as a proxy measure for the shorter distances faced by each household. By looking at some of these more direct factors, Barton and colleagues (2012) provide further evidence of a causal relationship between the built environment and travel behaviour, using survey data from 12 English suburbs. The modal shares for walking and driving varied widely between the suburbs but when the data was split by journey distance and journey purpose, the patterns across all 12 suburbs were fairly similar to each other.

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The implications of this finding can be illustrated by comparing two Bristol suburbs, at the two extremes in this survey (Figure 5.1). Bradley Stoke began construction in 1987, but the land allocated for a district centre remained undeveloped 20 years later when Barton and colleagues (2012) conducted their survey. Filton is an older, denser suburb with more local facilities. It lies two miles from Bradley Stoke, closer to Bristol city centre. The survey area was near to a local high street. Filton had the lowest share of car use and highest share of active travel (mainly walking) among the 12 areas – double that of Bradley Stoke. From the evidence of Figure 5.1, we might deduce that residents of Filton prefer to walk, whereas Bradley Stoke residents prefer to drive, but Figure 5.2 tells a different story. Figure 5.2 shows the active travel elements of Figure 5.1 broken down by distance bands. As we might expect, for shorter trips people are more likely to walk. As distance increases, they are more likely to drive. Although they walk much less overall, for any given distance, people in Bradley Stoke are almost as likely to walk as those in Filton. Filton residents walked more overall because they had more shops, services and facilities within walking distance. Figure 5.1: Modal share of all trips. Bristol suburbs surveyed % 100 90

53%

38%

26%

80 70 Walk/cycle

60

Public transport

50

Car 40 30 20

45%

57%

73%

Filton

All 12 suburbs

Bradley Stoke

10 0

Source: Barton et al (2012).

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50

Bradley Stoke 40

Filton

30 20 10 0 0-400m

400-800m

800m-1600m

1600m +

Source: Barton et al (2012).

Although causality may be difficult to prove, the weight of evidence suggests that (at least) three causal mechanisms explain the relationship between the built environment and travel behaviour to varying extents: • Built environment factors affect the physical, social and economic conditions that influence travel behaviour choices. • Individuals and households ‘self-select’ the areas that best satisfy their travel preferences. • The preferences of individuals and households are influenced by the area in which they live. The relative strength of each of these mechanisms is likely to vary in different contexts and also over time. The second mechanism may apply when households choose to move to a different area; it may also explain why some households choose to stay in their preferred area. For households who move to a different area, the third mechanism is likely to apply gradually over time, if at all. This makes it very difficult to evaluate or quantify: a longitudinal study, tracking the evolution of attitudes over time would be needed, and even using such a method, it would still be difficult to explain the behaviour of non-movers. If people who have lived in suburbs for many years are found to prefer driving to alternative modes, to what extent are these preferences

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influenced by their local environment (third mechanism) or underlying personal preferences (second mechanism)? No study has satisfactorily addressed this problem as yet, nor has any study comprehensively assessed the impacts of an urban intensification programme using longitudinal methods (which are lengthy and expensive). In the absence of such a study, the next section will give an overview of the outcomes of urban intensification in the UK, although any conclusions about causality must necessarily be tentative. Urban intensification (2000–11) Influenced by some of the evidence reviewed in this chapter, in the late 1990s and early 2000s the UK government introduced a policy of urban intensification. Minimum density guidelines were introduced for new residential developments; a target was set for 60% of new housing to be built on previously developed land (DETR, 2000) and maximum parking guidelines were published for new developments (DETR, 2001). These policies aimed to conserve undeveloped land, promote the economic regeneration of inner cities and engender modal shift away from driving. All of them were relaxed by a later government, partly because of concerns about unintended consequences such as parking on pavements (DCLG, 2011), building on gardens and a decline in construction of ‘family housing’ (DCLG, 2010; the validity of the latter argument was challenged by Melia, 2010). The abolition of the targets and guidelines was also motivated by a move towards ‘localism’. National planning policy in England now leaves decisions on density, parking and building on previously developed land to the discretion of local planning authorities (DCLG, 2012). The extent to which the policy of urban intensification had achieved its sustainable travel objectives was neither mentioned nor evaluated when the new government decided to change direction (DCLG, 2011). This section will briefly analyse macro-level evidence on the travel behaviour impacts of urban intensification in the early 2000s in the UK (leaving aside other social and environmental impacts). Between 2000 (when the national density guidelines were introduced) and 2006, the average density of new dwellings increased by two thirds and has remained at over 40 dwellings per hectare since then (DCLG, 2014, Table P231). The 60% target for building on previously developed land was exceeded in every year from 2004 until its abolition (and the removal of gardens from the definition of previously developed land) in 2010 (DCLG, 2014, Table P211). Although economic and demographic trends (such as smaller households) provided a favourable

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context, the timing of the changes shown in Figure 5.3 leaves little doubt that the planning policy change led directly to a significant increase in the density of new housing development. Figure 5.3: Percentage change in density of new housing and in annual miles driven per person, 1994–2011 % 90 Density

Driving

80 70 60 50 40

Density guidelines introduced

30 20 10 0 –10 1994

1996

1998

2000

2002

2004

2006

2008

2010

Source: DfT (2013); DCLG (2014, Table P 231).

During the same decade, total car passenger mileage, which had been rising continually since the 1950s, reached a plateau in 2004 and began to decline after 2007 (DfT, 2013, Table TSGB 0101). There is considerable uncertainty around the reasons for this international phenomenon of ‘peak car’; some writers have tentatively suggested that a shift towards living in high-density areas is part of the explanation (Goodwin and Van Dender, 2013). Given the uncertainties around causal mechanisms, it is uncertain whether national data can provide any useful insight into this hypothesised relationship. If the second mechanism (self-selection) explored earlier was the strongest of the three mechanisms and people acted on their underlying preferences regardless of location, then a policy to concentrate population growth in high density areas would change travel patterns in those areas. The new residents would on average drive more than the original residents.1 Figure 5.4 shows the population of electoral

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wards in England and Wales divided into four population density bands – roughly quartiles – in 2001. As expected, the policy of urban intensification increased the proportion of the population living in the densest urban wards. Figure 5.4: Percentage of population of England and Wales in four density bands % 29

Proportion of population in each band

28 27 26 25 2001

24

2011 23 22 21 20 11,000

Note: Office for National Statistics licensed under the Open Government Licence v.3.0. Source: ONS (2014a), ward-level data.

Across England and Wales, the proportion of the working population driving to work fell slightly from 55.2% in 2001 to 54.5% in 2011. Figure 5.5 shows the change within each of the four density bands. The share of driving fell slightly in the densest wards, and rose slightly in the other three bands. Whatever the role of attitudes and preferences, four consequences followed the policy of urban intensification: • The proportion of the population living in the densest areas, where people drive least, increased. • The proportion of commuters driving in those densest areas decreased. • The proportion of the population living in lower and medium density areas was reduced (absolute numbers rose very slightly). • The proportion of commuters driving in those areas increased.

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When assessing the impact of a national policy, it is not possible to observe the counterfactual, that is, what would have happened if the policy had never been implemented, so causality cannot be proven. Some general observations may be made on the outcomes that followed, however. Car ownership rose by 6% over the decade (ONS, 2014a, Table QS 404 EW), influenced by higher household incomes, so the fourth consequence would have been likely under either scenario. The first and third consequences were direct consequences of the intensification policy, which also contributed to the second consequence, due to increased pressure on limited road capacity in the denser areas. It seems that the policy did therefore achieve one of its principal aims: to constrain commuting by car. Figure 5.5: Population density and commuting by car in England and Wales % 70

Proportion driving to work

65 60 55 50

2001 2011

45 40 35 30

11,000

Note: Office for National Statistics licensed under the Open Government Licence v.3.0. Source: ONS (2014a), ward-level data .

Unintended consequences of behaviour change policies Urban intensification can produce undesirable and unintended consequences. The modal shift achieved by urban intensification is rarely proportional, so doubling densities will reduce but will not halve traffic generation. This ‘paradox of intensification’ means that a policy that benefits the global environment may worsen the local environment of intensified areas, unless it is accompanied by active traffic restraint in

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those areas (Melia et al, 2011). Specific data on intensified areas is not available but on major and minor urban roads as a whole, traffic trends were remarkably stable during the last decade, rising very slightly until 2007 and falling very slightly after the start of the recession (DfT, 2014). Echenique and colleagues (2012) argue (on the basis of modelling projections) that urban intensification may increase commuting distances because of a widening effect on housing prices. If so, this is not necessarily a consequence of intensification per se, but of the balance of restraint applying to housing and employment. Restraining housing in areas where employment opportunities are growing, or where there are already labour shortages, will cause some people to seek cheaper housing further from their places of work. The quantitative impact of this tendency in practice also remains to be assessed, but unlike the modal share for driving, the average commuting distance in England and Wales rose, from 13.4 km in 2001 to 15.0 km in 2011 (ONS, 2014b), partially offset by an increase in the proportion of people who mainly work from home, from 9.2% in 2001 to 10.3% in 2011. Box 5.2: Stop and think: unintended consequences Any policy may have unintended consequences. Sometimes research evidence may alert policymakers to the risks of unintended consequences. Research is more likely to reveal unintended consequences where the evidence comes from longterm, real-world observations. Experimental evidence (which may demonstrate a cause and effect) is much less likely to reveal unintended consequences. Realworld observational evidence cannot demonstrate cause and effect, because there is no way of comparing what actually happened with the counterfactual, that is, what would have happened if the policy had not been introduced. So whatever evidence is available, uncertainty about the impacts of a policy will always remain until that policy is implemented.

Behaviour change question 1: do permeable street networks lead to more cycling and walking? The last two factors in Table 5.1 – network connectivity (or permeability – the two terms are often used interchangeably2) and cycling/walking infrastructure – are linked, and the evidence supporting the claims made about their impacts on travel behaviour raise some similar issues to urban intensification. This section and the next will examine each of those factors in turn. The findings that permeable street networks reduce driving and increase walking and cycling are mainly based on comparisons between the two types of road layout shown in Figure 5.6 and Figure 5.7.

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The ‘gridiron’ street network illustrated in Figure 5.6 is typical of the downtown areas and older suburbs of many North American cities, whereas Figure 5.7 is typical of many suburbs built from the mid20th century onwards. Walking distances between any two points on Figure 5.7 will be longer – sometimes considerably longer – than in Figure 5.6. The fact that most of these suburbs are also low in density and land-use mix (with large areas zoned for housing only) creates a situation similar to the one described in Bradley Stoke. If there are no destinations within walking distance, then there will be very little walking; for many purposes, driving may be the only alternative. Some studies have tried to quantify the effect of network connectivity on travel behaviour using aggregate measures, such as the average length of road segments or the density of intersections. Studies using North American data usually find significant relationships between these measures and the frequency of active travel (such as McGinn et al, 2007; Berrigan et al, 2010). Some have also found negative Figure 5.6: Gridiron street layout, Philadelphia

Source: Openstreetmaps contributors.

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Evaluating the impact of policy Figure 5.7: Suburban layout, Arizona

Source: Openstreetmaps contributors.

associations with driving distances (Steiner et al, 2010) and number of trips by car (Cervero and Gorham, 1995). These studies control for a range of other built environment and socioeconomic factors, although none of them satisfactorily addresses the attitudinal and self-selection issues discussed earlier, so their quantitative estimates of impacts on travel behaviour need to be treated with some caution. Notwithstanding these caveats, the broad conclusions that layouts such as those in Figure 5.7 are likely to engender lower rates of active travel and longer journeys than layouts such as those in Figure 5.6 are highly plausible. Where the comparisons between neighbourhood types are less extreme, the effect on travel behaviour may not be so clear, however. In a UK context, using aggregate data from the county of Surrey, Hickman and Banister (2008) found no significant association between energy consumption from travel to work and a three-category ‘streetscape layout’ variable (grid/cul-de-sac/remote cul-de-sac) when controlling for other factors.3

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None of these studies, nor the many others comparing permeable grids with impermeable suburban areas, acknowledges the possibility that such comparisons might disguise countervailing forces. Increasing the permeability of street networks tends to reduce distances for walking and also for driving. A priori, we would expect this to: • encourage walking and reduce the distance of each walking trip; • encourage driving and reduce the distance of each driving trip. Regression analyses of travel behaviour with respect to network permeability would therefore measure the net differences between these countervailing effects, which are likely to vary in different local contexts. The networks shown in Figure 5.6 and Figure 5.7 are roads open to all forms of movement; the journey distances would be the same for pedestrians, cyclists and drivers. Planners in many continental European cities take a different approach – filtered permeability – where the sustainable modes are separated from private motor traffic in order to give them an advantage in terms of speed, distance and convenience (Melia, 2012). Figure 5.6 is an example of unfiltered permeability; Figure 5.7 is an impermeable network. The separation can come in many forms, such as cycle paths, bus gates or footbridges. The advantage is usually in form of a short-cut, although it could also be a time or comfort advantage – by avoiding a congested stretch of road or a steep hill, for example. The short-cut may be created by building a new link, such as a cycle/footbridge, or by closing roads to certain forms of traffic as illustrated in Figure 5.8 and Figure 5.9. Although the terminology varies, in continental European cities such as Freiburg, Münster, Copenhagen, Malmö, Amsterdam and Groningen, where cycling is an important mode, the principle of filtered permeability is a key element of transport planning strategies. The city region of Amsterdam measures the proportion of journeys that are faster by bicycle than by car in different areas of the city region and the aim is to raise these proportions over time (Sargentini and Valenta, 2014). Cambridge, the British city with the highest rate of cycling, has implemented similar measures, with the effect that many journeys, particularly those that cross the city centre, are significantly shorter by bicycle or on foot, than by car. The same is also true in Hackney, the borough with the highest rate of cycling in London (Melia, 2015).

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Evaluating the impact of policy Figure 5.8: Filtered permeability in Malmö, Sweden

Figure 5.9: Bus gate in Cambridge, UK

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Box 5.3: Case study: focus on the evidence around filtered permeability Three studies have concluded that the principle of filtered permeability encourages walking or cycling. In the US, Frank and Hawkins (2008) compared four areas in Washington State, similar except for their different street layouts. One of these was characterised by ‘fused grids’, where some of the streets of a ‘traditional grid’ (as in Figure 5.6) have been blocked to through traffic, but kept open for pedestrians and cyclists (using methods like that of Figure 5.8). Of the four types of area, the fused grids had the highest level of walking. Using aggregate cross-sectional data for the Netherlands, two studies have likewise found that in areas where cycle routes are more direct than the alternatives for general traffic, rates of cycling are higher (Rietveld and Daniel, 2004; Schepers et al, 2013). These three studies all used cross-sectional data, so did not resolve the problems of ascribing causality discussed earlier. Quasi-experimental methods offer one potential means of addressing those problems. A recent programme that aimed to build short-cuts for walking and cycling in different parts of the UK (Connect 2) provided one such opportunity. Two related articles evaluated the impacts on active travel and transport CO2 emissions of two new cycle bridges and a new cycle path, which created significant short-cuts for cycling and walking in three British towns or cities. Goodman and colleagues (2013) surveyed households living within 5km before, and two years after, the short-cuts were built. After controlling for demographic factors, they found that each kilometre closer to the new infrastructure was associated with an additional 15 minutes per week of walking or cycling. Most of this additional active travel was recreational, however; Brand and colleagues (2014) found no significant change in transportrelated CO2 emissions in the same area, concluding that the main effect of the new infrastructure was to encourage additional journeys rather than modal shift. Unlike some of the cities described earlier, the Connect 2 programme created additional permeability for active travel, but made no difference to the permeability of the road networks for private motor traffic. In Cambridge, the proportion of commuters driving to work fell from 42% in 2011 to 34% in 2001, mainly due to increased walking and cycling. Several filtering measures such as the one in Figure 5.9 were implemented over those two decades. Melia (2015) concludes that this modal shift was due at least in part to the traffic restraint and encouragement of active travel created by the filtering of permeability. This conclusion was based on observations and stakeholder interviews with no attempt to quantify the impact of each factor.

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Behaviour change question 2: do more cycle paths lead to more cycling? The inconclusive evidence in the previous section raises a broader problem of how to assess the impacts of multiple policies over an extended period of time. The behavioural impact of separate cycling infrastructure provides an illustration of the broader problem. In developed countries, rates of cycling fell sharply after World War II as car ownership rose. In some countries, particularly the Netherlands and Denmark, the decline was halted and reversed in the latter part of the 20th century (Pucher and Buehler, 2008). Individual cities in many European countries also achieved significant modal shift from car driving to cycling. Both Denmark and the Netherlands, and all of the European cities that achieved significant modal shift (of which the author is aware, through the literature and informal research since 2006), built extensive networks of separate cycle paths and other cycling infrastructure during the periods when cycling was increasing. The quality of this infrastructure (in terms of connectivity, consistency of design standards and priority over other traffic) is generally superior to infrastructure in countries such as Britain and France, where rates of cycling are much lower. Partly because of poor quality cycling infrastructure, some British cycling organisations have historically opposed segregated cycle paths (Aseasyasridingabike, 2013) and some advocates of this view have even argued that ‘[segregated] cycle facilities could lead to an overall decline in cycling’ (Franklin, 1999). In Dutch, Danish and German cities, Pucher and Buehler (2008) concluded that the most important factor promoting cycling was separate cycling facilities combined with extensive traffic calming of residential areas (other factors include compact land use planning and policies restraining car use. This conclusion, though highly plausible, was, like the one about Cambridge, based on observation, interviews and deduction, and could be contested. The pattern of simultaneous changes over many years leaves open the possibility of an alternative hypothesis that growth in cycling caused the infrastructure building (because of changes in political attitudes) rather than vice versa. Recognising this problem, Pucher and colleagues (2010) reviewed the international literature on programmes and policies to increase cycling. They found considerable variations in the estimated impacts of different factors including infrastructure measures. The methodology of the studies reviewed did not generally allow for causal conclusions to be drawn. Pucher and colleagues (2010) argue that the ‘ideal research design for evaluating interventions’ would be quasi-experimental, with

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before and after measurements compared to a control group. But other observations in the same article suggest that such an approach, even when rigorously conducted, might produce misleading conclusions for policymakers. This would be particularly likely where policymakers or advisers operate an evidence hierarchy, attaching greater weight to evidence from experimental or quasi-experimental methods (as advocated by Bamberg et al, 2011 and Graham-Rowe et al, 2011, among others). Figure 5.10: Causal influences on cycling Cycling infrastructure

Public policy

Attitudes to cycling

Rate of cycling

Other socio-economic and built environment factors

Figure 5.10 illustrates the main causal relationships gleaned from the literature and from the author’s informal research around European cities. The model could be applied in a similar way to other forms of transport. All of the relationships shown involve time lags and there are several iterative feedback loops, some of them (such as between public policy, socioeconomic factors and attitudes to cycling) running simultaneously in opposite directions. Where the change is in an upward direction, the expected direction of these relationships would be positive, so that, for example, cycling infrastructure that increased the rate of cycling would engender more positive attitudes to cycling, which would in turn increase cycling directly and would also encourage policymakers to implement more pro-cycling policies. This (also incorporating the ‘other factors’) is broadly the scenario described by Pucher and Buehler (2008) in Northern Europe. The synergies between the different boxes in Figure 5.10 may also apply within the ‘cycling infrastructure’ box; as Pucher and colleagues (2010, p 122) point out, ‘a complete system of bicycling infrastructure may have far more impact than the sum of its individual parts’. Thus it

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is not surprising that evaluations of limited interventions like Connect 2 have found only limited evidence of behaviour change or, as in one earlier quasi-experimental study of cycle paths built in British cities, no significant impact on rates of cycling (Harland, 1993). A quasi-experimental evaluation of multiple, long-term, synergistic changes, while theoretically possible, would raise many resource and practical problems, such as the possibility of control groups reacting to the interventions (Sloman et al, 2010). As a result, no such studies have been reported in the literature. Although it has not been formally evaluated in that way, one natural experiment demonstrates that, combined with synergistic measures, large-scale city-wide building of separate cycle routes, can substantially increase rates of cycling. Between 2006 and 2009, the city of Seville built 120 km of new cycle paths and several thousand additional cycle parking spaces at the same time as a new tram system and pedestrianisation of central areas. Starting from a low base, in a city with no culture of cycling, this combination of policies led to a tenfold increase in the number of cycle trips between 2006 and 2009, when the modal share of mechanised trips reached 6.6% (Castillo-Manzano and Sanchez-Braza, 2013). Box 5.4: Stop and think: brave decisions Given the discussion in this chapter about the uncertainties of cause and effect, it is a brave policymaker who decides to invest in big infrastructure schemes (such as Seville’s cycling network) in order to change behaviour. The potential benefits to such brave decision making are enormous, but the dangers are also clear.

Conclusion The evidence reviewed in this chapter supports the view that changes to the built environment can influence travel behaviour, but the methodological challenges mean that studies that claim to quantify the impact of individual policy measures need to be treated with caution. Urban intensification entails a range of intermediate impacts on factors directly affecting behaviour, such as road capacity per person and walking distance to the nearest shops or railway station. Overall, intensification tends to restrain car driving and encourage alternatives but also to concentrate traffic in intensified areas. This presents planners and policymakers with a dilemma of whether to accept a worsening of local environments, or to impose further restraint on vehicular movement. The urban intensification policies of the UK government in the early 2000s raised the density of new developments and reduced

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the prevalence of commuting by car, although unbalanced restraint of housing and employment may have contributed to longer commuting distances. The evidence on permeability of street networks is more ambiguous. In the North American context, where housing densities are low and many suburbs are zoned for housing only, impermeable street networks with long culs-de-sac produce lower levels of walking than neighbourhoods than in grid-based traditional areas. In European cities where circumstances are less extreme, increasing unfiltered permeability may have little or no impact on travel behaviour. Filtered permeability, which creates short-cuts for walking and cycling, encourages those modes but is only likely to engender modal shift if permeability for motor vehicles is reduced. In recent years, policymakers and their advisers have increasingly pressed researchers to quantify (and often monetise) the impacts of individual policy measures (Dodgson et al, 2009; Mackie and Worsley, 2013). However, policies that alter the built environment in order to change behaviour are, in practice, impossible to validly evaluate in that way. As illustrated by the evaluations of cycling infrastructure, built environment changes create synergies and iterative feedback loops; their impacts may build over time; the impact of comprehensive, connected cycle networks is greater than the sum of their parts. As a result, evidence hierarchies, which place greater weight on experimental evaluations of ‘the parts’, are likely to underestimate the impacts of such policies, or to wrongly conclude that they are ineffective. End-of-chapter questions • What problems do policymakers face when considering the ‘causes’ of behaviour change in the urban planning field? • To what extent do you think that filtered permeability should be used to achieve behaviour change (such as improved levels of walking or cycling and reduced car usage)?If you were budget holder and decision maker, would you invest in building more cycle paths in your town/city? • How do you think the ‘evidence’ supporting behaviour change should be or could be improved?

Notes This is a statement of the net aggregate situation: beneath the apparent stability of these aggregate relationships, there are always many people moving in different directions – in this case between high- and low-density areas. 1

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Evaluating the impact of policy Marshall (2005) defines the two terms differently: connectivity refers to the density of intersections within an area, whereas permeability refers to the capacity of a network to carry traffic in different directions, so widening the roads in a network would increase its permeability but not its connectivity. As this chapter deals with general principles rather than quantitative modelling, the two terms are used interchangeably to mean the extent to which networks enable travel in different directions.

2

This conclusion is not entirely clear in the conference paper cited (which shows only binary regressions and ‘all built environment’ factors in a multivariate regression). It was clarified by one of the authors in a separate discussion.

3

References Aseasyasridingabike (2013) ‘“No surrender” – the damaging, enduring legacy of the 1930s in British cycle campaigning’, http:// aseasyasridingabike.wordpress.com/2013/02/15/no-surrenderthe-damaging-enduring-legacy-of-the-1930s-in-british-cyclecampaigning Bamberg, S., Fujii, S., Friman, M. and Gärling, T. (2011) ‘Behaviour theory and soft transport policy measures’, Transport Policy, 18(1): 228-35. Barton, H., Horswell, M. and Millar, P. (2012) ‘Neighbourhood accessibility and active travel’, Planning Practice and Research, 27(2): 177-201. Berrigan, D., Pickle, L.W. and Dill, J. (2010) ‘Associations between street connectivity and active transportation’, International Journal of Health Geographics, 9. Brand, C., Goodman, A. and Ogilvie, D. (2014) ‘Evaluating the impacts of new walking and cycling infrastructure on carbon dioxide emissions from motorized travel: a controlled longitudinal study’, Applied Energy, 128: 284-95. Cao, X., Mokhtarian, P.L. and Handy, S. (2009) ‘Examining the impacts of residential self-selection on travel behaviour: a focus on empirical findings’, Transport Reviews, 29(3). Castillo-Manzano, J. and Sanchez-Braza, A. (2013) ‘Can anyone hate the bicycle? The hunt for an optimal local transportation policy to encourage bicycle usage’, Environmental Politics, 22(6): 1010-28. Cervero, R. and Gorham, R. (1995) ‘Commuting in transit versus automobile neighborhoods’, Journal of the American Planning Association, 61(2): 210-25.

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Clark, B., Chatterjee, K., Melia, S., Knies, G. and Laurie, H. (2014) Life transitions and travel behaviour study – drivers of change to commuting mode’, Life Transitions Project, Evidence Summary 2, www.travelbehaviour.org Clark, B., Chatterjee, K., Melia, S., Knies, G. and Laurie, H. (in press) ‘Life events and travel behaviour: exploring the inter-relationship using the UK household longitudinal study’, Transportation Research Record. DCLG (Department for Communities and Local Government) (2010) ‘New powers to prevent unwanted garden grabbing’, www.gov. uk/government/news/new-powers-to-prevent-unwanted-gardengrabbing DCLG (2011) ‘Pickles and Hammond to end the war on the motorist’, www.gov.uk/government/news/pickles-and-hammond-to-end-thewar-on-motorists DCLG (2012) National planning policy framework, London: Department for Communities and Local Government. DCLG (2014) ‘Live tables on land use change statistics’, www.gov. uk/government/statistical-data-sets/live-tables-on-land-use-changestatistics DETR (Department of the Environment, Transport and the Regions) (2000) Planning policy guidance note 3, Housing, London: The Stationery Office. DETR (2001) Planning policy guidance note 13, Transport, London: The Stationery Office. DfT (Department for Transport) (2014) ‘Table TRA 2505 – road traffic (vehicle kilometres) by road class in Great Britain, quarterly from 1993’, www.gov.uk DfT (2013) National travel survey: 2012, London: Department for Transport. Dodgson, J., Spackman, M., Pearman, A. and Phillips, L. (2009) Multicriteria analysis: A manual, London: Department for Communities and Local Government. Echenique, M.H., Hargreaves, A.J., Mitchell, G. and Namdeo, A. (2012) ‘Growing cities sustainably’, Journal of the American Planning Association, 78(2): 121-37. Frank, L.D. and Hawkins, D. (2008) Giving pedestrians an edge – Using street layout to influence transportation choice, Ottawa: Canada Mortgage and Housing Corporation. Franklin, J. (1999) ‘Two decades of the Redway cycle paths in Milton Keynes’, Traffic Engineering and Control, 40(7-8): 393-6.

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Goodman, A., Panter, J., Sharp, S.J. and Ogilvie, D. (2013) ‘Effectiveness and equity impacts of town-wide cycling initiatives in England: a longitudinal, controlled natural experimental study’, Social Science and Medicine, 97: 228-37. Goodwin, P. and Van Dender, K. (2013) ‘“Peak car” – themes and issues’, Transport Reviews, 33(3): 243-54. Graham-Rowe, E., Skippon, S., Gardner, B. and Abraham, C. (2011) ‘Can we reduce car use and, if so, how? A review of available evidence’, Transportation Research Part A: Policy and Practice, 45(5): 401-18. Harland, G. (1993) Cycle routes, Crowthorne: Transport Research Laboratory, Safety Resource Centre. Hickman, R. and Banister, D. (2008) ‘Transport and reduced energy consumption: the role of urban planning’, in Anon. 40th Universities Transport Study Group Conference. Litman, T. and Steele, R. (2013) Land use impacts on transport, Victoria Transport Policy Institute, www.vtpi.org/landtravel.pdf Mackie, P. and Worsley, T. (2013) International comparisons of transport appraisal practice, Report Number PPRO 04/03/31, Leeds: Institute for Transport Studies. Marshall, S. (2005) Streets and patterns, Abindgon: Spon Press. McGinn, A., Evenson, K., Herring, A., Huston, S. and Rodriguez, D. (2007) ‘Exploring associations between physical activity and perceived and objective measures of the built environment’, Journal of Urban Health, 84(2): 162-84. Melia, S. (2010) ‘Urban intensification and problems – real and imagined’, Town and Country Planning, July/August: 341-5. Melia, S. (2012) ‘Filtered and unfiltered permeability: The European and Anglo-Saxon approaches’, Project, 4: 6-9. Melia, S. (2015) Urban transport without the hot air, Cambridge: UIT Cambridge. Melia, S., Barton, H. and Parkhurst, G. (2011) ‘The paradox of intensification’, Transport Policy, 18(1): 46-52. Næss, P. (2009) ‘Residential self-selection and appropriate control variables in land use: travel studies’, Transport Reviews, 29(3): 293-324. ONS (2014a) ‘2011 census’, www.nomisweb.gov.uk ONS (2014b) ‘2011 census analysis, distance travelled to work’, www. ons.gov.uk/ons/rel/census/2011-census-analysis/distance-travelledto-work/index.html Pucher, J. and Buehler, R. (2008) ‘Making cycling irresistible: lessons from the Netherlands, Denmark and Germany’, Transport Reviews, 28(4): 495-528.

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Pucher, J., Dill, J. and Handy, S. (2010) ‘Infrastructure, programs, and policies to increase bicycling: an international review’, Preventive Medicine, 50: S106-S125. Rietveld, P. and Daniel, V. (2004) ‘Determinants of bicycle use: do municipal policies matter?’, Transportation Research Part A: Policy and Practice, 38(7): 531-50. Sargentini, M. and Valenta, S. (2014) ‘Transport planning in the Amsterdam city region’, unpublished. Schepers, P., Heinen, E., Methorst, R. and Wegman, F. (2013) ‘Road safety and bicycle usage impacts of unbundling vehicular and cycle traffic in Dutch urban networks’, European Journal of Transport and Infrastructure Research, 13(3): 221-38. Schwanen, T., Dijst, M. and Dieleman, F.M. (2004) ‘Policies for urban form and their impact on travel: the Netherlands experience’, Urban Studies, 41(3): 579. Sloman, L., Cairns, S., Newson, C., Anable, J., Pridmore, A. and Goodwin, P. (2010) The effects of Smarter Choice programmes in the Sustainable Travel Towns, London: Department for Transport. Steiner, R.L., Srinivasan, S., Provost, R.E., Mackey, J., Arafat, A.A. Anderson, N. and DeLarco, L. (2010) VMT-based traffic impact assessment: Development of a trip length model, Florida: University of Florida, http://cms.ce.ufl.edu Susilo, Y. and Maat, K. (2007) ‘The influence of built environment to the trends in commuting journeys in the Netherlands’, Transportation, 34(5): 589-609.

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Nudge: Recent developments in behavioural science and public policy Michael Hallsworth and Michael Sanders

Introduction As Chapters One, Four and Five have already explored from various angles, governments have always tried to influence the behaviour of those they govern. However, arguably the past 20 years have seen a new perspective develop among policymakers: they have become increasingly interested in the concept of ‘influencing behaviour’ itself as a generic policy challenge (Fletcher-Morgan and Leyland, 2010). This interest has been reflected in the increasing use in UK government documents of the terms ‘behaviour’ and ‘behaviour change’ as explicit targets for government activity (HM Government, 2010; Dolan et al, 2012, 2010). In the words of one recent study, ‘a behaviour change agenda has gradually been emerging’ (Jones et al, 2013, p xi). Commentators have suggested various causes for this shift. Over recent decades, governments have increasingly been tasked with addressing new, complex challenges, such as obesity, climate change and social exclusion (Duit and Galaz, 2008). Arguably, the novelty of these policy problems has often encouraged policymakers to approach them more abstractly, as sets of ‘behaviours’ to encourage or discourage, in contrast to the established perceptions, stakeholders and routines associated with more traditional areas of government activity. Other commentators suggest that the rise of neoliberal practices and structures have led authorities to find new ways of ‘governing the soul’, such as shaping the way that individuals manage their own conduct (Rose, 1990). For reasons of space, this chapter does not discuss these ideas in full. Instead, it focuses on another potential cause for the growth in the behaviour change agenda: changes in the analytic approaches available to governments, particularly the rise of ‘behavioural economics’.

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This is followed by a discussion of why these new approaches have proved attractive to the UK government in recent years; an account of the main institutional driver of such approaches in the UK, the Behavioural Insights Team established in the Cabinet Office in 2010; a comparison with social marketing approaches; and an examination of some common criticisms of applying these new analytic approaches to policy problems.

The rise of behavioural economics The 20th century witnessed the rise of economics as the dominant mode of policy analysis, with economists emerging as ‘technical experts whose advice is essential to decision-making’ (Backhouse, 2002, p 308). Much of this advice concerned predictions of how a policy would affect the behaviour of individuals. Most of these predictions were grounded in a ‘standard model’ of expected utility theory, which postulated that individuals gathered information on the various options available to them, weighed up the costs and benefits (as they defined them) associated with each option, and selected the optimal choice suggested by this analysis (Becker, 1968; DellaVigna, 2009). The standard model suggests that government intervention may be necessary if there are ‘market failures’ such as monopoly power, asymmetric information, or social costs – or if properly functioning markets produce outcomes that are unfavourable according to the government’s ‘social welfare function’ (what non-economists would call their ‘values’). The standard model suggests ways for the government to act (should it choose to do so), including taxation to redistribute wealth or to discourage actions with negative social consequences; information to resolve problems generated by asymmetry; and regulation where the social cost of an activity is deemed too high (see, for example, HM Treasury, 2003). From the perspective of economics, the past 40 years have seen the growth of empirical and theoretical evidence that individuals do not always fulfil the predictions of the standard model (Camerer et al, 2004). This happens because people often use heuristics (or ‘rules of thumb’) when making decisions, which can lead to ‘biases’ that mean they to fail to make the optimal decision. For example, investors may experience ‘home bias’, leading them to invest heavily in local industries where a more diversified portfolio might have been wiser (Lewis, 1999). People may procrastinate, and therefore tend to eat too much, exercise too little, and fail to save money for retirement (O’Donoghue and Rabin, 1999).

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If these biases exist, this would seem to increase the range of possible social welfare functions under which government intervention is desirable. However, there are practical and philosophical difficulties in government optimising on behalf of its citizens, since (among other reasons) it could have worse information about the ‘true’ or ‘optimal’ preferences of citizens they seek to help; indeed, some critics would question whether government can ever discover such preferences (Berlin, 1958). Regardless, the main point is that increasing academic evidence has shown how individuals may not make optimal choices, as identified by policymakers using standard economic models. (The word ‘irrational’ is sometimes used in the context, usually ill advisedly, given the difficulty of defining rationality; Elster, 2007.) Box 6.1: Stop and think: are you thinking rationally? Think about all the behaviours you, and those you know, engage in that are not optimal to your health and wellbeing. How much do you think about these behaviours in a deliberate, ‘economic’ way, weighing up the pros and cons carefully before deciding whether to go ahead? How much of the decision to engage is made in a less conscious, much more intuitive way?

Of course, we do not have to start from the discipline of economics. From the point of view of psychology, this movement has simply been the growing acknowledgement of the empirical findings regarding human behaviour produced by psychologists (Kahneman, 2011). The language of ‘bias’ is inappropriate because there is not an agreed standard model from which to deviate. However, this is a simplistic view that neglects the changes that have taken place in psychology itself – most notably a greater recognition of the role of environmental cues and automatic processes in determining behaviour (Camerer et al, 2005) than was present in more attitude-based models of behaviour (such as the theory of planned behaviour, discussed in Chapter Two). We can sum up the changes as follows. Over the past 40 years, both psychologists and economists have produced new empirical evidence about how individuals behave when presented with certain decisions or situations. Many of these findings question existing models of behaviour. These findings have increasingly been incorporated into policy analysis and design in recent years. Since economics has been the dominant mode of policy analysis, this shift has often been seen through the lens of an ascendant ‘behavioural economics’. However, it could equally be seen as the increasing influence of psychology in public policy – a change that even prominent economists recognise as desirable (Thaler, 2012). From either perspective, this movement

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represents an empirical questioning of the assumptions underlying policy decisions (Kahneman, 2011, p 141). The more interesting question may therefore be why and how government has embraced these findings, which we consider in the case study below. Box 6.2: Case study: the UK government’s adoption of the behavioural sciences (post 2010) In 2008, Richard Thaler and Cass Sunstein published Nudge: Improving decisions about health, wealth and happiness. Nudge presented ‘libertarian paternalism’, a particular application of behavioural economics to public policy that was intended to appeal to both right- and left-wing perspectives. The core proposal was that government could order the ‘choice architecture’ presented to individuals so that their heuristics would lead them to choose the option that the policymaker considered to be optimal (the paternalist element), although the individual remained free to choose differently, should they desire (the libertarian element). The Conservative Party, then in opposition, became interested in the ideas included in the book (McSmith, 2010). Richard Thaler subsequently advised the party in the period preceding the 2010 general election (Osborne and Thaler, 2010). There are several reasons why Nudge would have been attractive to the opposition at this point. Opposition parties often desire to adopt ‘new thinking’ to distinguish themselves from the party in power, and nudging was seen to supply this novelty (Haddon, 2012a, 2012b). Second, nudging chimed with the instincts of Conservative thinkers to avoid coercive legislation in favour of ‘a post-bureaucratic approach to regulation that makes use of new technologies and insights from social psychology and behavioural economics to achieve our policy goals in a less burdensome and intrusive way’ (Conservatives, 2009, p 3). Third, particularly after the financial crisis of 2008/09, nudging was perceived as an inexpensive means of achieving policy goals, since altering ‘choice architecture’ was often cost-free. However, to focus only on the Conservative Party’s support for Nudge gives an incomplete narrative. As Jones and colleagues (2013) have noted, there had been a growing and sustained engagement with the behavioural sciences since (arguably) the mid-1990s, which went broader than libertarian paternalism. For example, in 2004 the Prime Minister’s Strategy Unit published the Personal responsibility and changing behaviour issue paper, which discusses much of the literature associated with behavioural economics (Prime Minister’s Strategy Unit, 2004). Then, in 2009 the Cabinet Office minister Liam Byrne commissioned the Institute for Government to draw together this literature into a framework for policymaking. The result was the MINDSPACE report, which was subsequently

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Nudge widely adopted throughout the UK public sector, at least partly thanks to the high-level support given by actors such as the then head of the Civil Service, Sir Gus O’Donnell (Rutter, 2014). Both these reports (and most of the activities associated with them) had a technocratic focus, where behavioural sciences were seen as new tools for enhancing the effectiveness of government action. Three points are worth nothing here. First, the application of behavioural economics has not been a party political issue – both major parties have been supporters of its uptake. This may help to explain why attacks on the coalition’s use of behavioural science from the Labour opposition have been very limited (Woodhouse, 2011). Second, the technocratic strand often presents a broader vision of how behavioural sciences can be applied than the political narrative described here. Rather than seeing nudging as an alternative to regulation, which was a major attraction to the Conservative Party (Letwin et al, 2011), this strand has tended to present behavioural science as a way of complementing or enhancing existing policy options. For example, the MINDSPACE report explicitly states that this body of knowledge ‘powerfully complements and improves conventional policy tools, rather than acting as a replacement for them’ (Dolan et al, 2012, 2010). Finally, this strand has tended to acknowledge the technical and political challenges around applying such a body of knowledge. The 2004 report explicitly discusses the impact of these ideas on the concept of personal responsibility, while MINDSPACE contains a whole section that engages with the political philosophical arguments for and against applying behavioural sciences to public policy (including, for example, governmentality). These are relatively unusual moves for government documents to take, and suggest that the discourse around applying behavioural sciences has been more nuanced than many academic commentators, perhaps focusing purely on the political narrative, usually claim to be the case.

The Behavioural Insights Team The 2010 Coalition Agreement, which set out the priorities for the forthcoming administration, explicitly committed the government to ‘harnessing the insights from behavioural economics and social psychology’ (HM Government, 2010, p 12). Perhaps the most highprofile manifestation of this commitment was the creation, in August of that year, of a Behavioural Insights Team (BIT, of which both authors are members) to advance the use of behavioural sciences in government. The team was small (originally just eight people), was based in the Cabinet Office (the central coordinating department for government), and reported directly to the Cabinet Secretary (the

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most senior UK civil servant). It also incorporated a two-year ‘sunset clause’, which required BIT to demonstrate it had met three main objectives – including savings to government that far exceeded the cost of the team – to avoid being closed down (Behavioural Insights Team, 2012a). Despite its small size, the team has worked across a wide range of policy areas, and has published several accompanying reports, including those on fraud, error and debt; energy; charitable giving; and health (BIT, 2010; 2011; 2012b; 2013). We suggest that two features of the team proved to be particularly significant. The first is that its remit was (and is) not limited to implementing nudges, despite the close involvement of Richard Thaler, and despite the tendency of the media to refer to the ‘Nudge Unit’. Indeed, it is worth noting that the team used the term ‘behavioural insights’, not ‘behavioural sciences’, ‘behavioural economics’, or ‘behavioural change’. The term ‘behavioural insights’ was not widely used at this point. Although there were some contingent factors influencing this choice, it was also intended to capture some particular features of the team’s operation. One was that the broad range of disciplines embraced by the team, which included sociology, anthropology and design (BIT, 2014a). The other was a particular emphasis on application, rather than a more narrow theoretical interest in behavioural science for its own sake. Therefore, when confronted with a policy issue, the team’s starting point was not ‘how to nudge’ but to consider all the policy options available, using behavioural science as an analytic lens. The rationale was that the way in which policies were implemented could be enhanced by behavioural insights, regardless of the specific policy tool they employed. This stance gave the team greater flexibility, and thus credibility, with government officials. The second feature was to introduce a strong and sustained commitment to evaluating the impact of the team’s interventions. The team has been a strong proponent of the use of randomised controlled trials to assess the effectiveness of government interventions (Haynes et al, 2012). The main purpose of doing so was to address the criticism that many of the findings from behavioural sciences were based on laboratory experiments that may not generalise to real-world settings (Levitt and List, 2007). This is a particular concern, given that the power of contextual factors to influence behaviour has been one of the main findings to emerge from the behavioural sciences in recent years (Bargh and Chartrand, 1999). The commitment to producing new results arguably became a crucial factor in the continued existence and perceived of the team (John, 2014). The ability to demonstrate the impact of its interventions addressed scepticism from government

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officials about the efficacy of the team’s approaches (Bennhold, 2013). This led to more opportunities to conduct projects with departments, leading to a virtuous cycle. Results from the team’s interventions are now also entering the peer-reviewed literature, although peer-review timescales mean that many are still in publication (Haynes et al, 2012; Hallsworth et al, 2014; Sanders and Hallsworth, 2015). Box 6.3: Stop and think: the importance of evaluation The importance of effectively evaluating behaviour change initiatives was tackled in detail in Chapter Three. Without evidence that a particular technique, approach or policy is effective, decision makers and budget holders are unlikely – at least in principle – to invest in a wider-scale roll-out. However, the nature of the evidence collected about effectiveness is also crucial and (as Chapter Three explores) systematic evaluation is as important as systematic intervention design. Investing in careful evaluation was a crucial part of the plan for BIT’s acceptance across government.

Although the authors, as team members, are not in a position to make such a judgement, various commentators have suggested that the team has been successful, at least on its own terms (Bavel et al, 2013; Bennhold, 2013; OECD, 2014; World Bank, 2015). This perceived success has led to other governments creating organisations modelled, more or less, along the lines of the team (Thaler, 2013). Back in the UK, perceived success had led to increased demand from within government for the team’s services, but Civil Service headcount restrictions meant that such demand could not be met. The solution was to ‘spin out’ the team in April 2014 into a separate social purpose company, partly owned by the Cabinet Office, the employees, and Nesta (an innovation charity) (Wintour, 2014). By the end of 2014, the team had increased from 15 to 55 employees, established a strategic partnership with Harvard University, and launched a £3 million centre to improve adult skills (BIT, 2014b; 2014c). Box 6.4: A comparison with social marketing It is worth contrasting the increased prominence of behavioural sciences and nudging since 2010 with the relative fall in support suffered by social marketing during the same period. Social marketing was initially targeted in the freezing of advertising budgets in 2010 (Sweney, 2010). The Central Office of Information had its funding halved, before it was eventually abolished in 2011 (BBC, 2010; Sweney, 2011). The National Social Marketing Centre had its grant from the Department of Health withdrawn (Consumer Futures, 2012). Large programmes such as Change 4 Life continued to be funded, and there were some subsequent

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Beyond behaviour change increases in the government marketing budget in 2012, but it is clear that support for government social marketing was qualified during in this period (DH, 2011; Wheeler, 2012). The differences between social marketing and behavioural economics have been the source of some debate, and a reconciliation or fusion is clearly possible (Dibb, 2014). Indeed, some of the most famous behavioural economists (such as Dan Ariely and Michael Norton) have a background in marketing. However, we suggest that (in general) the coalition administration perceived social marketing to be a less attractive option for three main reasons. First, its focus on persuasive methods to produce changes in attitudes (and thus behaviour) was seen to reflect a ‘nannying’ approach that sat poorly with ministerial instincts. In contrast, nudges that simply rearranged the presentation of choices were seen as less intrusive options. Good illustrations of this point are the speeches made by Andrew Lansley to the British Medical Association and the Faculty of Public Health in 2010. The latter states that the government’s priority is ‘Nudging individuals in the right direction. Encouraging positive choices. Not lecturing or nannying. But making people feel empowered’ (Lansley, 2010). The second factor was the perception that social marketing demands significant resources, which was seen as a particular issue given general spending reductions. Marketing was generally seen to require in-depth qualitative research, as well as the purchase of media time (often ‘above the line’), both of which require specific expenditures. At the same time, we suggest that marketing was perceived as an act that was additional to the main government action – perhaps owing to the transitive nature of the verb ‘to market’, there must be something to market. This view was exacerbated by the perception that marketing was something done by a separate set of officials (the ‘communications people’), rather than those who form the policy itself. In contrast, the behavioural sciences were seen to work with the structure of the policy itself (for example, setting the default one way or another) and thus not to impose an ‘additional’ cost. Indeed, many of the Behavioural Insight Team’s interventions have been concerned with modifying existing processes – for example, the rewriting of government letters (Hallsworth et al, 2014), the sending of text messages to school pupils’ parents, or modifying the process of benefit administration. The final factor was a degree of scepticism about the effectiveness of social marketing in changing behaviour, despite the influence of Andreasen’s (1994) call for social marketing to focus on behaviour change. To put this scepticism provocatively and crudely, the perception was that social marketing generates interventions from qualitative evidence that does not predict actual behaviour well, and then assesses those interventions through self-reports that do not

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Nudge capture actual behaviour well. This critique was partly informed by the growing evidence that much behaviour is automatic, rather than conscious, a perspective that ‘fall[s] outside the social marketing ideology’ (Spotswood et al, 2012, p 167). In contrast, behavioural economics appeared to offer more (and more reliable) evidence of the impact of its interventions on actual behaviour. The programme to reduce government spending placed greater pressure on any apparent weaknesses in evaluation, so once again the importance of evaluation and the ‘right kind’ of evidence is highlighted. The result is a position that is summed up well by the Department of Health’s 2011 publication Changing behaviour, improving outcomes: A new social marketing strategy for public health: In the past, we have generally tried to change attitudes as a precursor or accompaniment to changing behaviours. While this feels intuitively right, it is troubling that, in health, people’s behaviours so often conflict with their stated attitudes. By changing the choice architecture, for example by changing default options or changing perceptions of social norms, it may be possible to change what people do without necessarily changing their attitudes…. We will commit public money only where there is evidence that social marketing can change those behaviours that lead to improved health outcomes. In consequence, this [social marketing] strategy will be delivered with substantially less than the spend committed in previous years. (DH, 2011, p 24)

Chapter Seven offers an alternative view of social marketing as forming an important part of a future multidisciplinary agenda for behaviour change.

Criticisms While the application of behavioural sciences has attracted strong political and administrative support, it has also attracted criticism. Some of this criticism has focused specifically on libertarian paternalism (Rebonato, 2012; White, 2013; Mols et al, 2015), while other strands have addressed the wider use of psychology in government (Jones et al, 2013). Below we discuss two main groups of criticisms, one politicalphilosophic, and the other technocratic. The first political-philosophic concerns are that applying behavioural sciences is paternalistic (in a negative sense), manipulative, disempowering, or some combination of these. We take each of these critiques in turn, although they are often presented in a confused and overlapping manner. The paternalist critique argues that the language of ‘biases’ and ‘irrationality’ gives a new, scientific justification to

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government action intended to ‘correct’ these biases and ensure that people fulfil their ‘real’ intentions (Jones et al, 2013). Let us first note that this critique is aimed at those policies addressing harm or benefit to the self (rather than others), which have long been seen as more controversial actions (Mill, 1859). It does not touch the wide range of government actions aimed at behaviours that affect others (or produce externalities, in the language of economists). Second, we must isolate the part of the critique that is specific to behavioural sciences, since this argument is often confused with an attack on paternalist actions per se. For example, this argument is often accompanied by one that says: ‘behavioural economics itself undermines the case for paternalism. It shows that people often make sub-optimal decisions because of biases. But policymakers, contrary to their belief, are also subject to these biases. Therefore, they will also make errors, and therefore they should not act’ (Waldron, 2014). This is an argument against paternalism per se, and appears to be particularly compelling because it uses behavioural economics as its driver. Indeed, it is often presented as if it were the coup de grâce of a wider critique. However, we would argue that this argument points towards the exact opposite conclusion. Rather than dispensing with behavioural sciences, we should use them to identify the cognitive and behavioural problems endemic in the policy process – and to come up with solutions. Note that this would not necessarily encourage paternalist action: applying behavioural sciences may suggest that the policy process is currently too flawed to support any action. The main point is that public welfare is likely to be extended more if policymakers are nudged themselves, rather than if the behavioural sciences are simply ignored. It appears, therefore, that it is the justification of paternalistic action that constitutes the specific criticism. We would argue that this is a question of how behavioural sciences are applied, rather than being a problem intrinsic to their application. We argue that they should be applied in a ‘humble’ way that first, seeks to understand the reasonableness of individuals’ actions, rather than cleaving to an inflexible a priori concept of what constitutes rationality in a given situation; and second, sets policy goals sensitively, based on this prior exploration (BIT, 2014a). We would be uncomfortable if the behavioural sciences were used simplistically and crudely to support a narrow view of rationality – this is bad policymaking. But we would suggest that the possibility of this happening does not automatically mean we should stop using the behavioural sciences: it means we should strengthen policymaking processes to ensure that they are used

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appropriately. As noted earlier, this may mean turning the lens of behavioural sciences back onto the policymaking process itself. The second criticism in this cluster is that behaviourally informed policies are manipulative, since they often address the automatic drivers of behaviour, which operate outside conscious awareness. We would offer two responses. The first is that these ideas only produce manipulative policies if they are used manipulatively. This is true of any policy approach (see past controversy over ‘stealth taxes’ [Jordan et al, 2003, p 184]). In practice, it is very difficult to separate out what elements of government action could be considered ‘manipulative’ or not. Is the shift to an opt-out pension system manipulative because it ‘exploits’ status quo bias? There is no deception involved; the rationale of the policy is clear; there was an extensive consultation process, including a unique national deliberative forum (Hills, 2007). Is it manipulative to rewrite letters requesting the late payment of tax to include social norm messages, which have been shown to be effective (and are truthful)? The purpose of these letters has always been clear; the recipient can reasonably assume that the tax authority is trying to persuade them to pay; one can clearly avoid receiving the letter by making an arrangement to pay on time (Hallsworth et al, 2014). We would argue that the best course of action is to recognise and discuss the potential for manipulative interventions to emerge from the application of behavioural sciences (as for all policies and policy approaches). The best way of doing this is for academics and commentators to produce frameworks for isolating when, in their opinion, the uses of behavioural sciences are appropriate and when they are not. The work of Hansen and Jespersen (2013) provides a good start, and it is worth noting that the MINDSPACE report also provides a framework for this purpose. We suggest that these issues can only usefully be tackled on a case-by-case basis (which is what policymakers do in practice), rather than requiring a blanket ban on (say) all nudges. These frameworks can then be added to the general requirement for government actions to be truthful, fair, transparent and reflective of citizens’ views and concerns. The final criticism in this group is that applying behavioural sciences is disempowering and infantilising, since they do not allow personal growth or learning. In response, we would like to point out that the behavioural sciences suggest many strategies that can be used consciously and deliberately by individuals to better achieve their goals. A good example is the wide body of evidence showing that the power of enhancing goal setting through the use of ‘implementation intentions’ (Gollwitzer and Sheeran, 2006). Another is the strategy of

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‘slim by design’, which uses evidence of automatic eating processes to help people consciously redesign their actions to prevent these automatic processes from taking hold (Wansink, 2014). A final example is the work of Gigerenzer (2014), which shows how we can proactively use heuristics to better understand risk. These approaches are firmly grounded in the use of behavioural science, but they are empowering not enervating. They have also applied to policymaking. BIT recently published a report that showed how social workers could improve their learning and decision-making processes through the conscious application of heuristics (Kirkman and Melrose, 2014). We can then identify two main technocratic critiques, which are in conflict with each other. The first criticises the evidence base for applying behavioural science to policy, claiming that it is does not offer a secure enough base for government action. One solution is more highquality evaluation of real-world effects through randomised controlled trials (RCTs) in the field (House of Lords, 2011). The second criticises these RCTs as presenting a simplistic, mechanistic view of behaviour and producing results with poor external validity (Cartwright, 2010; Cartwright and Hardie, 2012). For reasons for space, we deal only with the first argument (although there is much that can be said about the second, some of which is tackled in Chapter Thirteen). Box 6.5: Stop and think: the problem with RCTs The authors consider RCTs to be a valuable and relatively under-used approach to policy evaluation. However, the issue of when and how to use them to inform policymaking is often debated. For further reading on the subject, take a look at the following: • Cartwright, N. (2010) ‘What are randomised controlled trials good for?’, Philosophical Studies, 147(1): 59-70. • Goodwin, P. (2011) ‘Can travel’s random elements be controlled?’, Local Transport Today, 564. • Jadad, A.R. and Enkin, M. (2007) Randomized controlled trials: Questions, answers, and musings (2nd edn), Oxford: Blackwell. • Leigh, A. (2009) ‘What evidence should social policymakers use?’, Australian Treasury Economic Roundup, 1: 27-43. • Rowland, D., DiGuiseppi, C., Gross, M., Afolabi, E. and Roberts, I. (2003) ‘Randomised controlled trial of site specific advice on school travel patterns’, Archives of Disease in Childhood, 88(1): 8-11. • Melia, S. (2015) ‘Do randomised control trials offer a solution to “low quality” transport research?’, Paper presented at 47th Annual UTSG Conference, London, UK, 5-7 January, http://eprints.uwe.ac.uk/16117/60/UTSG%202015%20-%20 Melia.pdf

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In terms of the evidence base, a few different criticisms can be identified. One, made by the House of Lords Science and Technology Select Committee, is that ‘although much was understood about human behaviour from basic research, there [i]s relatively little evidence about how this understanding could be applied in practice to change the behaviour of populations’ (2011, p 5). This is a fair criticism, and one that taps into criticisms that behavioural economics is too focused on individual behaviour and neglects the way wider societal influences and interactions affect behaviour (often in non-linear ways) (Ormerod, 2010). Another criticism is that behavioural interventions vary greatly in the terminologies they use, and often do not report their interventions in sufficient detail (Michie et al, 2009). We agree and welcome attempts to address these issues such as those identified in Chapter Three). A common criticism is that it is not clear that interventions based on specific academic studies will work in any given policy situation (Schön, 1973; John et al, 2011; Marteau et al, 2011). Indeed, Goldacre’s (2011b) initial scepticism was drawn, at least partially, from the concern that ‘all [The Behavioural Insights Team] will do is over-extrapolate from behavioural economics research’, with little consideration of whether that research actually produces the intended effects. There is a wider debate about the external validity of findings from laboratory experiments that we cannot examine now (Levitt and List, 2007). Some recent studies, such as those by Belot and colleagues (2010) and Barr and Zeitlin (2010), suggest that behaviour in games is correlated with behaviour in real life, for example. In other cases, concepts such as anchoring effects (Jung et al, 2014) and framing (Sanders, 2014) have been shown to have smaller effects in the field than in the laboratory. Regardless of this wider debate, it is worth noting that concerns over whether applying behavioural sciences results in real-world effects have been addressed directly by recent practice. As stated earlier, BIT emphasised the importance of robust evaluation through randomised trials (Haynes et al, 2012). This focus led Goldacre (2011b) to reverse his initial criticisms, and for the House of Lords Committee to state in its follow-up report that ‘[t]he work of the Behavioural Insights Team (BIT) is to be commended. In particular, we are impressed by their work in pioneering the use of Randomised Controlled Trials to determine the effectiveness of interventions’ (Lord Selborne, 2014). More generally, there is a growing literature in which behavioural interventions are tested using robust methods in policy contexts – for examples, see Finkelstein et al (2011); Haynes et al (2012); Fryer (2013); Hallsworth et al, (2014) . The use of ‘social norm’ messages

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has been particularly widely used in a policy context and this class of experiments is reviewed by John and colleagues (2014).

Conclusion Although the application of behavioural sciences to public policy is in its relative infancy, there are signs that this may prove an enduring development. Six years after the publication of Nudge, the major fiveyear policy documents from both the NHS and Public Health England continue to state explicit support for behavioural economics and nudging (NHS, 2014; Public Health England, 2014). The World Bank’s 2015 World Development Report focuses specifically on applying behavioural sciences to policy. The Obama administration created a Social and Behavioural Sciences Team in 2012, as have countries such as the Netherlands, Germany, Australia and Italy. Indeed, a study of the international prevalence of such an agenda found that ‘51 states have developed centrally directed policy initiatives that have been influenced by the new behavioural sciences’ (Whitehead et al, 2014, p 4). Given this rising interest, we argue that the most profitable debates are those that focus on the most effective, equitable and appropriate use of the behavioural sciences in policymaking, rather than those that simply aim to eliminate their use entirely. We believe that such interventions can advance the public good in ways that are acceptable to the public. Debates about how this is done are crucial to ensuring that governments use these ideas respectfully and judiciously. End-of-chapter questions • Why were ‘nudge’ approaches adopted with so much relish by the coalition government from 2010? • From a political perspective, what benefits are there to nudging that social marketing does not hold? • What are the main criticisms of ‘nudge’? • Why did Goldacre and the House of Lords Science and Technology Committee change their minds about ‘nudge’ approaches?

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Barr, A. and Zeitlin, A. (2010) Dictator games in the lab and in nature: External validity tested and investigated in Ugandan primary schools, Economics Series Working Papers, Oxford: University of Oxford, Department of Economics. Bavel, B., Herrmann, B., Esposito, G. and Proestakis, A. (2013) Applying behavioural sciences to EU policy-making, JRC Scientific And Policy Reports, No. JRC83284, Institute for Prospective and Technological Studies, Joint Research Centre, Luxembourg: European Commission. BBC (2010) ‘Government advertising budget slashed’, www.bbc.co.uk/ news/technology-10851273 Becker, G. (1968) ‘Crime and punishment: an economic approach’, Journal of Political Economy, 76(2): 169-217. BIT (Behavioural Insights Team) (2010) ‘Applying behavioural insight to health’, www.gov.uk/government/uploads/system/uploads/ attachment_data/file/60524/403936_BehaviouralInsight_acc.pdf BIT (2011) ‘Behaviour change and energy use’, www.behaviouralinsights. co.uk/sites/default/files/behaviour-change-and-energy-use.pdf. BIT (2012a) ‘Welcome to the BIT Blog!’, www.behaviouralinsights. co.uk/blogpost/welcome-bit-blog BIT (2012b)  ‘Applying behavioural insights to reduce fraud, error and debt’, www.gov.uk/government/uploads/system/uploads/ attachment_data/file/60539/BIT_FraudErrorDebt_accessible.pdf BIT (2013)  ‘Applying behavioural insights to charitable giving’, www.behaviouralinsights.co.uk/sites/default/files/BIT_Charitable_ Giving_Paper%20%281%29.pdf BIT (2014a) ‘EAST: four simple ways to apply behavioural insights’, www.behaviouralinsights.co.uk/sites/default/files/BIT%20 Publication%20EAST_FA_WEB.pdf BIT (2014b) ‘New $1m partnership between the Behavioural Insights Team and Harvard’, www.behaviouralinsights.co.uk/blogpost/pressrelease-new-1m-partnership-between-behavioural-insights-teamand-harvard BIT (2014c) ‘Adult educators comes together to celebrate launch of the Behavioural Research Centre for Adult Skills and Knowledge (ASK)’, www.behaviouralinsights.co.uk/blogpost/adult-educators-comestogether-celebrate-launch-behavioural-research-centre-adult-skills Belot, M., Duch, R. and Miller, L. (2010) Who should be called to the lab:  A comprehensive comparison of students and non-students in classic experimental games, Nuffield College Discussion Papers, Oxford: University of Oxford.

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Bennhold, K. (2013) ‘Britain’s Ministry of Nudges’, New York Times, www.nytimes.com/2013/12/08/business/international/britainsministry-of-nudges.html?pagewanted=alland_r=0 Berlin, I. (1958) Two concepts of liberty, Oxford: Clarendon Press. Camerer, C., Loewenstein, G. and Prelec, D. (2005) ‘Neuroeconomics: how neuroscience can inform economics’,  Journal of Economic Literature, 43(1): 9-64. Camerer, C., Loewenstein, G. and Rabin, M. (2004)  Advances in behavioral economics, New York, NY: Russell Sage Foundation. Cartwright, N. (2010) ‘What are randomised controlled trials good for?’, Philosophical Studies, 147(1): 59-70. Cartwright, N. and Hardie, J. (2012)  Evidence-based policy, Oxford: Oxford University Press. Conservatives (2009)  ‘Regulation in the post-bureaucratic age’, www.conservatives.com/~/media/Files/Policy%20Documents/ BetterRegulation.ashx?dl=true Consumer Futures (2012)  Consumer focus annual report and accounts 2012/13, London: The Stationery Office, www.consumerfutures. org.uk/files/2013/07/Annual-Report-2012-13-Back-section.pdf DellaVigna, S. (2009) ‘Psychology and economics: evidence from the Field’, Journal of Economic Literature, 47(2): 315-72. DH (Department of Health) (2011)  Changing behaviours, improving outcomes: A new social marketing strategy for public health, London: DH, www.gov.uk/government/uploads/system/uploads/attachment_ data/file/215610/dh_126449.pdf Dibb, S. (2014) ‘Up, up and away: social marketing breaks free’, Journal of Marketing Management, 30(11-12): 1159-85. Dolan, P., Hallsworth, M., Halpern, D., King, D., Metcalfe, R. and Vlaev, I. (2012) ‘Influencing behaviour: The mindspace way’, Journal of Economic Psychology, 33(1): 264–77. Duit, A. and Galaz, V. (2008) ‘Governance and complexity: emerging issues for governance theory’, Governance, 21(3): 311-35. Elster, J. (2007)  Explaining social behavior, Cambridge: Cambridge University Press. Finkelstein, A., Taubman, S., Wright, B., Bernstein, M., Gruber, J., Newhouse, J., Allen, H. and Baicker, K. (2011) The Oregon Health Insurance Experiment: Evidence from the first year, Cambridge, MA: National Bureau of Economic Research. Fletcher-Morgan, C. and Leyland, K. (2010) ‘Making people more responsible: the Blair governments’ programme for changing citizens’ behaviour’, Political Studies, 58(3): 427-49.

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Fryer Jr, R.G. (2013) Information and student achievement: Evidence from a cellular phone experiment, Working Paper No. w19113, Cambridge, MA: National Bureau of Economic Research. Gigerenzer, G. (2014) Risk savvy: How to make good decisions, London: Allen Lane. Goldacre, B. (2011a) ‘Effective things can come from silly places’, The Guardian, www.theguardian.com/commentisfree/2011/jul/08/badscience-effective-things-silly-places Goldacre, B. (2011b) ‘How can you tell if a policy is working? Run a trial’,  The Guardian, www.theguardian.com/commentisfree/2011/ may/14/bad-science-ben-goldacre-randomised-trials Gollwitzer, P.M. and Sheeran, P. (2006) ‘Implementation intentions and goal achievement: a meta-analysis of effects and processes’, Advances in Experimental Social Psychology, 38: 69-119. Haddon, C. (2012a)  Making policy in opposition: The development of universal credit, 2005-2010, London: Institute for Government. Haddon, C. (2012b) Making policy in opposition: The work programme, 2007-2010, London: Institute for Government. Hallsworth, M., List, J., Metcalfe, R.D. and Vlaev, I. (2014) The behavioralist as tax collector: Using natural field experiments to enhance tax compliance, Working Paper No. w20007, Cambridge, MA: National Bureau of Economic Research. Hansen, P.G. and Jespersen, A.M. (2013) ‘Nudge and the manipulation of choice: a framework for the responsible use of the nudge approach to behaviour change in public policy’,  European Journal of Risk Regulation, 4(1): 3-28. Haynes, L., Service, O., Goldacre, B. and Torgerson, D. (2012) ‘Test, learn, adapt: developing public policy with randomised controlled trials’, www.behaviouralinsights.co.uk/sites/default/files/TLA1906126.pdf Hills, J. (2007) ‘Pensions, public opinion and policy’, in J. Hills, J. Le Grand and D. Piachaud (eds) Making social policy work: Case studies on poverty, place and policy, Bristol: Policy Press, pp 221-43. HM Government (2010)  ‘The coalition: our programme for government’, www.gov.uk/government/uploads/system/uploads/ attachment_data/file/78977/coalition_programme_for_government. pdf HM Treasury (2003)  ‘The green book: appraisal and evaluation in central government’, www.gov.uk/government/uploads/system/ uploads/attachment_data/file/220541/green_book_complete.pdf

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House of Lords Science and Technology Select Committee (2011) Behaviour change, HL Paper 179, London: The Stationery Office, www.publications.parliament.uk/pa/ld201012/ldselect/ ldsctech/179/179 John, P. (2014) ‘Policy entrepreneurship in UK central government: the Behavioural Insights Team and the use of randomized controlled trials’, Public Policy and Administration, 29(3): 257-67. John, P., Cotterill, S., Mosely, A., Richardson, L., Smith, G., Stoker, G. and Whales, C. (2011) Nudge, nudge, think, think: Experimenting with ways to change cvic behaviour, London: Bloomsbury. John, P., Sanders, M. and Wang, J. (2014) ‘The use of descriptive norms in public administration: a panacea for improving citizen behaviours’, SSRN Journal. Available at http://ssrn.com/abstract=2514536 Jones, R., Pykett, J. and Whitehead, M. (2013) Changing behaviours: On the rise of the psychological state, Cheltenham: Edward Elgar. Jordan, A., Wurzel, R.K., Zito, R. and Brückner, L. (2003) ‘Policy innovation or “muddling through”? “New” environmental policy instruments in the United Kingdom’, Environmental Politics, 12(1): 179-200. Jung, M.H., Perfecto, H. and Nelson, L.D. (2014) ‘Anchoring in payment: evaluating a judgmental heuristic in field experimental settings’, SSRN Journal, http://journals.ama.org/doi/abs/10.1509/ jmr.14.0238 Kahneman, D. (2011) Thinking, fast and slow, New York, NY: Farrar, Straus and Giroux. Kirkman, E. and Melrose, K. (2014) ‘Clinical judgement and decisionmaking in children’s social work: an analysis of the ‘front door’ system’, www.gov.uk/government/uploads/system/uploads/attachment_ data/file/305516/RR337_-_Clinical_Judgement_and_DecisionMaking_in_Childrens_Social_Work.pdf Lansley, A. (2010) ‘A new approach to public health’, Speech by the Secretary of State for Health to the UK Faculty of Public Health Conference, http://webarchive.nationalarchives.gov.uk/+/www. dh.gov.uk/en/MediaCentre/Speeches/DH_117280 Letwin, O., Miltom, A. and Baker, N. (2011) ‘Oral evidence’, in House of Lords Science and Technology Select Committee, Behaviour change, HL Paper 179, London: The Stationery Office, www.publications. parliament.uk/pa/ld201012/ldselect/ldsctech/179/179 Levitt, S. and List, J. (2007) ‘What do laboratory experiments measuring social preferences reveal about the real world?’, Journal of Economic Perspectives, 21(2): 153-74.

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Lewis, K.K. (1999) ‘Trying to explain home bias in equities and consumption’, Journal of Economic Literature, 37(2): 571-608. Lord Selborne (2014) ‘The science and technology select committee, follow up on the 2011 report “behavioural change”’, letter, www. parliament.uk/documents/lords-committees/science-technology/ behaviourchangefollowup/LetwinBehaviourChangeLtr20140722.pdf Marteau, T.M., Ogilvie, D., Roland, M., Suhrcke, M. and Kelly, M.P. (2011) ‘Judging nudging: can nudging improve population health?’, British Medical Journal, 342: d228. McSmith, A. (2010) ‘First Obama, now Cameron embraces “Nudge Theory”’,  The Independent, www.independent.co.uk/ news/uk/politics/first-obama-now-cameron-embraces-nudgetheory-2050127.html Michie, S., Fixsen, D., Grimshaw, J.M. and Eccles, M.P. (2009) ‘Specifying and reporting complex behaviour change interventions: the need for a scientific method’, Implementation Science, 4(1), http:// www.biomedcentral.com/content/pdf/1748-5908-4-40.pdf Mill, J. (1859) On liberty, London: J.W. Parker and Son. Mols, F., Haslam, S.A., Jetten, J. and Steffens, N.K. (2015) ‘Why a nudge is not enough: a social identity critique of governance by stealth’, European Journal of Political Research, 54(1): 81-98. NHS (2014) ‘Five year forward view’, www.england.nhs.uk/wpcontent/uploads/2014/10/5yfv-web.pdf O’Donoghue, T. and Rabin, M. (1999) ‘Doing it now or later’, American Economic Review, 89(1): 103-24. OECD (Organisation for Economic Co-operation and Development) (2014) ‘OECD Observatory of Public Sector Innovation’, www.oecd. org/governance/observatory-public-sector-innovation/home/#d. en.251129 Ormerod, P. (2010) N squared: Public policy and the power of networks, London: Royal Society of Arts. Osborne, G. and Thaler, R. (2010) ‘We can make you behave’, The Guardian, www.theguardian.com/commentisfree/2010/jan/28/wecan-make-you-behave Prime Minister’s Strategy Unit (2004)  ‘Personal responsibility and changing behaviour’, http://webarchive.nationalarchives.gov.uk/+/ http:/www.cabinetoffice.gov.uk/media/cabinetoffice/strategy/assets/ pr2.pdf Public Health England (2014)  ‘From evidence into action: opportunities to protect and improve the nation’s health’, www. gov.uk/government/uploads/system/uploads/attachment_data/ file/366852/PHE_Priorities.pdf

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Rebonato, R. (2012) Taking liberties: A critical examination of libertarian paternalism, Basingstoke: Palgrave Macmillan. Rose, N.S. (1990) Governing the soul, London: Routledge. Rutter, J. (2014) ‘MINDSPACE grows up – behavioural economics in government’, www.instituteforgovernment.org.uk/blog/6952/ mindspace-grows-up-behavioural-economics-in-government Sanders, M. (2014) A nudge in the dark: An artefactual experiment investigating the effects of priming in the presence of distractions, CMPO Working Paper No. 13/330, Bristol: University of Bristol. Sanders, M. and Hallsworth, M. (2015) ‘Applying behavioural economics in a health policy context: dispatches from the front lines’, in C. Roberto and I. Kawachi (eds) Behavioral Economics and Public Health, Oxford: Oxford University Press. Schön, D.A. (1973) Beyond the stable state: Public and private learning in a changing society, Harmondsworth: Penguin. Spotswood, F., French, J., Tapp, A. and Stead, M. (2012) ‘Some reasonable but uncomfortable questions about social marketing’, Journal of Social Marketing, 2(3): 163-75. Sweney, M. (2010) ‘Coalition government freezes advertising budget’, The Guardian, www.theguardian.com/media/2010/may/24/ coalition-freezes-advertising-budget Sweney, M. (2011) ‘Government to cut 1,000 marketing jobs and axe COI’, The Guardian, www.theguardian.com/media/2011/mar/18/ government-communications-budget-cuts Thaler, R.H. (2012) ‘Watching before writing the rules’, New York Times, www.nytimes.com/2012/07/08/business/behavioral-sciencecan-help-guide-policy-economic-view.html?pagewanted=alland_r=0 Thaler, R.H. (2013) ‘Public policies, made to fit people’, New York Times, www.nytimes.com/2013/08/25/business/public-policiesmade-to-fit-people.html Thaler, R.H. and Sunstein, C.R. (2008) Nudge: Improving decisions about health, wealth and happiness, New Haven, CT: Yale University Press. Waldron, J. (2014) ‘It’s all for your own good. The New York Review’, www.nybooks.com/articles/archives/2014/oct/09/cass-sunstein-itsall-your-own-good Wansink, B. (2014) Slim by design, New York, NY: Harper Collins. Wheeler, B. (2012) ‘Government marketing budget “to increase”’, www.bbc.co.uk/news/uk-politics-19489251 White, M.D. (2013)  The manipulation of choice: Ethics and libertarian paternalism, New York, NY: Palgrave Macmillan.

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Whitehead, M., Jones, R., Howell, R., Lilley, R. and Pykett, J. (2014)  Nudging all over the world: Assessing the global impact of the behavioural sciences on public policy, Swindon: Economic and Social Research Council. Wintour, P. (2014) ‘Government’s behaviour insight team to become a mutual and sell services’, The Guardian, www.theguardian.com/ politics/2014/feb/05/government-behaviour-insight-nudge-mutualnesta-funding Woodhouse, C. (2011) ‘Cameron’s ‘nudge unit’ should be given the elbow, says Labour MP’,  London Evening Standard, www.standard. co.uk/news/politics/camerons-nudge-unit-should-be-given-theelbow-says-labour-mp-6426428.html World Bank (2015) World Development Report 2015: Mind, society, and behavior, Washington, DC: World Bank.

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Social marketing and multidisciplinary behaviour change Alan Tapp and Sharyn Rundle-Thiele

Introduction This chapter presents quite a different picture of social marketing from that in Chapter Six, one in which social marketing can make an important and valued contribution to behaviour change and specifically a field of behaviour change that encompasses multidisciplinary thinking. Social marketing is generally poorly understood, with the most powerful elements of social marketing typically overlooked. A broad range of books on social marketing are in print (for example, Eagle et al, 2013; Kubacki and Rundle-Thiele 2013; Brennan et al, 2014; Hastings and Domegan, 2014), yet many myths and misunderstandings continue to prevail today. Thus, this chapter begins by exposing and clearing up the most important myths about social marketing, and then revisits the most powerful concepts that social marketers can bring to the field of behaviour change. Second, we know that many social change academics express concern at the use of market forces to change behaviours. Some of these critiques include social marketing in their sights and may have some merit. This chapter discusses and responds to these. Our final aim is perhaps our most important. We look to the future and examine the potential role of social marketing in an integrated multidisciplinary environment. Behaviour change encompasses a wide range of approaches, including education, training, enforcement, infrastructure, technology, urban planning, community development, health promotion and social marketing. Each discipline has evolved with its own unique theories, tools and techniques, and there is a lack of connectedness of behaviour change fields, meaning they are rarely combined. This has not gone unnoticed: The sector has been criticised as operating within silos, and this narrow operating structure may be a contributing factor towards an inability to attain sustainable

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behaviour change (Rayner and Lang, 2009; Schneider and Stokols, 2009; House of Lords Science and Technology Select Committee, 2011). Nevertheless, academics and professionals within each discipline have tended to persist in using long-standing narrow foci in the belief that their approach may be superior to other behaviour change approaches and/or that a single approach will suffice. Social marketing has also been accused of disciplinary myopia (Brug et al, 2005; Rayner and Lang, 2009), and a key aim in this chapter is to respond to this critique and argue that social marketing is in fact well placed to play an important and perhaps central role in a new multidisciplinary paradigm. This chapter therefore explores the challenge of how best to combine social marketing with other behaviour change fields to move towards a multidisciplinary approach that can achieve common aims. Hence we end the chapter by proposing an applied model for behaviour change that positions social marketing alongside other fields in such a way as to make clear its distinctive contribution.

Social marketing’s ‘mythunderstandings’ Social marketing suffers from a series of myths and misunderstandings (Donovan, 2011). We examine selected key issues in turn. Social marketing = social media Googling the term ‘social marketing’ returns many hits that relate to social media agencies selling commercial marketing services (campaigns using Twitter, Facebook, and so on). However, with the exception of the use of social media within social marketing programmes, there is in fact no link between social marketing as it was originally coined in 1971 (25 years before the internet became generally available) and social media. In seeking a resolution, some social marketers favour renaming the field ‘marketing for behaviour change’ to restore clarity. The SPLATT effect Social marketing practitioners have got used to being approached by clients wanting help with ‘Some Posters, Leaflets, Ads and Things like That’. Our colleague Sara Bird of the Bristol Social Marketing Centre jokingly dubbed this the ‘SPLATT’ effect of social marketing. These perceptions – that social marketing equals advertising – stem from the tendency of many communications programs to be (often wrongly) labelled as ‘social marketing’. Examples include Peterson

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et al, 2005; Henao et al, 2006; Maddock et al, 2008; Peterson et al, 2008; Reger-Nash et al, 2008; Gebel et al, 2011; and Heinrich et al, 2011. In fact, social marketing, reflecting commercial marketing, consists of far more than communications, as we discuss later in this chapter. Communications are often used to make the citizen aware of an offering or to serve as an important reminder to maintain a desired behaviour, which allows for personal growth and learning not possible in ‘nudge’ approaches. However, communications on their own are very rarely sufficient to compete with commercial market offerings. Valued alternatives are needed for sustained behaviour change. Social marketing is tactical not strategic Non-marketers tend to make sense of social marketing through some of its most visible components: the tactical tools and techniques used such as incentive schemes, communication campaigns, membership clubs, and so on. The conclusion is erroneously drawn that this is the sum total of social marketing. The iceberg analogy (the substance lies below the sea) holds here, as we will see a little later when we review the major concepts used by social marketers. Social marketing relies on cognitive ‘rational man’ models Early pioneers, most notably Kotler and Zaltman (1971), created many legacies for how social marketing has been perceived, which continue to this day. Kotler, originally an economist, codified marketing as an ‘economic exchange’ in which a seller responded to the self-interests of the buyer by offering a suitable product. The exchange concept was then transported by him to social marketing, and it remains one of the core concepts of social marketing. However, consistent with its commercial counterpart, social marketing has the capacity to extend far beyond rational information appeals. For example, social marketers can create culture change at population level, work with communities, alter environments, create and break habits and work on social norms. Commercial marketing history demonstrates quite clearly that the claim that marketers rely solely on ‘rational man’ approaches is misleading. Marketers’ awareness and use of ‘automatic’ processing stretches back, in some cases, hundreds of years. The use of ‘opt-out’ clubs by mail order firms (first used in the 1880s by Sears Roebuck), eye-level shelving in stores (at least back to the 1920s and probably before), ‘reciprocity’ deals between business people (Victorian times) – all these and more have long been and remain part of commercial

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marketing practice and therefore may be deployed within social marketing. For example, WeightWatchers, a programme designed using marketing principles, contains a rich mixture of components aimed at both cognitive processes, such as a diet plan and feedback, and automatic psychological processes, such as social influence and choice architecture. Box 7.1: Stop and think: the rise of behavioural economics Noting the recent popularisation of behavioural economics (explored in depth in Chapter Six), social marketers could be forgiven for feeling somewhat sardonic about the latter field’s claims to have invented techniques that address automatic processing. On the other hand, the recent surge in interest in behavioural economics has in part reflected the curious reluctance of social marketers (notwithstanding examples such as WeightWatchers) to regularly use the full range of commercial techniques at their disposal. Reasons for this reluctance are unclear, but we would speculate that the lack of a commercial marketing background among many social marketing practitioners, aligned to a reluctance to use techniques seen as manipulative (because the citizen is not offered informed choice), may be driving factors here.

Social marketing equals the 4Ps Lastly, we consider the many misconceptions surrounding the 4Ps of social marketing: product, price, place and promotion (see Andreasen, 2002), which continue to abound. While commonly discussed in both commercial and social marketing textbooks, in practice the 4Ps are often labels that post-rationalise an intervention as being inspired by social marketing when in fact it was nothing of the kind. Too often campaigns labelled as social marketing fail to extend beyond communication, a concern when these campaigns then proceed to label themselves as having a full marketing mix. For example, a communications-only campaign may claim the product is the benefit offered to the citizen rather than a true product or service that delivers an alternative tangible bundle of benefits and value for which the citizen would willingly exchange time and/or money. This is misleading. The 4Ps do have their uses, but we find this ‘labelling’ effect can be unhelpful.

Social marketing’s key concepts Having explained what social marketing is not, we now move to what we regard as its key concepts. Comparing marketing to education and law is our first step in illustrating the distinctive contribution of

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social marketing to behaviour change. The work of Rothschild (1999) underpins the following explanation. Box 7.2: Social marketing as the ‘middle ground’ We use the problem of obesity to illustrate how education, marketing and law might be deployed to change behaviour. First, an educator assumes that people will make their decisions about cutting down on energy-dense foods and doing more exercise on the basis of being fully informed about the health benefits of doing so. The implicit assumption here is that motivation to comply is already strong and it is merely a lack of comprehensible information that prevents the behaviour being adopted. Second, following a downstream view of social marketing (that is, one that focuses on the ‘doer’ of the problem behaviour), a marketer might create an ‘offer’ that invites people to join a programme that includes social contact and peer support, regular and controlled monitoring and feedback, cooking and activity classes, and a ‘points-based’ food programme that sets limits on energy intake. This downstream use of social marketing assumes that the existing levels of motivation and knowledge are insufficient to generate changes in behaviour without an external boost. Therefore, the effective delivery of an alternative tangible bundle of benefits and value is needed to achieve the desired behaviour change. In contrast, upstream social marketing is concerned with influencing public policy, prioritisation and budget allocation. It is concerned with the causal agents and determinants of social problems, and focuses on creating change within policy or regulations to make environments more conducive to the desired behaviour. For example, a reduction in smoking might be attained through the introduction of plain packaging. Scholars are increasingly advocating that social marketers consider simultaneously implementing upstream and downstream methods to increase the effectiveness of their campaigns (Hoek and Jones, 2011; Wymer, 2011). Third, a law-based approach ‘will be appropriate when the pre-existing selfinterest of the target cannot be overcome with additional rewards through exchange, when rewarding is inconsistent with societal goals, or when the rights of the target are believed to be irrelevant’ (Rothschild, 1999, p 30). The implication here is that education and marketing offer free choice and accept that if people fail to adopt the pro-social behaviour, then society will pick up the costs of these choices. The regulatory option, on the other hand, attempts to use coercion to achieve the desired aim. The option of law is typically chosen when the costs to society are too high to allow ‘free’ choice.

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Beyond behaviour change In many ways, marketing adopts a middle position between education and law (discussed by Rothschild [1999] in considerable detail). The choice of marketing assumes that there is a gap between the pro-social behaviour and the citizen’s self-interest, but that this gap may be filled by an intervention of some kind. The intervention improves the attractiveness of the pro-social behaviour, reducing Figure 7.1: The education/law continuum

Individual focus Focus on individual change Develop personal skills Typically more cognitive

Environmental focus Build healthy policy Create supportive environmental Typically more behavioural Public and policymakers

Appetite for intervention determines location on continuum

its ‘costs of adoption’ by the individual or group. In turn, society bears the intervention costs, which society takes on when the long-term costs of citizen non-cooperation are high. Marketing is chosen when it is clear that no amount of education will motivate people to change, when personal growth and learning is desired, and when regulation is not appropriate (due to an unwillingness to constrict ‘freedoms’, unpleasant side-effects, inability to enforce, uncooperative or militant industry or populace, and so on).

The principles of social marketing Customer orientation This famous quote from Peter Drucker (2006, pp 64-5) remains unsurpassed in getting to the heart of the power of marketing: Marketing is so basic that it cannot be considered a separate function. It is the whole business seen from the point of view of its final result, that is, from the customer’s point of view…. Business success is not determined by the producer but by the customer.

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This philosophy was operationalised by marketing academics through the development of ‘market orientation’, an organisational ethos that places the ‘needs of the market’ at the head of the firm’s priorities and assumes that marketing is a concern for all departments. Thus a market orientation centres the citizen at the heart of strategy and implementation. Rather than ‘selling what we make’, marketers ask which product customers would value. Research clearly indicates that market- or externally oriented firms outperform firms that are more internally focused (Narver and Slater, 1990). A full debate for translating the concept of market orientation into the world of behaviour change would take more space than we have, but we raise the idea because market orientation offers a key for social marketers to strategically connect with other fields in providing integrated behaviour change solutions focused on the citizen and their needs, discussed at length later in this chapter. Competition Marketers are competitively minded. In the case of commercial marketing, marketers seek to win market share and beat the competition. This thinking distinguishes marketing from other behaviour change disciplines. In directly recognising and addressing behavioural competition, social marketers compete for the citizen’s time and attention through their strategies (Andreasen, 2002). Social marketers offer ‘unique and meaningful benefits’ that deliver better value than the competition (Hastings (2003, p 307). These are offered to the citizen on the assumption that there is discretion (choice) on acceptance or rejection of the offer. Therefore the onus is on the marketer to ensure that the offer is as attractive as possible. Exchange Another key principle of social marketing is the development of mutually beneficial exchanges for citizens. Exchange can be difficult to achieve when the desired behaviour is to decrease or stop a preexisting behaviour. Understanding the ‘competition’ can provide insight into what would represent a valuable exchange to the target audience. Examples of exchanges in social marketing abound. In the ‘10,000 Steps Ghent’ intervention (De Cocker et al, 2011), pedometers were sold to the public for 20 euros to increase the community’s levels of physical activity. ‘Canada on the Move’ partnered with Kellogg’s, which placed pedometers inside cereal boxes (Craig et al, 2007). In

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the ‘Cycling Connecting Communities’ intervention, members of the public were offered community bike rides and free bike hire (Rissel et al, 2010). A final example of exchange is the ‘Fit and Fab’ campaign, which offered dance and gym sessions free for the first six weeks after which the cost was £1 (Withall et al, 2012). Customer insight Social marketers use formative research to uncover insights into the motives, opportunities, barriers and triggers that surround behaviour changes. The most common tools include focus groups and surveys (Rundle-Thiele et al, 2013a), although calls have been made to extend formative research beyond self-report methods such as surveys and focus groups towards more innovative research methods to better understand citizens (Rundle-Thiele et al, 2013a). Social marketers have no preferential theory in guiding their search for insights; rather, they will seek to examine the problem from a broad theoretical base. Recently, Carins and Rundle-Thiele (2014b) employed an ecological view of eating behaviour to examine the food environment that surrounds military citizens. Food outlets were assessed using the Nutrition Environment Measures Survey in store, Nutrition Environment Measures Study in restaurants and military Nutrition Environment Assessment Tool instruments to determine how well food outlets support healthy eating. This broad (eclectic) nature of insight gathering lends itself to ecological models of behaviour (discussed further in Chapter Thirteen) such as the one in Figure 7.2. Use of segmentation Andreasen (2002) states that careful segmentation of target audiences is necessary in social marketing to ‘ensure maximum efficiency and effectiveness in the use of scarce resources’ (p 104). Andreasen also makes it clear that segmentation (splitting up populations according to different characteristics or needs) and targeting (prioritising one or more of these segments at the expense of others) are two different concepts. Segmentation can be based on one or more of demographic, psychographic, geographic, behavioural and epidemiological factors. Segmentation is based on the understanding that populations are typically heterogeneous (Evers et al, 2013) and that segments with similar needs and wants can be identified from the larger population. A clear example can be found in the ‘Power Play’ intervention (Keihner

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Social marketing and multidisciplinary behaviour change Figure 7.2: The social ecology model Macro system infrastructure

Exo system

media

Meso system: system of microsystems Micro system friends family

individual

activities

politics cultures Source: Bronfenbrenner (1977).

et al, 2011), which used ten grade-specific activities for Grade 4 and Grade 5 children to provide stronger links between a healthy behavioural goal and their core academic subjects. For example, Grade 4 children made a plan to include at least five servings of fruit and vegetables in their day, and Grade 5 children made a plan that incorporated fruit and vegetables and limited unhealthy foods. Application of services and relationship marketing thinking Social marketing applies the commercial marketing focus on service delivery that is widely used in the hospitality and tourism industries. ‘Good service’ can mean many things, such as rapid serving of people in a rush; personalisation and unique tailoring of the offer; and by no means least, personal service such as a commercial gym offering an ongoing course with a trainer. These principles (that ‘customer satisfaction’ is key because satisfied customers are more inclined to return for future business) can be applied to behaviour change contexts, such as public health. From Stop Smoking services to WeightWatchers, service delivery can be a vital ingredient in success.

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Box 7.3: Case study: social marketing and service delivery – redesigning breastfeeding services Tapp and colleagues (Tapp et al, 2009) worked with a local health service team to explore the problem of low breastfeeding rates in young mothers. It emerged that the young mothers placed a low priority on breastfeeding, and this motivational problem was compounded by their alienation from breastfeeding (the ‘cultural norm’ was to bottle feed using commercial baby milk), their low levels of confidence generally in life (with these translating into breastfeeding), and the perception they had of unsympathetic attention to their needs from midwives. An extensive qualitative research project led to recommendations for a re-engineered clinical pathway that included the use of peer breastfeeding champions – young volunteer mums who were able to connect with the audience in an empathetic way. Other roles for social marketing included working on long-term communications to normalise breastfeeding, and, recognising the difficulties of the health message, on shorter-term incentives to engage the new mothers in the programme.

The idea of ‘relationship marketing’ also has enormous strategic potential. Relationship strategies would emphasise relationships and the adoption of an open-ended contact with the audience, such as offering personal ongoing contact (a gym instructor for example), or a database of customers (WeightWatchers, for example) within the intervention. These are powerful ways of creating behaviour change, but may be costly and so may require some of these costs to be met by the individual – in turn requiring enough motivation to comply from people who wish to pay. Such approaches increasingly overlap in their design with commercial offers, perhaps via the idea of paid for membership that offers various benefits. Combining social marketing activities into a management process Finally, the principles and tools explored in the points so far are infused into various activities, organised by social marketers into a strategic management process (see Figure 7.3). A recent study (Carins and Rundle-Thiele, 2014a) indicates that behaviour change is more likely when more of the social marketing benchmark criteria are employed (see Andreasen, 2002). This section has briefly presented the most important components of social marketing. If there is a gap between individual and societal interests when considering a particular behaviour, we have seen that social marketing is centrally placed to offer a wide variety of possible solutions. However, using social marketing to change behaviours

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Social marketing and multidisciplinary behaviour change Figure 7.3: A typical social marketing management process Citizen insights

Segmentation

Create an intervention

Exchange

Promote

Evaluate

has been subject to a number of criticisms, some of which have more substance than others. We now examine the major critiques, acknowledging the substance of arguments that have some merit, while refuting other arguments that we see as flawed.

Criticisms of social marketing Marketing offers only short-term change It is true that social marketing interventions, and the funding schemes that support them, too often continue to take a short-term approach to behavioural change, with most interventions lasting for a month, while in rare cases campaigns may last a few years (Grier and Bryant, 2005). Practitioners in the social change space must be mindful that changing behaviour is difficult when budgets are short term and do not equal the resources that competitive forces bring to bear. Consider UK statistics reported in Hastings and Angus (2011), which suggest that industry-funded efforts to promote safer drinking ($US 104 million) are greatly out-gunned by alcohol advertising ($US 4.9 billion). As a result, young people are 239 times more likely to see an alcohol advertisement than an advertisement promoting safe drinking (Rundle-Thiele et al, 2013b). Social marketing is not the only behaviour change field

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receiving this criticism. Health interventions, for example, are often extremely brief. Doctors may prescribe a six-week gym programme for tackling long-term lack of exercise, for example. Marketing is expensive and difficult to justify This is a somewhat UK-focused debate that gained currency on the change of government in Britain in 2010 and the attendant reduction in social marketing budgets in favour of funding the ‘Nudge Unit’ (see Chapter Six for more about this). The criticism is that social marketing fails to provide adequate return on investment because of its reliance on costly research and mass advertising, the value of which is difficult to measure. In contrast, ‘nudge’ techniques are typically small in scale and can be tested in controlled trials over short time periods, allowing rapid assessments of cost-effectiveness. However, there is a robust history within marketing of running matched controls to evaluate campaign impact (Tapp, 1998). Also, social advertising (which can form part of social marketing) may indeed be expensive, but it reaches many people. The UK’s road safety ‘Think’ campaign required a £10 million yearly budget, but is still regarded as successful by the funder, the UK Department for Transport. Finally, it is absolutely correct to point out that market research is expensive, but when marketers are working on large-scale programmes that are ‘new’, and hence have a likely need for insights to help avoid sizeable cost penalties from flawed designs, then research is justified. Marketing is what ‘the enemy’ does and is therefore amoral When debating behaviour change with other fields, we have occasionally come across a general distaste for the use of marketing methods. A common view is that marketing is used by the very people who cause the most problems – firms like Coca-Cola, McDonalds, Diageo, and Rothmans – with the implication that marketing is part of the problem. Hastings’ response to such criticism is to point out the undoubted success of these techniques and ask ‘Why should the Devil have all the best tunes?’ (Hastings, 2007). Further, we would agree with Hastings in arguing that it is asking a lot to counter multinational corporations without access to the same toolkit and timeframes. A further, related, charge is that the use of exchanges can sometimes be amoral. Sandel (2012), for instance, contends that markets can crowd out morals – that markets change the character of the things they touch. Using examples such as offering money to children as a

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reward for reading, Sandel points out that the child’s response will be simple and powerful but damaging because the value of reading the book for higher reasoning is lost. Moral reasoning requires debate and requires effort to think through, whereas market-based decisions become an automatic habit: we become acculturated into exchanges as the default incentive to behave. Sandel says that the shallows affect the deep. That is, our everyday small decisions and behaviours affect our deeply held values and beliefs. This is similar to the argument that Crompton (author of Chapter Eleven of this volume) makes in Common Cause (2010): that markets erode our moral structures by replacing them with an incentive structure. Crompton’s thesis concentrates on what he calls ‘bigger than self ’ (that is societal) problems: concern for others, a ‘sense of ownership’ of societal as well as personal wellbeing, social justice, environmental concerns, and so on. An example of an ‘everyday’ behaviour of these ‘big’ issues is littering. If people value the wider environment, they would not litter. Thus, the argument runs, incentivising people not to litter may be an inappropriate use of market mechanisms. These are important debates, ones with which we imagine many social marketers would have considerable sympathy. We agree that it would be helpful to create more clarity of the competing priorities of short-term pragmatism (‘use market forces’) versus long-term culture change (‘avoid market forces’). Pragmatic opportunities to use markets may be justified in some conditions, while resisting the temptation to return to exchanges if it is felt long-term damage may accrue. Recent commercial use of market forces has been deployed in the car insurance sector to generate better driving behaviour – commercial gain being the engine of growth – with insurance firms now commonly using ‘black boxes’ to monitor driving. The alternative – encouraging a duty of care to others and hence safer driving – feels like a long way off. A perhaps more subtle point is that in their everyday work social marketers often avoid the use of direct exchanges. ‘Exchanges’ in most social marketing programmes are behavioural swaps – internal exchanges made with oneself. Thus, while external exchanges of the ‘lose weight and get cash’ type may sometimes receive consideration, it may be that exchanges of this type are regarded as designs of last resort, used when other ‘lose weight and feel better’ or ‘lose weight by joining WeightWatchers’ approaches have failed. We do, however, recognise the more substantive argument that the temptation to resort to market forces of any type has the danger to desensitise the populace to making decisions based on values, morals and public-spiritedness. Indeed, Sandel and Crompton’s criticisms of market exchanges are

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thought-provoking and helpful in opening up a new debate about behaviour change: What are society’s priorities for behaviour change? Are they a pragmatic ‘return on investment’ or long-term cultural wellbeing and contentment? (Indeed, further questions arise, not least about the limits of ‘interventions’ of any type in response to wideranging societal problems.) We contend that exchanges, as part of wider society, need not be harmful. Humans have traded goods for thousands of years; indeed, many would argue that trade has done far more good than harm in enabling human society to progress. However, we would support the case for, wherever possible, avoiding simple exchanges (if they crowd out morals) in favour of more rounded, multifaceted approaches to behaviour change, using exchanges to attract initial interest, for example, but then influencing behaviours through education, social contact, support and building common causes. This might be done through the use of multidisciplinary models that do not focus on one specific approach but a myriad of complementary ones. As a contribution in taking these thoughts forward, we propose such a model in the final section of this chapter.

Multidiscipline modelling and a distinctive role for social marketing Rothschild’s (1999) model implies three types of behaviour change: educating people, offering an exchange of some sort, and/or forcing change through law. This logic implies that any intervention that contains a proposition of some sort – an ‘offer’ – is by definition a social marketing intervention. The trouble is that colleagues elsewhere in the behaviour change world might be somewhat surprised to hear that all interventions can be described as containing a marketing component. Let us consider why interventions might be poorer without social marketing input. After all, the professional expertise and capability for creating, for example, cycle pathways to promote exercise, clearly reside primarily within the civil engineers of the transportation sector. However, cycle paths that emerge from local authority policy tend to be ‘expert led’: urban planners decide on the design and implementation of the cycleway, and then citizens are invited to use it. This top-down thinking contrasts with cycle-path projects that adopt a citizen focus. Here, the project would start with comprehensive ‘citizen insight’ research and then instead of being a ‘cycle-path’ project, becomes a ‘how to get non-cyclists to cycle more’ project. This then invites multi-agency participation by including, for example, workplace travel

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planners, cycle ‘buddy groups’ (where an experienced cyclist offers to show new cyclists the safest/most attractive routes to work), sport/ leisure stakeholders, and so on. Thus the added value that social marketers have to offer a multiagency team of behaviour change professionals is to ensure that the dominant concept is market orientation: a ‘marketing mentality’ that is owned by everyone, not just the social marketer on the team. We reemphasise here the primacy of market orientation in explaining what strategic marketing has to offer and note the considerable literature (led by Kohli and Jaworski [1990] and Narver and Slater [1990]) that demonstrates the power of this concept. Social marketers are behaviour change designers and can therefore work alongside other professions to design more effective interventions, as this case study shows: Box 7.4: Case study: working across professions and redesigning interventions: ‘Wheels, Skills and Thrills’ Co-author Alan Tapp was approached by a local authority road safety officer concerned about the rising number of deaths involving young male drivers aged 17-25 in a very deprived area of the city. The team was told: ‘We keep sending firefighters into the schools to “scare them straight” with stories of crashes and the awful consequences but it doesn’t work’. A two-year government sponsored ‘innovation project’ was the result, providing the scope to work across a combination of solutions. Initial scoping led to a shortlist of promising intervention designs and partners, and a community worker from the neighbourhood was appointed project manager. The young men’s difficult background and history of driving offences and crashes made this post very challenging. Following extensive research, co-creation and a trial period, a final intervention design was reached. The team worked together to redesign the Institute of Advanced Motorists driver training delivery to maximise its attractiveness for the cohort. In the driver course, the word ‘safety’ was under-played, with the emphasis on ‘skills’ such as vehicle handling. The project also used ‘telematics’ – ‘black boxes’ within cars that use accelerometry to measure aggressive driving manoeuvres and other driver characteristics. These provided in-car feedback – red-amber-green light systems attached to the windscreen that offered warnings if pre-set limits were breached. The programme was highly successful according to pre-post driver assessments and black box measures, all pointing to highly significant changes in the men’s behaviour. As a road safety officer noted, ‘It is the only intervention I have ever seen work with this community group’. For the social marketers involved, the

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Beyond behaviour change satisfaction lay in working alongside technologists and training deliverers to redesign their delivery in a way that balanced the needs of motivation, capability and opportunity to change (for more details, see Tapp et al [2013]).

‘Wheels, Skills and Thrills’ illustrates the flexibility of strategic social marketing in working with a wide variety of professional practitioners to better effect change. However, the question remains as to how such multidisciplinarity might be encouraged as a matter of course. Earlier, we outlined the social marketing management process as it is typically articulated (Figure 7.3). In Figure 7.4 we propose a wider behaviour change management process that emphasises multidisciplinarity, within which social marketing is integrated. Figure 7.4: Multidisciplinary behaviour change management process integrating social marketing Decide the optimum interdisciplinary team

Insights, segmentation Work across professions, to design a multi-agency intervention

Innovate

Controlled trial

Evaluate

This emphasis on multidisciplinarity also frees us to revisit Rothschild’s (1999) model. If we accept a shift in emphasis from ‘exchanges’ to ‘market orientation/insight and design capability’, we can then revisit the boundaries between education, marketing and law. For example, the ‘added value’ conceptualisation of social marketing opens the door for ‘edu-marketing’ that combines information with motivational persuasion. Here, educationalists might lead on message content, while marketers lead on message design. In the real world of multi-agency practice, this kind of cooperation is already common. Consider ‘Game On: Know Alcohol’, which employs online games and a series of

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experiential activities to deliver alcohol moderation drinking messages to 14- to 16-year-old adolescents. Use of social marketing principles underpinned program design (Rundle-Thiele et al, 2013b). Games developed for ‘Game On: Know Alcohol’1 are now embedded into alcohol education curricula. For example, two games accompanied by lesson plan and teacher resources are freely available for teacher use in 183 Queensland state high schools to educate adolescents about the concepts of standard drinks (Perfect Pour) and loss of control from alcohol drinking (Dumb Driver). Another example of social marketing working in a multidisciplinary way – this time using incorporating upstream approaches – is ‘Active Seattle’, which reported revisions of school zones (that is, signage that reduced the speed limit) and of sidewalk requirements (see Deehr and Shumann, 2009). Changes to infrastructure policy were also reported in ‘Get Active Orlando’, where social marketers were involved in developments in the city’s landscape including designating primary and secondary pedestrian corridors with wider sidewalks, and the incorporation of awnings into building design, and additional trees, lighting, and bike parking throughout newly developed and redeveloped areas (see McCreedy and Leslie, 2009). Emerging evidence certainly suggests there is room for multi-agency practice. Figure 7.5 summarises our proposition for expanding the educationmarketing-law model into multi-agency practice. In the model, we offer some examples of how the marketing concept – using citizen insights to help design solutions to behaviour change – may be applied to education (left-hand box), to interventions that create propositions of various types (centre box), and to laws and regulations (right-hand box). Figure 7.5: Increasing permeability between education, marketing and law Marketing’s role in education

Marketing’s role in interventions

Marketing’s role in regulation

Citizen oriented

Helping other professions with citizen orientation

Citizen oriented policy

 Persuasive  Engaging  Training

Co-creating:  Services  Infrastructure  Technology and so on

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 Responding to lack of enforcement  Dealing with procedural justice

Beyond behaviour change

Conclusion Social marketing insiders feel passionately that their field has much to offer and is sometimes (wrongly) overlooked. Outsiders often misunderstand social marketing and at times regard it with suspicion. Meanwhile, neutral policymakers who have a stake in behaviour change may look on the entire meta-field of behaviour change with frustration that disciplines cannot work more effectively together. In this chapter, we have tried to confront these agendas head on. We have offered an explanation of social marketing – emphasising that social marketing is a way of thinking that starts and ends with the customer – including its key features and its potentially unique contribution to behaviour change. We have also tried to respond to some prominent criticisms of market-based mechanisms for behaviour change. Lastly, as a way of responding to the key agenda of this book, we have offered a framework for the use of social marketing within a multidisciplinary model. This is an emerging, evolving debate, and we hope that this chapter can be a starting point in such a debate. End-of-chapter questions • What are some of the common ‘mythunderstandings’ about social marketing? • What are the unique characteristics of social marketing? • Why might use of social marketing enhance other behaviour change disciplines such as public health, education and urban planning? • How would social marketing be integrated into a behaviour change management process? • What is the difference between education, marketing and law?

Note 1

See http://gameon.rcs.griffith.edu.au

References Andreasen, A.R. (2002) ‘Marketing social marketing in the social change marketplace’, Journal of Public Policy and Marketing, 3-13. Brennan, L., Binney, W., Parker, L., Aleti, T. and Nguyen, L. (2014) Social marketing and behaviour change: Models, theory and applications, Cheltenham: Edward Elgar. Bronfenbrenner, U. (1977) ‘Toward an experimental ecology of human development’, American Psychologist, July: 513-31.

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Brug, J., Conner, M., Harre, N. and Kremers, S. (2005) ‘The transtheoretical model and stages of change: a critique. Observations by five commentators on the paper by Adams, J. and White, M. (2004) “Why don’t stage based activity intervention promotions work?”’, Health Education Research, 20(2): 244-58. Carins, J. and Rundle-Thiele, S.R. (2014a) ‘Eating for the better: a social marketing review (2000-2012)’, Public Health Nutrition, 17(7): 1628-39. Carins, J. and Rundle-Thiele, S.R. (2014b) ‘Fighting to eat healthfully: measurements of the military food environment’,  Journal of Social Marketing, 4(3): 223-39. Craig, C.L., Tudor-Locke, C. and Bauman, A. (2007)’ Twelve-month effects of Canada on the Move: a population-wide campaign to promote pedometer use and walking’, Health Education Research, 22(3): 406-13. Crompton, T. (2010) Common cause: The case for working with our cultural values, Surrey: WWF. De Cocker, K.A., De Bourdeaudhuij, I.M., Brown, W.J. and Cardon, G.M. (2011) ‘Four-year follow-up of the community intervention “10 000 steps Ghent”’, Health Education Research, 26(2): 372-80. Deehr, R.C. and Shumann, A. (2009) ‘Active Seattle achieving walkability in diverse neighborhoods’, American Journal of Preventive Medicine, 37(6): S403-S411. Donovan, R. (2011) ‘Social marketing’s mythunderstandings’, Journal of Social Marketing, 1(1): 8-16. Drucker, P. (2006) Management: Tasks, responsibilities, practices, New York, NY: Harper and Row. Eagle, L., Dahl, S., Hill, S., Bird, S., Spotswood, F. and Tapp, A. (2013) Social marketing, Harlow: Pearson. Evers, U., Jones, S.C., Caputi, P. and Iverson, D. (2013) ‘Promoting asthma awareness to older adults: formative research for a social marketing campaign’, Journal of Asthma and Allergy Educators, 4(2): 77-84. Gebel, K., Bauman, A.E., Reger-Nash, B. and Leyden, K.M. (2011) ‘Does the environment moderate the impact of a mass media campaign to promote walking?’, American Journal of Health Promotion, 26(1): 45-8. Grier, S. and Bryant, C.A. (2005) ‘Social marketing in public health’, Annual Review of Public Health, 26: 319-39. Hastings, G. (2003) ‘Relational paradigms in social marketing’, Journal of Macromarketing, 23(1): 6-15.

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Hastings, G. (2007) Social marketing: Why should the devil have all the best tunes?, Oxford: Elsevier. Hastings, G. and Angus, K. (2011) ‘When is social marketing not social marketing?’, Journal of Social Marketing, 1(1): 45-53. Hastings, G. and Domegan, C. (eds) (2014) Social marketing: From tunes to symphonies (2nd edn), London: Routledge. Heinrich, K.M., Aki, N.N., Hansen-Smith, H., Fenton, M. and Maddock, J. (2011) ‘A comprehensive multi-level approach for passing safe routes to school and complete streets policies in Hawaii’, Journal of Physical Activity and Health, 8(s1): s135-40. Henao, J.C., Rodriguez, J. and Wilbum, S.T. (2006) ‘Salsa y Salud: increasing healthy lifestyle awareness through a radio-based initiative’, Journal of Nutrition Education and Behavior, 38(4): 267-8. Hoek, J. and Jones, S.C. (2011) ‘Regulation, public health and social marketing: a behaviour change trinity’,  Journal of Social Marketing, 1(1): 32-44. House of Lords Science and Technology Select Committee (2011)  Behaviour change, London: The Stationery Office, www. publications.parliament.uk/pa/ld201012/ldselect/ldsctech/179/179 Keihner, A.J., Meigs, R., Sugerman, S., Backman, D., Garbolino, T. and Mitchell, P. (2011) ‘The Power Play! Campaign’s school idea and resource kits improve determinants of fruit and vegetable intake and physical activity among fourth- and fifth-grade children’, Journal of Nutrition Education and Behavior, 43(4S2): 122-9. Kohli, A.K. and Jaworski, B.J. (1990) ‘Market orientation: the construct, research propositions, and managerial implications’, Journal of Marketing, 54(2): 1-18. Kotler, P. and Zaltman, G. (1971) ‘Social marketing: an approach to planned social change’, Journal of Marketing, 35(3): 3-12. Kubacki, K. and Rundle-Thiele, S. (2013) Contemporary issues in social marketing, Cambridge: Cambridge Scholars. Maddock, J.E., Silbanuz, A. and Reger-Nash, B. (2008) ‘Formative research to develop a mass media campaign to increase physical activity and nutrition in a multiethnic state’, Journal of Health Communication, 13(3): 208-15. McCreedy, M. and Leslie, J.G. (2009) ‘Get Active Orlando: changing the built environment to increase physical activity’, American Journal of Preventive Medicine, 37(6): s395-402. Narver, J.C. and Slater, S.F. (1990) ‘The effect of a market orientation on business profitability’, Journal of Marketing, 54(4): 20-35.

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Peterson, M., Abraham, A. and Waterfield, A. (2005) ‘Marketing physical activity: lessons learned from a statewide media campaign’, Health Promotion Practice, 6(4): 437-46. Peterson, M., Chandlee, M. and Abraham, A. (2008) ‘Cost-effectiveness analysis of a statewide media campaign to promote adolescent physical activity’, Health Promotion Practice, 9(4): 426-33. Rayner, G. and Lang, T. (2009) ‘Obesity: using the ecologic public health approach to overcome policy carcophony’, in P.G. Kopelman, I.D. Caterson and W.H. Dietz (eds) Clinical obesity in adults and children, London: Blackwell, pp 452-70. Reger-Nash, B., Bauman, A., Cooper, L., Chey, T., Simon, K.J., Brann, M. and Leyden, K.M. (2008) ‘WV walks: replication with expanded reach’, Journal of Physical Activity and Health, 5(1): 19-27. Rissel, C.E., New, C., Wen, L.M., Merom, D., Bauman, A.E. and Garrard, J. (2010) ‘The effectiveness of community-based cycling promotion: findings from the Cycling Connecting Communities project in Sydney, Australia’, International Journal of Behavioral Nutrition and Physical Activity, 7(8), www.ijbnpa.org/content/pdf/1479-58687-8.pdf Rothschild, M.L. (1999) ‘Carrots, sticks, and promises: a conceptual framework for the management of public health and social issue behaviors’, Journal of Marketing, 63(4): 24-37. Rundle-Thiele, S.R. Kubacki, K., Leo, C., Arli, D., Carins, J., Dietrich, T., Palmer, J. and Szablewska, N. (2013a) ‘Social marketing: current issues – future challenges’, in K. Kubacki and S.R. Rundle-Thiele (eds) Contemporary issues in social marketing, Cambridge: Cambridge Scholars. Rundle-Thiele, S.R., Russell-Bennett, R., Leo, C. and Dietrich, T. (2013b) ‘Moderating teen drinking: combining social marketing and education’, Health Education, 113(5): 2. Sandel, M. (2012) What money can’t buy: The moral limits of markets, Penguin: Allen Lane. Schneider, M. and Stokols, D. (2009) ‘Multilevel theories of behaviour change: a social ecological perspective’, in K.A. Riekert, J.K. Ockene and L. Pbert (eds) The handbook of health behaviour change, New York, NY: Springer. Tapp, A. (1998) Principles of direct and database marketing, London: Financial Times Management, Pitman. Tapp, A., Pressley, A., Baugh, M. and White, P. (2013) ‘Wheels, Skills and Thrills: a social marketing trial to reduce aggressive driving from young men in deprived areas’, Accident Analysis and Prevention, 58: 148-57.

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Tapp, A., Rhodes, C., Withall, J. and Warren, S. (2009) Encouraging breastfeeding using social marketing, Report for Bristol PCT, Bristol: Bristol Social Marketing Centre. Withall, J., Jago, R. and Fox, K.R. (2012) ‘The effect a of communitybased social marketing campaign on recruitment and retention of low-income groups into physical activity programmes – a controlled before-and-after study’, BMC Public Health, 12: 836. Wymer, W. (2011) ‘Developing more effective social marketing strategies’, Journal of Social Marketing, 1(1): 17-31.

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EIGHT

Technology and the formation of socially positive behaviours Adam Joinson and Lukasz Piwek

Introduction This chapter explores the impact that technology has on our behaviour, and how it can be – and is being – used purposefully to achieve change. Since the first basic stone and bone tools were used by PlioPleistocene hominids over three million years ago (McPherron et al, 2010), the ability of humans to fashion tools has not only extended our capacity to conduct tasks, but may also have had a transformative impact on our own selves. For instance, tool development may have been a key facilitator in the development of a large, energy-hungry brain in humans (Gibbons, 1998). In more recent times, technologies and inventions – ranging from tally marks as a pre-cursor to numbers, the number zero, writing, the printing press, the stirrup, and the computer – have transformed not only individual human abilities through an extension of physical capabilities (McLuhan, 1964), but also society through both the intended and unintended consequences of widespread adoption and use. The notion that technological developments can transform not only society and individual behaviour, but also the very evolution of humankind, is well established within the field of technology studies. For instance, White (1964) describes how the development of the stirrup not only transformed medieval warfare, but also led to the development of feudal systems (although later historians have disputed the causality she asserts). Similarly, while the digital camera may seem to be a simple upgrade of the film camera, the ubiquity of digital photography is now beginning to have far-reaching consequences (such as in the production and consumption of pornography). This is by no means limited to digital technology – the invention of the printing press in the 1450s has been described as destroying ‘the oral society … and its effects were to be felt in every area of human activity’ (Burke,

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1991, p 71). Similarly, writing has been viewed as a development that ‘restructures consciousness’; it separates the knower from the known and creates a distance between the author and the reader (Ong, 1986). Ong further argues that writing may have a neuropsychological effect – encouraging left hemisphere activity in readers of alphabetic scripts. However, the development of technology and tools also frees us from mundane, everyday jobs. For instance, we do not need to remember a shopping list because technological solutions, like smartphones, increase our capacity to remember a large number of items and transform the nature of the task itself into one of checking the list against our grocery shopping rather than a memory and shopping task.

The impact of technology on social behaviour The impact of technology on social behaviour is not a simple relationship of cause and effect. Not all technology and tools are widely adopted (like the video phone), and users often appropriate a technology to their own ends (like using an ansaphone to screen calls). The way a technology affects society is an ‘assemblage’ of multiple factors, both social and technological (Shove and Southerton, 2000). Kiesler (1997) draws a distinction between technologies that amplify and those that transform: Some technological change is primarily amplifying, making it possible for people to do what they have done before, but more accurately, quickly or cheaply. In other cases, technology is truly transformative: It leads to qualitative change in how people think about the world, in their social roles and institutions, in the ways they work, and in the political and economic challenges they face…. Sometimes the amplifying effect is what we see first, never realising there is a later transformative effect to come, or that the amplifying technology is part of a larger social change. (pp xii-xiii) A useful way of thinking about the impact of technology on behaviour is that it operates through three related processes: extension, amplification and shaping (see Figure 8.1). ‘Extension’ relates to the notion that tools can be used to extend human capabilities (that is, to communicate, remember and articulate). ‘Amplification’ is how technology use can amplify existing effects through this increased capability. ‘Shaping’ refers to the ways in which technology and tools

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can provide the choice architecture that independently influences behaviour. Finally, ‘transformative’ effect rises from synergic effect of extension, amplification and shaping, where technology begins to exert a widely felt effect on societal values and more general human behaviours. Figure 8.1: The extend-amplify-shape-transform (EAST) framework for technology and behaviour change

Extend human capabilities

Transform Shape behaviour

Amplify effects

We now discuss each process in turn. Technology as an extender The notion that technology can simply extend our current capabilities is well established. Indeed, McLuhan (1964) defined ‘media’ as any technology that ‘creates extensions of the human body and senses’ (p 239). Similarly, Fogg (2002) argues that technology can be persuasive by increasing people’s capabilities in a number of ways. For instance, it can make a specific behaviour easier to enact, by leading a user through a process or by performing calculations or measurements that motivate the user. Fogg’s notion of tools increasing the ease of action is closest in definition to the idea of a tool as an extension of human capability or an amplifier of existing social interactions. For instance, the inclusion of ‘share on Facebook’ menu options within a smartphone operating system makes it easier to share content with a user’s contacts by removing the steps to completing the action. Similarly, Amazon’s ‘one-click’ technology makes purchasing (including impulse purchasing) easier than when users needed to enter or verify credit card and delivery details with each purchase.

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However, it is too simplistic to argue that simply because a tool extends or augments existing capabilities it is not transformative. Take, for example, the development and implementation of lifestyle self-monitoring tools (current examples include Fitbit, Nike+ and BodyMedia). Most of the facilities provided by these tools are available in a non-digital form. For instance, you could count all the steps you take in one day, record your heart beat using your pulse and a watch, or measure your blood pressure using an aneroid sphygmomanometer with a dial, bulb, and air valve. However, new tools such as the Fitbit not only make it easier to collect and collate this information, but critically they also support self-monitoring. Self-monitoring is a key behaviour change technique (Abraham and Michie, 2008) that has been implicated in supporting behaviour change endeavours in a range of domains, including energy consumption (Brandon and Lewis, 1999), dietary management (Rosser et al, 2009) and physical activity (Hurling et al, 2007). Technology as an amplifier While the examples given earlier illustrate the potential ways in which technology extends human capabilities, a second possibility is that new technology amplifies existing social processes and behavioural responses. For instance, computer-mediated communication (CMC) extends our ability to communicate via text across time and distance, while simultaneously amplifying social processes that have a behavioural component (Walther, 1992; 1996). For instance, Tidwell and Walther (2002) studied CMC through the lens of uncertainty reduction theory (Berger, 1979), and report that participants in their CMC condition engaged in questioning behaviour differently from their face-to-face participants. Similarly, hyper-personal interaction (Walther, 1996) in CMC – feelings of exaggerated liking and connectedness – rely on the amplification of offline social processes via the extensions caused by mediation (for instance, disclosure via increased levels of selfawareness (Joinson, 2001) or uncertainty reduction strategies (Tidwell and Walther, 2002). Technology as an amplifier can also operate alongside its use as an extension through increased ease of use, visibility or utility. For instance, smart monitoring technologies –discussed in more detail later – act by extending our capability to collate and analyse self-related information, while simultaneously amplifying the effect of, say, self-monitoring on motivation and self-regulation of behaviour. In the discussion of social media in this chapter, we also look at how the increased visibility of

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users to varied audiences can be used to amplify existing effects, leading to identifiable behavioural consequences. Finally, when considering the impact of new technology on human behaviour it is also important to recognise that we tend to respond to technology itself as if it were a social actor (Reeves and Nass, 1996). For instance, people apply existing social norms such as reciprocity, politeness and empathy to computers as well as to other people (Fogg and Nass, 1997; Nass and Moon, 2000). In terms of behaviour change, this effect is important – for instance, while a technology can have a profound effect on behaviour by extending capabilities and amplifying effects, it may simultaneously introduce entirely new outcomes by triggering responses to computers and tools as social actors. This possibility leads to a third way technology can influence behaviour – through shaping. Technology and the shaping of behaviour An additional way we can think about technology and social behaviour is through the ‘nudges’ technology can provide for specific types of action through its design. (For more on ‘nudge’ see Chapter Six.) The cognitive psychologist Gibson (1979) introduced the idea of affordances to explain his notion of direct perception. According to Gibson (1979), objects or environments have certain properties that lead to different types of behaviour. For instance, the handles on a tea set provide an obvious affordance for holding. Benches on train stations have specific shape and handles to keep homeless people from sleeping on them. This idea of objects affording certain types of behaviour was adopted enthusiastically by human-computer interaction researchers, most notably Don Norman (1998). In applying the notion of affordances to everyday objects, Norman (1998) argues that affordances are the ‘perceived and actual properties of the thing, primarily those fundamental properties that determine just how the thing could possibly be used’ (p 9). So, just as a flat smooth surface affords walking, so the telephone affords (‘is for’) talking, but not walking on. What is important about the idea of affordances is that they imply a direct, in some cases designed, link between the properties of an object, material or tool, and the uses to which it is put. Take, for instance, social network sites such as Facebook or LinkedIn. While these sites extend and amplify, they also shape behaviour through the use of defaults (such as in their privacy settings). The power of a default option to change people’s behaviour has been well

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established in a number of fields, including healthcare (Halpern et al, 2007), pension uptake (Madrian and Shea, 2001) and organ donation (Johnson and Goldstein, 2003). In terms of the development and design of technology or tool, the designer has considerable leverage not only over the default selections, but also over the ways in which options are presented. Again, there is considerable evidence from the field of behavioural economics to suggest that the method of presentation of options has a significant impact on how people make decisions and subsequently behave (Ariely, 2010). For instance, people tend to weigh losses more heavily than gains (Kahneman and Tversky, 1979), give too much weight to small probabilities (for example, 5% moving to 10% compared with 60% moving to 65%), and evaluate events differently when they are further in the future (known as ‘hyperbolic discounting’). If we understand the goals and motives that people seek from a tool or technology, we can also design specific behaviours and actions into the use of the technology. In his study of uses and gratifications of Facebook, Joinson (2008) found that relatively open privacy settings were related to wanting to use the site to meet new people. So, if a gratification of Facebook is to make new contacts, then a specific behaviour, such as allowing Google’s search engine to index the profile name and page, is required in order to maximise the likelihood of gaining that gratification. Similarly, routes through a site (or educational resource) can be specifically designed to elicit or require actions in order to move to the next stage (something Fogg [2002] calls ‘tunnelling’). Technology as transformative The degree to which a technology is also transformative is difficult to identify without the benefit of hindsight. Simply because a tool or technology extends our capabilities, and perhaps amplifies existing relations, does not exclude the possibility that it will have a transformative effect further down the line. For instance, the growth in availability of pornography, and relative ease of access to it by young people, can be seen as both extending (in terms of access) and amplifying (in terms of the potential impact on attitudes towards sexual behaviour and sexual violence). However, it is possible that in the long term the combination of extension and amplification effects will have a transformative impact on teens’ later relationships, something that has been already been the focus of considerable concern (Freitas, 2013; Hald et al, in press). In a similar vein, the recent widespread adoption and use of social media such as Twitter and Facebook can be seen in terms of

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both extension (of previous ways of connecting and sharing) and amplification (via CMC process, self-affirmation and so on), as well as shaping behaviour within the site itself. For example, when a new user signs into Facebook, they are encouraged to ‘find friends’ by allowing access to their email contacts list, and (as of April 2013), the default privacy setting for new users is ‘Public’ for postings, with search engines also being able, by default, to link to the new users’ timeline. When the outcomes of extension, amplification and shaping combine – as in the example described earlier – then we can start to think about technology as transformative in that it no longer becomes an extension of human behaviour and capabilities, but it in turn begins to exert a widely felt effect on societal values and more general human behaviours. The longevity of these transformative effects is difficult to predict – technology is shaped by society, and the ways in which a (potentially) transformative technology is adopted and adapted will in a large part determine its wider impact.

Using technology to change behaviour This chapter now looks more closely at three ways in which technology and tools can be used to change behaviour, namely smart tracking wearable technologies, smartphones and social media. In each case, we examine the current technology on offer, analyse it using the EAST framework explored earlier, and look at how it could be used to create socially positive behaviours. Smart tracking technology and behavioural self-monitoring We are entering a new era of smart, personalised and effortless selfmonitoring. It is now possible to record temperature, perspiration and heart rate using a single, attractive-looking, wearable device (Figure 8.2). Most smartphones are spiked with GPS, accelerometers, altimeters and compasses, and some even have pressure, humidity and temperature sensors. Devices are not only extending our capabilities of communication and information access, but also our ability to gather information about the environment and ourselves that was never possible before without clinical grade equipment and testing labs. In the context of behaviour change, the impact of smart technology on behaviour can be connected to three main factors: tracking with feedback, personalisation and simplicity. Feedback intervention is one of the oldest processes investigated in psychological research, and its

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beneficial effect on performance has been dated to studies back in 1905 (Kluger and DeNisi, 1996). Figure 8.2: Examples of consumer-level smart technology that enables sophisticated self-monitoring: (a) Nike+ fitness tracker; (b) Basis Peak sleep and biometric smart watch; (c) Withings Smart Body Analyser

Note: Thanks to Basis, an Intel company, for permission to reproduce this image.

Box 8.1: Case study: Nike+ A great example of a successful smart technology that harnesses the potential of feedback is Nike+. Nike+ eliminates the tedium of tracking performance by using data from an accelerometer to give immediate personal feedback on distance and speed when jogging. This enables a sense of control and reinforcement to improve performance. Feedback on performance increases likelihood of continuing to produce behaviour (Bandura, 1977). Nike+ also shows feedback on other people’s results and allows them to publicly share their own performance. This observation by others increases the likelihood of continuing a desired behaviour (McCarney et al, 2007; McClusky, 2009). Feedback on other people’s performance also triggers a broad spectrum of social influence mechanisms like social proof, competition and comparison (Cialdini, 2001), and therefore contributes to the amplification potential of the technology to change behaviour.

Aside from feedback, personalisation is another important technique of behaviour change boosted by smart technology. Thanks to tracking sensors, processing power and online connectivity of smart devices, the analysis of performance and feedback can be delivered on the personalised platform in real time or rather at the ‘right’ time for the user. Correct tailoring and timing of information provision in behaviour change is a very important factor in delivering a non-invasive user experience (Fogg, 2002). Research in health interventions for behaviour change shows that providing personalised information is

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more effective than generic information for behaviour change (Noar et al, 2007). This way, personalisation is tightly linked with tracking and feedback, in the sense that it benefits from more data collected about the user. Box 8.2: Case study: Google Maps Google Maps uses GPS-based location and traffic analysis to predict how long it will take for the user to get to the specific location. If the user has an important meeting recorded in the online calendar, Google sends the notification at the right time to remind the user they need to leave soon to get to their meeting on time. This is a smooth and effortless process with tracking sensors working in the background, and personalised reminders serving a simple purpose of efficient time management for the user.

This brings us to simplicity, which also benefits from smart technologies. Simplicity enables users to increase the benefit:cost ratio, and therefore stimulates motivation to engage (Bandura, 1977) and reduces the cognitive effort required to do so (Mayer and Moreno, 2003). We frame it as a shaping factor. Simplicity can be greatly achieved with smart technologies using the principles of user interface design. For instance, it has been widely reported that capacitive touchscreen smartphones and tablets (such as Apple’s iPad) enable smooth computing experience for older generations of users (Umemuro, 2004; Kobayashi et al, 2011), who typically have more difficulties in adapting to mouse-and-keyboard interfaces. Touchscreen devices have been evaluated by this group as more intuitive and engaging, and their learning curve has proved to be much smoother with this technology than with mouse-and-keyboard based devices (Jaimes and Sebe, 2007; Saljo, 2010). With the simplicity of a single touch of an icon, users can check their emails, make a call, or snap a photo. Simplicity should eventually lead to seamless use of technology so that users do not really notice the moment when a specific digital solution becomes a natural part of their daily routine. Smartphones as the platform for behaviour change Worldwide, mobile broadband users (who typically use smartphones) numbered approximately 370 million in 2009 and 720 million in 2011, and was due to increase to 1.8 billion in 2014 (Portio Research, 2011). By 2025, it is predicted that the majority of the projected eight billion people in the world will carry a smartphone (Miller, 2012). Typical smartphones combine features such as portability, fast processing power, large memory, advanced operating system, high-definition camera and

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touch screen. These features enable smartphones to replace and merge a huge range of other devices such as landline phones, digital cameras, radios, voice recorders, GPS navigators, handheld game consoles, alarm clocks, calendars and calculators (Miller, 2012). Additionally, the majority of smartphones continuously record numerous variables every few seconds, from location and levels of movement to the number of calls we make, the number of letters we type when sending text messages, or the proximity to other similar devices that we pass on our way to work. Box 8.3: Stop and think: are digital technologies for behaviour change a ‘solution in search of a problem’? With the technological potential available for behaviour change, it is somehow surprising that we are not yet immersed in the reality of personal, integrated smart technologies and intelligent environments that help us to make better choices regarding our health, financial savings, or travel. Indeed, companies like Nike, Apple and Google take full advantage of the rising trend in the use of smart devices, but rarely with the stated aim of creating a socially beneficial outcome. From the perspective of practical application in the behaviour change domain, the current landscape for smart technology and behaviour change looks surprisingly barren. The use of technology in many behaviour change interventions seems almost forced, unintuitive and ecologically invalid for practical application. An example where (so far) research has failed to effectively use smart technology for behaviour change is technology-assisted interventions designed to support weight loss (Neville et al, 2009). A common experimental design used in this domain is to provide participants with a pedometer measuring levels of physical activity, ask them to set up the weekly dietary goals using an interactive web form and send them tailored email advice. Such an approach has been shown to produce results no different from just asking participants to exercise more (Booth et al, 2008). What is lacking in the majority of such interventions is a simple and personalised user interface with a robust feedback model that takes advantage of social influence and is wrapped up in smart technology. Additionally, many existing ‘wearables’ suffer from being a ‘solution in search of a problem’. In other words, they do not add the functional value that is expected from personal technology of that type, and they require too much effort, which breaks the seamless experience that users expect. Poor affordance and implementation of wearable platforms stems in part from the rapid nature of development, suggesting a lack of controlled trials and usability tests.

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From a behaviour change perspective, smartphones are one of the most promising smart technologies that could be flexibly adapted as a platform for behaviour change interventions. Attached to us during the day, charging on our bedside tables at night, smartphones potentially hold the key to decoding the complex patterns of our everyday lives. Indeed, we already know that tiny digital traces of continuous mobile activity can reveal our identity (De Montjoye et al, 2013) and consumer preferences (Kohne et al, 2005). Indeed, using data from smartphone sensors, we can make inferences about user contexts (Lathia et al, 2013), physical activities (Lane et al, 2011), emotions (Rachuri et al, 2010) and stress (Lu et al, 2012). Moreover, we can make highly accurate predictions about the personality traits of users by analysing the linguistic content of text messages (Holtgraves, 2011) or by examining the average time users spend on phone calls or messaging (Ehrenberg et al, 2008). Smartphones have already been used in research projects for large-scale behaviour data gathering (such as by Killingsworth and Gilbert, 2010; Lathia et al, 2013; MacKerron and Mourato, 2013). For example, the Mappiness Project (MacKerron and Mourato, 2013) collected over three million mood reports with GPS locations and ambient noise levels from 45,000 users through an iPhone app. The authors used this data to show that participants were significantly happier outdoors in all green or natural habitat types than they were in urban environments. While still in the early stages, such projects show that in the near future smartphones will enable researchers and practitioners to study and deliver simple, personalised, large-scale behaviour change interventions with instant self-monitoring and feedback system for the users. Data mined from smartphone sensors could be integrated and analysed to provide valuable information to support health-related behaviour change interventions, from exercise and healthy eating to anxiety management. Efficient and intelligent tracking could help users save money by enabling them to make better shopping choices and energy savings, and to recycle in a smarter way. Social media and behaviour The EAST framework for understanding the role of technology in behaviour can also be applied to our understanding of social media. At its core, social media such as Facebook extends our ability to connect to others and to share and consume content (Joinson, 2008). Meanwhile that use also amplifies existing social processes and effects such as self-affirmation (Toma and Hancock, 2013), self-control (Wilcox and Stephen, 2013), awareness of the audience (Marder et

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al, 2012) and social impact (and anxiety) associated with multiple audiences (Binder et al, 2009; Joinson et al, 2011). This amplification can be especially useful for encouraging behaviour change through the power of ‘pledging’ and multiple audiences. There is considerable evidence that people are motivated to maintain consistency between their attitudes and behaviour, an effect that is particularly strong when there is an audience (Cialdini, 2001). For instance, Williams et al (2005) report that an experimental group who signed a contract to increase their daily exercise did so significantly more than a group that was given just an exercise plan, but no contract. Failure to maintain a commitment made in public not only risks internal inconsistency, but also reputational damage (Bicchieri, 2006). Facebook has also designed persuasive elements in order to shape behaviour (Fogg and Eckles, 2007). According to Fogg and Eckles (2007), social media designers attempt to move users through three key phases of involvement with the site: discovery, superficial involvement and true commitment (see Figure 8.3). The goal for a designer of a social media site is to encourage behaviours that form ‘true commitment’ actions: involving others, staying active and loyal, and creating value and content. In a related study, Vasalou and colleagues (2010) examined how various elements of the Facebook site were used by participants from five countries (UK, US, Italy, Greece and France) at different phases of involvement with the site. The authors of the study found that the use of Facebook features tended to change as users moved through stages in time: photos and status updates increased in importance (that is, ‘creating value and content’), while games and applications (more ‘superficial’ involvement) became less significant. Additionally, cultural background was an important factor in determining how users engaged in each of the target behaviours in the true commitment phase. Just as social media can shape behaviour by making it easier to engage in behaviours (such as inviting all email contacts to become friends), so it can also shape behaviour by making undesired actions more difficult to complete. For example, social media shapes the ways in which we interact with others. On Facebook we have only one category of contact – friend – and by default share the same information across all members of that group. This may cause anxiety among users trying to manage an impression to competing audiences (Joinson et al, 2001), and lead to self-censorship of their behaviour. However, alternative approaches (such as Google+) are available that allow for a more nuanced approach to sharing by grouping contacts. Similarly, on Facebook there are two responses available to content – ‘like’ or ignore.

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On Twitter, the character limit is an obvious shaper of behaviour – but subtler shaping also occurs. For example, if a user wishes their content to be distributed on Twitter (‘retweeted’), they must leave enough spare characters for the retweet tag and their username to be included in the forwarded text. Figure 8.3: Behaviour chain model

Learn about service

Visit site

Decide to try

Get started

Create value and content

Involve others

Phase 1: Discovery

Phase 2: Superficial involvement

Phase 3: True commitment Stay active and loyal

Source: Fogg and Eckles (2007).

Despite the focus on negative impacts (such as via privacy infringement and multiple audiences) of social media (Joinson et al, 2011), there are a number of ways in which social media can be used in order to influence behaviour for positive outcomes. As noted earlier, the power of commitment in increasing the likelihood of behaviour is well established. We would predict therefore that making statements in semi-public spaces such as Facebook increases the likelihood of an intention to enact behaviour change being completed. This is potentially important, since, anecdotally, a relatively popular use of social networks is what we term ‘intention-pledge’ status updates,

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ranging from intentions to change behaviour to exercise intentions and New Year resolutions. Social media also provides an opportunity for influencing others’ behaviour through the communication of social norms. This may range from the ‘sharing’ of content on Facebook to retweets on Twitter and recommendations/favouriting on many other platforms. This communication of social norms has been shown to reduce negative behaviour in a range of contexts, including exam cheating (McCabe and Trevino, 1997), health-risk behaviours such as smoking, sexual activity and drug use among teens (Beal et al, 2001) and drink driving (Brown, 1998). According to routine activity theory, for a crime to occur, three factors need to be present – a motivated offender, a potential victim and an absence of capable guardians (Clarke and Felson, 1993). The visibility of action and intentions in social media, and likelihood of capable guardians being present because of multiple audiences, may therefore decrease the likelihood of socially negative behaviour occurring. Outside individual behaviour, social media has the potential through extension and amplification to have far-reaching societal consequences, as seen in the ‘Arab Spring’ (Wulf et al, 2013). These authors report from Sidi Bouzid (in Tunisia) on the ways in which social media was used not only to spread information, but also to organise and connect disparate groups across the country. Social media can connect protestors with those providing wider social solidarity (Starbird and Palen, 2012), while also providing information (and coordination) from the site of the protest itself, something also seen in the use of social media in mass emergencies. Box 8.4: Stop and think: the end of privacy? The acceleration of the development of a digital landscape has surpassed our ability to manage how our personal data is shared and distributed. We use smartphones and computers for our jobs, education, travelling, shopping and entertainment. While we have some control over privacy settings in social networks, we leave a continuous trail of digital footprints behind us each time when we use smartphones, personal computers or wearables. Our identity, preferences and habits can be easily extracted from these footprints, making us potentially vulnerable to invasive marketing targeting or identity theft. One of the big challenges in the 21st century will be to address how our personal data is collected, stored and used, to prevent it from being mishandled.

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Conclusion In this chapter, we have argued that technology and tools can be used to extend, amplify and shape behaviours, and that in doing so they may have a transformative effect. As social scientists, we usually assume that a behaviour is preceded by a decision or preference of some kind (as in the theory of planned behaviour (Ajzen, 1991), discussed at length in Chapter Two. However, there is also evidence that behaviour creates a preference, rather than simply being the product of a preference (Ariely and Norton, 2008). So, if technology and tools are changing behaviour, they may, in turn, also be changing people’s attitudes towards those same actions. We conclude therefore that it is critically important that we understand not only how new media technologies and tools are changing behaviour, but also how these processes can be harnessed in order to create a social good. End-of-chapter questions • Think about your smartphone use. Which aspects of your daily behaviour has it changed the most? • How do you think technology will be integrated into behaviour change interventions in the future? • Can you think of any downsides to self-monitoring using technology for someone wanting to lose weight, for example? • Think about the ‘digital traces’ you leave behind – such as photos, ‘tweets’, ‘likes’ or webpages you visit. What story do those traces tell about you? Is it a story you like or does it reveal more than you want it to?

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McCabe, D.L. and Trevino, L.K. (1997) ‘Individual and contextual influences on academic dishonesty: a multicampus investigation’, Research in Higher Education, 38(3): 379-96. McCarney, R., Warner, J., Iliffe, S., Van Haselen, R., Griffin, M. and Fisher, P. (2007) ‘The Hawthorne effect: a randomised, controlled trial’, BMC Medical Research Methodology, 7: 30. McClusky, M. (2009) ‘The Nike experiment: how the shoe giant un- leashed the power of personal metrics’, Wired Magazine, http:// visualizinginfo.pbworks.com/f/TheNikeExperiment.pdf McLuhan, M. (1964) Understanding media: The extensions of Man, New York, NY: McGraw Hill (reissued MIT Press, 1995). McPherron, S.P., Alemseged, Z., Marean, C.W., Wynn, J.G., Reed, D., Geraads, D. and Barat, H.A. (2010) ‘Evidence for stone-toolassisted consumption of animal tissues before 3.39 million years ago at Dikika, Ethiopia’, Nature, 466(7308): 857-60. Miller, G. (2012) ‘The smartphone psychology manifesto’, Perspectives on Psychological Science, 7(3): 221-37. Nass, C. and Moon, Y. (2000) ‘Machines and mindlessness: social responses to computers’, Journal of Social Issues, 56(1): 81-103. Neville, L.M., O’Hara, B. and Milat, A. (2009) ‘Computer-tailored physical activity behavior change interventions targeting adults: a systematic review’, The International Journal of Behavioral Nutrition and Physical Activity, 6: 30. Noar, S.M., Benac, C.N. and Harris, M.S. (2007) ‘Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions’, Psychological Bulletin, 133(4): 673-93. Norman, D.A. (1998) The psychology of everyday things, New York, NY: Basic Books. Ong, W.J. (1986) ‘Writing is a technology that restructures thought’, in G. Baumann (ed) The written word: Literacy in transition, Oxford: Clarendon Press, pp 23-50. Portio Research (2011) Portio Research mobile factbook 2011, www. portioresearch.com/Portio%20Research%20Ltd%20Mobile%20 Factbook%202011.pdf Rachuri, K.K., Musolesi, M., Mascolo, C., Rentfrow, P.J., Longworth, C. and Aucinas, A. (2010) ‘EmotionSense: a mobile phones based adaptive platform for experimental social psychology research’, In Proceedings of the 12th ACM international conference on Ubiquitous computing - Ubicomp 10 (p 281), New York, NY: ACM Press. Reeves, B. and Nass, C. (1996) The media equation: How people treat computers, television, and new media like real people and places, Chicago, IL: CSLI Publications, University of Chicago Press.

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Rosser, B.A, Vowles, K.E., Keogh, E., Eccleston, C. and Mountain, G.A. (2009) ‘Technologically-assisted behaviour change: a systematic review of studies of novel technologies for the management of chronic illness’, Journal of Telemedicine and Telecare, 15(7): 327-38. Saljo, R. (2010) ‘Digital tools and challenges to institutional traditions of learning: technologies, social memory and the performative nature of learning’, Journal of Computer Assisted Learning, 26(1): 53-64. Shove, E. and Southerton, D. (2000) ‘Defrosting the freezer: from novelty to convenience: a narrative of normalization’, Journal of Material Culture, 5: 301-19. Starbird, K. and Palen, L. (2012) ‘(How) will the revolution be retweeted?’, Proceedings of ACM-CSCW 2012, New York, NY: ACM, pp 7-16. Tidwell, L.C. and Walther, J.B. (2002) ‘Computer mediated communication effects on disclosure, impressions, and interpersonal evaluations: getting to know one another a bit at a time’, Human Communication Research, 28(3): 317-48. Toma, C. and Hancock, J.T. (2013) ‘Self-affirmation underlies Facebook use’, Personality and Social Psychology Bulletin, 39(3): 321-31. Umemuro, H. (2004) ‘Lowering elderly Japanese users? Resistance towards computers by using touchscreen technology’, Universal Access in the Information Society, 3(3-4): 276-88. Vasalou, A., Joinson, A. and Courvoisier, D. (2010) ‘Cultural differences, experience with social networks and the nature of “true commitment” in Facebook’, International Journal of Human-Computer Studies, 68: 719-28. Walther, J.B. (1992) ‘Interpersonal effects in computer-mediated communication: a relational perspective’, Communication Research, 19: 52-90. Walther, J.B. (1996) ‘Computer-mediated communication impersonal, interpersonal, and hyper personal interaction’, Communication Research, 23(1): 3-43. White, L.T. (1964) Medieval technology and social change, Oxford: Oxford University Press. Wilcox, K. and Stephen, A.T. (2013) ‘Are close friends the enemy? Online social networks, self-esteem, and self-control’ Journal of Consumer Research, 40(1): 90-103. Williams, B., Bezner, J., Chesbro, S. and Leavitt, R. (2005) ‘The effect of a behavioral contract on adherence to a walking program in postmenopausal African American women’, Journal of Geriatric Physical Therapy, 21: 332-42.

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Wulf, V., Misaki, K., Atam, M., Randall, D. and Rohde, M. (2013) ‘“On the ground” in Sidi Bouzid: investigating social media use during the Tunisian revolution’, in Proceedings of the 2013 Conference on Computer Supported Cooperative Work, New York, NY: ACM, pp 1409-18.

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Part Two Critique, innovation and new ideas

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Stakeholder marketing and the subversion of public health Gerard Hastings and Marisa de Andrade

Introduction This chapter discusses the fundamental conflicts of interest that occur when the corporate sector gets involved in devising and influencing public health policy. Corporations spend other people’s – their shareholders’ – money, and are therefore governed by the ‘fiduciary imperative’ (Bakan, 2004) which requires then to put returns to their shareholders ahead of any other concern. It is therefore completely illogical to expect them to prioritise public welfare. This is the job of everyone else – government, civil society and citizens. If, as Milton Friedman famously proclaimed, the business of business is business, why do multinationals keep getting so conspicuously involved with good causes? Why does Tesco provide so many computers for UK schools and Philip Morris fund services for battered women? Should they not be getting on with their core tasks of selling us more groceries and cigarettes, and thereby making more money for their shareholders? The reality is that multinational companies actually are getting on with their core tasks when they engage in these seemingly philanthropic activities. School computers and women’s refuges are as much part of their marketing strategies as advertising campaigns and product innovation. These acts are not philanthropic at all, but deliberately designed to enhance profitability and boost shareholder returns. Furthermore, the corporation’s fiduciary imperative ensures that this will always be the case. And when this faux-philanthropy is used to promote the consumption of hazardous products, such as tobacco, alcohol and ultra-processed food, it will cause just as much public health harm. This apparent generosity is partly targeted at consumers. It is combined with conventional marketing activity, such as advertising and

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brand building, with the purpose of making customers feel valued on the one hand and trusting of the company on the other. In this way it encourages not just one-off purchases, but ongoing loyalty. Corporate good deeds, however, are also very deliberately aimed at policymakers and politicians. The purpose is much the same: to build relationships and trust. Thus consumer marketing is complemented by ‘stakeholder marketing’. And it is increasingly clear that political leaders are just as susceptible to marketing as those who vote them into office. Because of the access to power it gives, this susceptibility threatens not only public health, but our whole way of life. This chapter will look in detail at how stakeholder marketing works and discuss how civil society should respond. It begins with a theoretical exploration of the phenomenon and its component activities of causerelated marketing (CRM) and corporate social responsibility (CSR), showing how these all need to be seen through a relational lens. The business aim is to develop strategic alliances and partnerships with stakeholders and so build trust. This reduces accountability, mutes critical analysis and softens any regulatory response. The net effect then is not to temper business performance but to enhance it. Next, the chapter presents empirical evidence to illustrate these phenomena in practice. This was gathered through participant observation at a conference on corporate affairs for senior executives. This shows that while individual executives may express concern about the obvious conflicts of interest at play, this unease is overridden by the systemic pressure of the fiduciary imperative. In conclusion, the chapter argues that stakeholder marketing explains why public health partnerships with industry will always be fundamentally conflicted. The only solution is to establish a cordon sanitaire around public health policy, to protect it from commercial influence. Milton Friedman’s dictum is a truism, and its corollary is that it is the business of everyone else – government, civil society and ordinary citizens – to look after the commonweal.

The principles of stakeholder marketing The impact of advertising on consumer behaviour is now well established. Systematic reviews on alcohol, tobacco and food promotion have demonstrated its capacity to encourage both initiation and continued consumption (Lovato et al, 2003; Cairns et al, 2008; Anderson et al, 2009). It is also well recognised that ubiquitous distribution, sophisticated packaging, seductive pricing, beautiful point of sale display and perpetual product innovation are used with great

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skill to build the brands that extend the pull of advertising into the power of marketing (see for example Baker, 2003). However, corporations do not just need customers to secure their continued growth, they need power and influence, and for this they turn their attention to politicians, policymakers and other stakeholders. The more blatant attempts to get these groups on side – overt lobbying, donations to campaign funds, revolving-door employment practices – already get considerable attention, but the work of the corporate marketer in this arena is less well recognised. ‘Stakeholder marketing’ uses the same subtle and seductive approach of the marketing aimed at the public, but now the target is those who have power. The aim is to build and burnish corporate reputations; in stakeholder marketing, corporate identity is as important as the brand is in consumer marketing (Hastings and Angus, 2004). Two linked techniques are typically used: CRM and CSR. CRM involves the corporation linking up with a personable and self-evidently worthy issue such as child literacy or indigenous rights, and making sure the world knows about its apparent generosity in supporting these causes (Adkins, 2003). One notorious example concerns the tobacco giant Philip Morris, which sponsored women’s refuges in the US, but was then shown to be spending more on promoting the largesse of this act than on the refuges (Dorfman, 2000). CSR wraps this type of specific beneficence in long-term commitments to good practice – a tactic becomes a strategy and sporadic good deeds turn into mutually beneficial relationships between business and government. Stakeholder marketing emerged in the sixties and seventies from a need to manage negative publicity about corporate wrongdoing and fend off legal action and mandatory restrictions. It has evolved into ‘a flexible and soft form of regulation’ that functions as a looser, more relaxed system of global governance (Eberlein and Kerwer, 2002). It is not directly enforced by governments or those in power, but negotiated by the actors, including business, within decentralised networks, who are themselves responsible for coordinating this light-touch regulation (Garsten and Jacobsson, 2013). The array of stakeholders involved in this consensual arrangement or ‘governance without government’ (Peters and Pierre, 1998; Cutler et al, 1999; Hall and Biersteker, 2002) blurs the line between public and private stakeholders with ‘soft law’ (rules without sanctions) bridging the gap between the partners (Morth, 2004, 2006; Scott, 2004). Underpinning this form of governance is the notion of consensus, or, as Mouffe (1993, p 6) puts it, ‘an apparent excess of consensus’, which stifles real debate and rejects any alternative that conflicts with the status

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quo. There is no legitimate space for the articulation of contradictory views or indeed evidence in this ‘harmony ideology’ (Nader, 1990) as consensus is the assumption at the ‘point of departure’ rather than the ‘end result’ after deliberation (Garsten and Jacobsson, 2013). This polite unanimity within governance networks may breed trust and empowerment for constituent stakeholders and legitimise knowledge claims (Shelton, 2000; Heritier, 2001). It also reinforces power dynamics within the network by allowing powerful agents, whose influence is closely linked to vested interest, to forbid the expression of competing points of view, thereby moulding the preferences of others (Nye, 2004; Lukes, 2005; Garsten and Jacobsson, 2013). Drawing from these conceptualisations of governance, Garsten and Jacobsson (2013, p 429) define CSR as ‘the deliberate inclusion of perceived public interest into corporate decision-making, thus reducing the available space for articulation of diverging interests’. The resultant consent, which the authors consider to be ‘a form of corporate regulation integrated into a business model’, is grounded in the principles of voluntarism, dialogue and partnership and ‘assumes the good will of all involved’ (Garsten and Jacobsson, 2013). Stakeholders engaged with CSR use language that reflects on togetherness, collaboration, dedication and cooperation, but rarely refer to interest or conflicts of interest (Garsten and Jacobsson, 2013). On the contrary, it is assumed that all stakeholders have an analogous stake (Jenkins, 2005). Box 9.1: Stop and think: the fallout from CSR and CRM Despite what we are led to believe from the so-called benevolence of big corporations, analysis of business practice shows that the stakeholder marketing mindset has enabled the corporate sector to reduce accountability, co-opt the critical analysis of their practices and enhance business performance.

Reducing accountability The oil multinational Shell is credited with taking stakeholder marketing into the mainstream of business thinking. In the early 1990s, Shell wanted to quell discontent among the local Ogoni people, whose land in the Niger Delta it was despoiling, and called on Nigeria’s military dictatorship for help. This resulted in savage repression, dozens of people being shot down and the subsequent execution of Ogoni leader Ken Saro-Wiwa. Shell’s response to the ensuing outcry was to invest heavily in CSR. Commitments to better behaviour were undertaken and promises to be more responsive to the needs of local people were

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made. Subsequent inquiries, however, show these to be no more than fine words over which the inevitable commercial priorities won out. Two separate reports, the first by Christian Aid (2004) and the second by Amnesty International in 2011 (Amnesty International and CEHRD, 2011), have recorded continued depredation of the Niger Delta and immense suffering by its inhabitants. For example, the Amnesty report noted that there had been two major oil spills in 2008 that between them were as devastating as the Exxon Valdez oil spill, ‘one of the worst environmental disasters in U.S. history’.1 The humanitarian response was woeful and took months to materialise: Eight months later, Shell finally appeared to recognize that people’s food sources had been affected. On 2 May 2009, Shell staff brought food relief to the community. It included 50 bags of rice, 50 bags of beans, 50 bags of garri (a cassava product), 50 cartons of sugar, 50 cartons of milk powder, 50 cartons of tea, 50 cartons of tomatoes and 50 tins of groundnut oil. (Amnesty International and CEHRD, 2011, p 11) In the quarter July to September 2011, the same year as Amnesty’s report, the company posted profits of $7.2 billion (Rowley, 2011). Five years later, compensation was still a matter of legal dispute, with local people rejecting a £30 million offer as ‘cruel and derisory’ (Vidal, 2013). The Christian Aid report drew the conclusion that ‘corporate enthusiasm for CSR is not driven primarily by a desire to improve the lot of the communities in which companies work. Rather, companies are concerned with their own reputations, with the potential damage of public campaigns directed against them, and overwhelmingly, with the desire – and the imperative – to secure ever greater profits’ (Christian Aid, 2004, p 5). The charity also points out that CSR is used ‘to block attempts to establish the mandatory international regulation of companies’ activities’ in favour of voluntary codes and discretionary agreements. Experience from many markets illustrates the fragility of such soft measures as soon as they conflict with bottom-line priorities, but the baby milk market is especially poignant. The words of Jasmine Whitbread, Chief Executive Officer of Save the Children UK, say it all: ‘I shouldn’t be standing in front of you, on the 25 year anniversary of the Code, telling you so little has changed and that companies continue to encourage mothers to spend money they don’t have on manufactured food most of them

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don’t need. I shouldn’t be standing in front of you because it shouldn’t still be happening. But it is, because the voluntary code clearly isn’t working, and children are dying as a result’ (Save the Children and CORE, 2007, p 3). Box 9.2: Stop and think: soft measures to regulate business As the baby milk example illustrates, there is a huge problem with voluntary codes that are designed, in theory, to keep corporate companies in check. Their bottom line is always profit, so the motivation to comply – or even set meaningful codes in the first place – is limited. Discussion later in this chapter about the alcohol Public Health Responsibility Deal – a collaborative pledge – explores the limitations of voluntary codes in more depth.

Co-opting critical analysis Making the move from being part of the problem to being part of the solution provides the corporate sector with the opportunity to reset the agenda. When a beverage multinational adopts an anti-obesity mantel, its starting point is that it is fine to consume empty calories; the only issue is how we adjust our lives to facilitate it. Box 9.3: Case study: Coca Cola’s obesity campaign Coca Cola’s obesity-related CSR typifies the failings of stakeholder marketing from a societal perspective. The principal focus is on exercise not diet, and the tone is encouraging and upbeat. The company’s advertising campaign boasts that each can of Coke provides ‘139 happy calories to spend on extra happy activities’ – such as ‘25 minutes of letting your dog be your GPS’, ‘10 minutes of letting your body do the talking’ (aka dancing) or just ‘75 seconds of laughing out loud’. Covering all the bases, the ad continues: ‘but if today you don’t feel like doing it … have a Coke with zero calories’ (a reference to the company’s product Coke Zero). But, whatever you do, the commercial concludes, ‘open happiness’ (Coke’s corporate slogan since 1999). So the public health problem of obesity has been turned into a marketing opportunity for Coke despite the fact that two thirds of the US population is now overweight, half of whom – that is nearly 100 million people – are clinically obese and sugary drinks like Coke are, on average, supplying every American with an annual dose of 3,700 teaspoons of sugar – which amounts to 60,000 calories (Moss, 2013).

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The same distortion as in the Coca Cola case occurs when an alcohol corporation is consulted on public health. It is assumed that the principal of alcohol consumption is a given; the issue becomes not whether but how we drink (McCambridge et al, 2014). Likewise, if tobacco companies get involved in harm reduction, the highly regressive concept of turning nicotine dependence into a profit-making opportunity will be the starting point (Hastings et al, 2012). These are textbook examples of agenda setting: we are told not so much what to think, but what to think about. In each case, profits come before people and public health joins promotion, place, pricing and product development to become the fifth P of the marketing mix.

Enhancing business performance Interestingly, the business sector is open about the self-seeking intent of stakeholder marketing. A typical business textbook, for instance, points out that it helps in … enhancing reputation, building image and brands, creating relationships and loyalty among customers and stakeholders, adding value, generating awareness and PR, driving trial and traffic, providing product and service differentiation, developing emotional engagement with the consumer and other stakeholders, and obviously increasing sales, income and volume. (Adkins, 2003, p 674) The same text underlines the blatant quid pro quo agenda: ‘whatever cause-related marketing is, it certainly is not philanthropy or altruism’ (Adkins, 2003, p 670). Practitioners are equally candid. This is a spokesperson for Marks and Spencer talking about the company’s ambitious plan to ‘combat climate change, reduce waste, safeguard natural resources, trade ethically and build a healthier nation’, which she explains is a matter of ‘enlightened self-interest’. The reaction among customers has been to ‘increase trust in the M and S brand more than any other ad campaign’ and this had been ‘very good for profits’ (Worth, 2007, pp 5-6). When done well, the boundary between consumer and stakeholder marketing is virtually seamless. Tesco, for example, in its computer for schools campaign, invites local politicians to accept IT equipment on behalf of particular schools. An invitation to officiate at a good news public ceremony, complete with local media coverage, is extremely attractive, and beneficiaries show their gratitude: thus one Member of

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Parliament’s (MP’s) website talks of the equipment coming ‘courtesy of Tesco’ and of the ‘generosity of Tesco’2 as well as extolling the virtues of the whole campaign. This provides a perfect extension of Tesco’s core slogan ‘every little helps’. This Tesco example also shows how stakeholder marketing recognises the collective nature of our lives, and that MPs are just as important a target as shoppers. Our decisions about whether to smoke, eat fast food or drink alcohol are both matter of individual choice and a function of our environment. Thus my beer consumption will be influenced by my personal preferences, but also by the availability of accessible outlets, taxation policy, social attitudes to drinking, drink-driving laws and so on. These latter influences are the domain of stakeholders and, especially, policymakers. In essence, then, marketers, in seeking to change our consumption behaviour, also recognise the need to change policymaking behaviour.

From the horse’s mouth Business thinking on stakeholder marketing and CSR continues to evolve, and following the advice of McHenry (2009), we used an industry conference on responsible business to gain an understanding of the ‘inner workings’ of internal corporate processes that is rarely seen ‘outside of litigation’. The event was expensive to attend and attracted serious players from a range of blue chip companies, including those from the alcohol, pharmaceutical and food sectors. It included lots of informal sessions so as to provide opportunities for networking and debate, so it also attracted stakeholders from government, non-government organisations (NGOs), firms specialising in corporate reputation management, academics, think-tanks and media representatives. Openness and freedom of expression were actively encouraged, as was free reporting of discussions. In this spirit, we are sharing some of the debates in this chapter, although without attributing quotes. The discussions covered many fields, from climate change to human rights, and the issue of public health was prominent. The event perfectly illustrates the extensive benefits of stakeholder marketing for the corporate sector – and the concomitant risks for society. Specifically, the three benefits that emerge from the literature of reducing accountability, co-opting the critical analysis of business practices and enhancing business performance are very much in evidence.

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Reducing accountability Accountability is reduced by turning the threat of regulation into a proactive opportunity to seize the agenda. A session on engagement with policymakers provided an insight into how CSR can be used as a stakeholder marketing tool. Led by a senior manager from a leading drinks manufacturer, it focused on how it makes it possible for a company to turn its greatest risks – regulation, responsible consumption and environment sustainability – into its greatest opportunities. According to the representative, the stifling regulation now enforced on the tobacco industry could, in the absence of careful relationship building, happen in other sectors: ‘The health lobby is getting stronger and stronger, they are getting more people on their side and in the UK really the tobacco industry has almost been hidden now to the point where you can’t even display cigarettes. In supermarkets it’s almost an under the counter transaction; clearly they are now turning their focus onto alcohol.’ The representative went on to list possible threats, including restrictions on advertising, graphic health warnings as on tobacco products, and controls on distribution and display, and concluded ‘“so we could either roll over and say ‘well it’s coming our way’ or we can try and start to proactively demonstrate that we are responsible manufacturers”. The idea of ‘responsible drinking’ therefore creates an opportunity for the alcohol industry to engage with key policymakers through stakeholder marketing, and companies can operate how they want to now, rather than waiting and risk being told what to do by government in the future. The alcohol industry representative explained how this professing of benevolence helps curb government regulation by “keeping back legislation at bay [sic] for as long as we [alcohol industry] possibly can”. This thinking has been taken a step further with the Portman Group: “We have got an independent body called the Portman Group which again is an industry body, funded by us, set up by us … it’s all voluntary.” The use of the term ‘independent’ is revealing; given that the Portman Group is wholly paid for by the drinks industry, it can only be interpreted as appearing to be, but not actually being, independent. The resulting benefits are then spelled out: easy and confidential access to the regulator – “so if you thought that advert had a problem … you could either anonymously or proactively contact the Portman Group,

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which has a set of independent adjudicators who will look at it”; and pre-empting more muscular mandatory action – “it’s kind of knowing that effectively there is going to be some sort of regulatory backlash at some point so let’s set up an independent body which is funded by us before we are forced to do it”. The Public Health Responsibility Deal on alcohol took this thinking to a new level in 2012. It was set up by the Department of Health with the aim of addressing concerns about alcohol and public health through collaborative pledges with industry (separate and analogous arrangements were established for diet, health, wellbeing and exercise). An alcohol company representative explained that these pledges can be useful for business as they result in new relationships with suppliers, increase discussions with government and minimise the impact of government regulation on their business. By voluntarily making changes in product labelling, for example, alcohol companies can, again, fend off regulation and “do it now the way you [they] want to rather than be told to by the government”. Thus the Public Health Responsibility Deal comes to resemble the perfect example of successful stakeholder marketing: a mutually beneficial relationship between business and policymakers that assumes a consensual foundation – we are all in this together and share the same goals and ambitions. In reality, however, the corporation’s fiduciary imperative gives this the lie: government’s concern is with public interest; the multinational’s is with shareholder return. The suppression of critical thinking The discordance between these two objectives is, at first glance, almost undetectable. For example, one of the ways in which the alcohol industry worked with government to ‘make responsible consumption the right thing to do’ was to introduce lower alcohol by volume (ABV) products on to the market. As alcohol companies get tax breaks on 2.8% or less ABV beers, these are ‘profit-making products’ for industry, and, as one representative noted, it is “a proper win-win for us [industry] and for our customers and it’s something that the government is quite keen for us to be seen to be doing”. If heavy drinkers are indeed turning to lower alcohol – and therefore reduced harm products – then this would be a ‘win’ for public health and industry. However, discussion at the conference showed that this is far from clear, and growing profitability means the move takes on its own momentum:

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‘Are we taking it from higher ABV products? Or are we taking from somewhere else?... It’s really difficult for us now because actually this is a great success, so are we taking kids from Coke and lemonade into this category and is it their stepping stone? Are we taking people who have previously had … a cup of tea?’ This creates genuine concern for the individual, but the systemic pressures to maximise profits are clear: ‘This really is a difficult dilemma but actually we are in a growing category … you then nervously sit there thinking “well I wonder who is drinking it?” … but that is the same as any products … is it 16-year-old kids who want to get into it? Or is it people who currently … you know 25- to 30-year-olds, who are drinking [other products] and we want them to swap?’ The problem is reinforced by consumer marketing, which is driven by customer preferences and sales targets rather than public health priorities: ‘The problem you have as soon as you start marketing something as a low alcohol beer is people won’t buy it because people don’t want a low alcohol beer. You want a beer or you want a coffee…. You don’t want to make people think that they are doing anything other than drinking alcohol, or beer … you are almost going down the route of choice editing actually.’ Meanwhile, the logic of stakeholder marketing, and the perpetual need to maximise shareholder returns, means that this dubiety is hidden from the stakeholder (in this case the UK government), which is effectively told what it wants to hear – that this is ‘absolutely responsible drinking because we have taken the amount of alcohol that you can physically consume out of the market’. The government, having very publicly signed up to joint working has, as much as business, a vested interest in its success. Just as the first victim of war is truth, the first victim of stakeholder marketing is critical analysis.

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Better for business A specific example discussed at the conference graphically illustrates just how great the benefits of successful stakeholder marketing can be for business. The alcohol duty escalator, introduced by the previous UK government, which added inflation plus 2% to the price of all alcohol products, was deeply unpopular with industry. This was abandoned in the 2013 UK budget, and as a result a planned 3p increase in beer duty became a 1p reduction. This, according to an alcohol industry representative, came from four years of marketing to MPs, which involved inviting them to the company, talking through company developments, taking them on tours of local breweries and having regular meetings: ‘There is definitely an element of schmoozing so there is a bit of wining and dining, inviting them along to industry events, big celebrations invite them along to … get the MP to come along and do that handshake-type thing. Give them a photo op – they love that. If there is … a radio programme that wants to do an interview. Give them a profile and make it their story.… And that’s what you want effectively, because you don’t want to be seen to be lobbying … you want lobbying to happen.’ Building strong relationships with influential stakeholders is key for shaping policy, as is evident from this alcohol industry representative’s anecdote: ‘The night before the budget we got a phone call from [a named politician], who has been absolutely amazing in supporting us and supporting this agenda [dropping the duty escalator]. It’s been discussed in the House of Commons … they have had legal debates on it going into the election, [the politician] was lobbying to people so, and low and behold, somewhere around midnight the night before the budget.… I think [the politician] may have had a beer … because there was giggling and shouting and cheering on the phone and [the politician] said “you need to wait and see what’s going to happen today” and the beer duty escalator disappeared.’

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Once again, such immensely successful stakeholder marketing comes fully into its own when combined with effective consumer marketing. A CSR manager explained these two levels: ‘We have a huge arts platform and spend a lot of money preserving arts and things … the arts and philanthropy is where the marketing comes in, it’s where we can get tons of press ... but where we’re really trying to hit, is the stakeholders. And it’s major stakeholders for us like governments, the regulators – it’s the top piece.’ The same sentiment was echoed by an alcohol company executive: ‘CSR is about engaging – it may be NGOs, it may be government, it may be customers at your point of purchase – and it’s actually if you can get all of those lined up then your brand guys do the consumer piece ... it’s up to your brand guys then to deliver it … but actually the business strategy behind it is done for all sorts of different reasons.’ A final phrase points to the underlying driver: “If you are a marketing director or a CEO or a planner even a sustainability manager you have judicial responsibility to generate, to give, best value for your shareholders.” The good cause and the responsibility come second to this fundamental purpose. This contradiction between seeming benevolence and actual selfishness creates strains; as an alcohol company rep pointed out, it is “a bit like the greenwash and finish. You can’t do one thing in isolation.” This makes trust a challenging concept. According to the CEO of a leading consumer product: “Trust is one of those CSR words that everyone bangs on about … [and] there are three ways to build trust: transparency, real choice (not reported choice) and mutual benefit – what’s in it for them is equal to what’s in it for me.” Transparency, informed choice and mutual benefit are attractive qualities, but unlikely to emerge from a system built on double standards; there was certainly little evidence of them in the two examples of the reduced alcohol products and the duty escalator. Nonetheless, the rhetoric is powerful. As one participant put it: “You can have better government if it’s talking to a wide range of stakeholders [including industry] … as long as you’ve got checks and balances and things are completely transparent and lines aren’t crossed.” The problem is that stakeholder marketing replaces checks

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and balances with voluntary codes, introduces opacity by masking motives and blurs the lines. Box 9.4: Stop and think: the role of social marketing Social marketers use their knowledge of marketing to achieve behaviour change, and often a critical examination of the marketing activities of corporate companies is not included in the ‘job specification’ of a social marketer. Based on the discussion in this chapter, do you think critical marketing should be a core part of the social marketing discipline and that social marketers – experts in marketing as applied to complex societal problems – are well placed to hold corporate marketers to account?

Conclusion Consumer marketing builds on a basic contradiction. On the one hand, it lauds consumer sovereignty, choice and service; successful businesses are those that listen to their customers, understand their needs and meet them in the most satisfying way. Marketing activity is devoted to achieving and communicating this purpose. On the other hand, the fiduciary imperative demands that shareholder interests are prioritised. This explains the oxymoron of a tobacco multinational being consummate marketers but also killing one in two of their most loyal customers. Stakeholder marketing is equally conflicted. CSR is not a form of philanthropy but a tool to manage the external threat of regulation and enhance business performance. These double standards are dangerous for three reasons. First, they remain hidden. The seemingly benevolent rhetoric of consumer sovereignty and corporate social responsibility is loud and persistent and effectively drowns out alternate perspectives. The corporate sector has massive resources and these are used to get across this misleading view of the world. Second, they lead to the introduction of terms like ‘relationships’, ‘trust’ and ‘responsibility’, which personalise the issue and make it more difficult to think through the underlying principles. Raising concerns about conflict of interest can come to seem offensive when the people in question are sitting in the same room and sharing the discussion; personable qualities in particular individuals can further muddle thinking (‘Corporate Affairs Director A from company B is such a nice bloke’); and known critics, who are prepared to tread less sensitively on this delicate ground, are likely to be excluded, much as you would not invite known antagonists to a dinner party.

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Third, and most importantly, they disguise the fact that the problems with stakeholder marketing are not personal but systemic. The individuals caught up in it are simply doing what they have to do. The comments from the conference participants about low alcohol products, introduced at the government’s behest to encourage responsible drinking, are that it has become ‘a great success’ and is part of a ‘growing category’ and thereby is co-opted by the company’s core focus on profitability ‘as soon as you start to market something’. This was not a matter of personal integrity, but of a system that is deliberately designed to focus on shareholder value and will always default to this position. Recommendations The implications of CSR being a stakeholder marketing strategy stretch way beyond public health and demand attention across civil society. In essence there is a need for much greater transparency, realism and practical guidance on how to proceed. Above all, it is essential to recognise that corporations are required to focus on shareholder value to the exclusion of all other priorities. This means that they can never be the champions of wider public, community or planetary welfare. Corporate social responsibility is a good thing: companies should be expected to behave to the highest ethical standards. However, its contribution to the commonweal has severe limitations because it will always be servant to the fiduciary imperative. In particular, it can never be allowed to replace statutory provision and regulation on the one hand, or full corporate accountability on the other. So how to proceed? How should public health and others in civil society engage with the corporate sector? In 2007, WHO addressed this problem with particular reference to the alcohol market. It concluded that it should ‘continue its practice of no collaboration with the various sectors of the alcohol industry. Any interaction should be confined to discussion of the contribution the alcohol industry can make to the reduction of alcohol-related harm only in the context of their roles as producers, distributors and marketers of alcohol, and not in terms of alcohol policy development or health promotion’ (WHO, 2007, p 48). The WHO position has three great strengths: it recognises the reality of the corporate sector’s existence; that its expertise and contribution is necessarily limited to its business activities; and that these activities sometimes harm public health. In short, it echoes the Friedman quote with which this chapter began: the business of business is business. And by extension it demonstrates that the job of safeguarding public health

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and wider human welfare falls not to business, but to government, civil society and citizens. The extent to which we confuse these realities is the extent to which the commonweal will be damaged. End-of-chapter questions • The UK government thought it would help public health if more low alcohol beers were produced. How did the discussions at the conference suggest this might backfire? To what extent do conflicts of interest explain these dangers? • Why is CSR an oxymoron? Discuss from the perspective of consumer and stakeholder marketing. • If you were the CEO of Diageo, why might you invest in CSR? • When Andrew Lansley became UK Minister of Health in 2010, he announced that the food and drinks industries would be become part of the public health solution through what he terms ‘Responsibility Deals’. Find out what you can about these and discuss whether or not they succeeded. • Read Christian Aid (2004) ‘Behind the mask: the real face of corporate social responsibility’, www.st-andrews.ac.uk /media/csear/app2practice-docs/ CSEAR_behind-the-mask.pdf. Discuss the pros and cons of CSR as used by Shell in the Niger Delta.

Notes See www.huff ingtonpost.com/2014/03/24/exxon-valdez-oil-spillphotos_n_5020845.html 1

2

See www.conorburns.com/news/tesco-computers-schools

References Adkins, S. (2003) ‘Cause-related marketing: who cares wins’, in M.J. Baker (ed) The marketing book (5th edn), Oxford: ButterworthHeinemann. Amnesty International and CEHRD (Centre for Environment, Human Rights and Development) (2011) The true ‘tragedy’: Delays and failures in tackling oil spills in the Niger Delta, London: Amnesty International. Anderson, P., de Bruijn, A., Angus, K., Gordon, R. and Hastings, G. (2009) ‘Impact of alcohol advertising and media exposure on adolescent alcohol use: a systematic review of longitudinal studies’, Alcohol Alcoholism, 44: 229-43. Bakan, J. (2004) The corporation: The pathological pursuit of profit and power, Toronto: The Penguin Group (Canada). Baker, M.J. (ed) (2003) The marketing book (5th edn), Oxford: Butterworth-Heinemann.

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Cairns, G., Angus, K. and Hastings, G. (2008) The extent, nature and effects of food promotion to children: A review of the evidence to December 2008, Geneva: WHO. Christian Aid (2004) ‘Behind the mask: the real face of corporate social responsibility’, https://www.st-andrews.ac.uk/media/csear/ app2practice-docs/CSEAR_behind-the-mask.pdf Cutler, A.C., Haufler, V. and Porter, T. (eds) (1999) Private authority and international affairs, New York, NY: State University of New York Press. Dorfman, L. (2000) ‘Philip Morr is Puts Up Good Citizen Smokescreen’, AlterNet, 26 November, http://www.alternet.org/ story/10129/philip_morris_puts_up_good_citizen_smokescreen Eberlein, B. and Kerwer, D. (2002), ‘Theorising the new modes of European Union governance’, European Integration online Papers (EIoP), 6. Garsten, C. and Jacobsson, K. (2013) ‘Post-political regulation: soft power and post-political visions in global governance’, Critical Sociology, 39(3): 421-37. Hall, R.B. and Biersteker, T. (2002) The emergence of private authority in global governance, Cambridge: Cambridge University Press. Hastings, G. and Angus, K. (2004) ‘The influence of the tobacco industry on European tobacco-control policy’, in  The ASPECT consortium, tobacco or health in the European Union past, present and future, prepared with financing from the EC Directorate-General for Health and Consumer Protection, Luxembourg: Office for Official Publications of the European Communities.  Hastings, G., De Andrade, M. and Moodie, C. (2012) ‘Tobacco harm reduction: the devil is in the deployment’, British Medical Journal, 345: e8412. Heritier, A. (2001) ‘New modes of governance in Europe: policy making without legislating?’, in A. Heritier (ed) Common goods: Reinventing European and international governance, Lanham: Rowman and Littlefield, pp 85-104. Jenkins, R. (2005) ‘Globalization, corporate social responsibility and poverty’, International Affairs, 81(3): 525-40. Lovato, C., Linn, G., Stead, L.F. and Best, A. (2003) ‘Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours’, Cochrane Database Systematic Review, 4: CD003439. Lukes, S. (2005) ‘Power and the battle for hearts and minds’, Millennium: Journal of International Studies, 33(3): 477-93. McCambridge, J., Kypri, K., Miller, P., Hawkins, B. and Hastings, G. (2014) ‘Be aware of Drinkaware addiction’, Addiction, 109(4): 519-24.

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McHenry, L. (2009) ‘Ghosts in the machine: comment on Sismondo’, Social Studies of Science, 39(6): 943-7. Morth, U. (2006) ‘Soft regulation and global democracy’, in M.L. Djelic and K. Sahlin-Andresson (eds) Transnational governance. Institutional dynamics of regulation, Cambridge: Cambridge University Press, pp 119-35. Morth, U. (ed) (2004) Soft law in governance and regulation: An interdisciplinary analysis, Cheltenham: Edward Elgar. Moss, M. (2013) Salt, sugar, fat: How the food giants hooked us, London: Random House. Mouffe, C. (1993) The return of the political, London: Verso. Nader, L. (1990) Harmony ideology : justice and control in a Zapotec mountain village, Palo Alto, CA: Stanford University Press. Nye, J.S. (2004) Soft power: The means to succeed in world politics, New York, NY: Public Affairs. Peters, B.G. and Pierre, J. (1998) ‘Governance without government? Rethinking public administration’, Journal of Public Administration Research and Theory, 8(2): 223-43. Rowley, E. (2011) ‘Never mind the Euro bailout, worry about growth, says Shell’, The Telegraph, 27 October, www.telegraph.co.uk/finance/ newsbysector/energy/oilandgas/8852496/Never-mind-the-eurobailout-worry-about-growth-says-Shell.html Save the Children and CORE (Corporate Responsibility Coalition) (2007) ‘Why corporate social responsibility is failing children’, London: Save the Children and CORE, www.savethechildren.org. uk/sites/default/files/docs/Why_CSR_is_failing_children_1.pdf Scott, C. (2004) ‘Regulation in the age of governance: the rise of the post-regulatory state’, in J. Jordana and D. Levi-Faur (eds) The politics of regulation, Cheltenham: Edward Elgar, pp 145-74. Shelton, D. (ed) (2000) Commitment and compliance. The role of nonbinding norms in the international legal system, Oxford: Oxford University Press. Vidal, J. (2013) ‘Niger Delta oil spill victims reject “derisory” Shell compensation offer’, The Guardian, 13 September, www.theguardian. com/global-development/2013/sep/13/niger-delta-oil-shellcompensation WHO (World Health Organization) (2007) Expert Committee on Problems Related to Alcohol Consumption, Second Report, WHO: Geneva. Worth, J. (2007) ‘Corporate responsibility: companies who care?’, New Internationalist, Dec: 5-6.

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Participation in behaviour change: technique or tyranny? Katie Collins

Introduction Others doubtless wrote them off as anonymous benefit mums. But they’ve shown themselves to be articulate, successful activists. They were once treated as a problem, to be shuttled between temporary accommodation; now they’re pushing solutions to the real issue. (Chakrabortty, 2014) ‘Focus E15’ is a group of 29 young single mothers, many of them teenagers. In 2013, they were told they faced eviction from the hostel in which they lived and advised to look for cheaper accommodation in other cities, away from friends and family (Butler, 2013). At first they did what the council suggested, registering as homeless and looking for alternative accommodation, but with no success. So instead of moving away from London, where they had always lived and where their support networks were, they began a campaign, launched from a market stall. They stormed council offices and held a party in one of the show flats owned by the housing association that was evicting them. More recently, Focus E15 has taken over abandoned housing near the Olympic Village in East London, converting a building, which was still connected to utilities with working appliances, into a social centre with toys and food on offer to those who need them. It is from here that the group continues to run its campaign for access to good-quality social housing for all who need it. The campaign has garnered support from celebrities like Russell Brand, who featured it on his daily social media-based news channel The Trews in 2014. More recently, Focus E15 has begun to encourage people to contact their MP in support of the campaign, and this plea is being shared widely on social media. Behaviour change experts are beginning to ask whether – and how – it might be possible to encourage people to take the initiative in this

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way, to come together to tackle challenging issues like obesity in their communities, or risky drinking, or speeding. Consequently, terms like ‘co-creation’ and ‘participation’ have started to become buzz words in behaviour change, albeit that there are myriad interpretations of what these terms might mean. Participatory approaches have an impressive pedigree in disciplines like health promotion (Minkler and Cox, 1980), education (Kemmis and McTaggart, 2005), design (Sanders and Stappers, 2008), community development (Fals-Borda and Rahman, 1991) and even theology (Berryman, 1987). At core, they are underpinned by a simple idea: rather than developing an intervention (or research or product or policy or service) separately from the people involved, the intervention is openly developed with them, treating them as partners in the process, not passive recipients. The benefits are thought to be both practical and political: practical because such an approach allows for specific and local insights to be incorporated in an intervention, perhaps making it more likely to be effective; and political because it is an opportunity to reflect on (and hopefully challenge) oppressive power dynamics, even injustices, involved in top-down interventions. Indeed, it is reasonable to assume that most people would prefer to be involved in decisions that affect them, in most situations. Of course, there are exceptions. But despite this affinity we have with approaches that appeal to our instinctive preference for democracy and fairness, I think it would be a mistake to assume that all co-creative interventions are therefore inherently better, or more ethical, than top-down interventions simply because they involve participation in some form. The question that underpins this chapter is therefore not how participatory approaches might help behaviour change practitioners tackle issues like obesity or climate change, but whether the approach should be used at all and, if so, under what conditions. Or is attempting to recreate activist-led campaigns like Focus E15, without agitating for systemic change at the same time, simply contributing to social and economic inequality? The chapter begins with a theoretical overview of the landscape of participation, concerned primarily with ethical and political matters rather than the mechanics of running a participatory project. It concludes by exploring the ways in which participatory and co-creative methods might come to be part of the behaviour change canon in a way that is transformative rather than tyrannical.

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The language of ‘co’ A useful starting point is to explore the many different terms used to describe interventions designed with rather than for people, such as ‘co-created’, ‘co-designed’, ‘co-produced’ and ‘participatory’. These are all terms that frequently crop up in the literature, but this is an area that could benefit from some clarification. The term ‘co-creation’ has become strongly associated with value co-creation theory in business (Prahalad and Ramaswamy, 2004; Vargo and Lusch, 2004). Founded in the recognition of what proponents call a more comprehensive and inclusive logic for marketing (Ferreira and Proenca, 2009), value co-creation actually has more to do with an alternative theoretical conception of how various resources, including those provided by the customer, are combined to create value than with any sort of social intervention design. Another perspective on co-creation from consumer research draws on the observation that the past two decades of marketing thought have been characterised by a subtle shift in the way consumers are conceptualised. From passive entities that sit patiently at the end of the value chain (Pongsakornrungsilp and Schroeder, 2011), consumers have been recast as active agents that resist efforts to ‘constrain, control and manipulate them’ (Gabriel and Lang, 2008, p 334). This has been described as a profound transformation in the producer–consumer relationship (Pettinger, 2004; Arvidsson, 2005), from producer-recipient to collaborating partner (Wikström, 1996). Thus, co-creation (same term, somewhat different interpretation) is also thought to be a necessary response to the challenges of sophisticated and demanding customers who resist categorisation and control (Holt, 2002; Fırat and Dholakia, 2006). In extending this argument, some scholars have assigned to co-creation an ideological mantle; by characterising consumers as creative collaborators, they become empowered to seek self-fulfilment through their labour and to create value that would otherwise go unrealised (Bonsu and Darmody, 2008). This interpretation of co-creation is less about a theory of how value is realised via resource integration, and more about an assumption that the traditional balance of power between an organisation and its consumers is shifting. For designers and artists, the term co-creation has more in common with this interpretation, characterised by Sanders and Stappers (2008, p 6) as ‘collective creativity’ that can be applied in a vast number of contexts, ‘from the physical to the metaphysical and from the material to the spiritual’. The various co-creative interpretations in design, such as interaction design (Moggridge and Atkinson, 2007), service design (Sangiorgi,

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2011) and transformation design (Burns et al, 2006) have been characterised as part of an overall movement away from the design of products (architecture, interior, communication) and towards design for a purpose (experience, interaction, emotion) (Sanders and Stappers, 2008). The literature on transformation and service design draws on work on co-creation in business and organisation studies outlined previously (Junginger, 2008; Junginger and Sangiorgi, 2009), but design theorists are also forging new links with ideas from social innovation (Cottam and Leadbeater, 2004; Manzini, 2008) and cementing old ones with the public sector (Thackara, 2007). Co-production is one such idea with a significant heritage of its own, which also has some parallels with Bonsu and Darmody’s (2008) conceptualisation of consumers seeking self-fulfilment through labour. Co-production, however, places a stronger emphasis on challenging consumerism, emphasising social justice and the core economy (Coote and Goodwin, 2010), defined as ‘a particular way of getting things done, where the people who are currently described as “providers” and “users” work together in an equal and reciprocal partnership, pooling different kinds of knowledge and skill. Co-production draws upon a long history of self-help, mutual aid and participative local action’ (p 6). This is quite a tangled web of terminology and ideas, all underpinned to a greater or lesser extent by the notion of ‘participation’, which also seems to be the preferred term in research, in politics and in the international development literature. The word participation often signifies a step back, both in time and from the nitty gritty of technique, as the next section explains.

Participation’s radical heritage To understand participation as a behaviour change technique, it is helpful to understand something of its heritage. Participatory research (also known as participatory action research) is often traced back to the critical pedagogy movement spearheaded by philosopher-activists Paulo Freire, Myles Horton and Julius Nyerere (Tandon, 2008). Probably the best known pioneer is Paulo Freire (1921-97), who was born in the Brazilian city of Recife to a middle-class family that was soon to experience first hand the ‘plight of the wretched of the earth’ as a result of the economic crisis of 1929 (Shaull, 2005, p 30). This experience is thought to have had a profound influence on Freire, helping him to see that the dispossessed existed in a culture of hopelessness and silence, in which a critical response was impossible. In his early 20s, Freire studied law and philosophy in Recife, taught in secondary schools for a while,

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and, in 1946, started work for SESI (Serviço Social da Indústria), a nonprofit organisation promoting the welfare of workers. His experiences there are thought to be a significant turning point in the development of his theories: first, in understanding the way that oppressed groups learned about their world in their own language, ‘the language of the people’ (Freire, 2000, p 96), and second, in appreciating the value of learning through practice. In the late 1950s and early 1960s, Freire’s concern as Professor of Educational Philosophy and director of the Social Outreach Program at the University of Recife was to inspire his students to learn the language of the people, enabling them to conduct research in the service of social change, rather than working as ‘instruments of the reproduction of inequality’ (Lownds, 2005, p 45). Freire and his students used ‘culture circles’ (1973, p 81), in which themes like nationalism, democracy and illiteracy were discussed. Later, he adopted the same basic method for teaching adults to read in Recife. In 1962, Brazilian president João Goulart sanctioned Freire’s method officially, but in 1964, a coup toppled the progressive Goulart regime and Freire, along with many other left-wing intellectuals, became an enemy of the state. Military police confiscated Freire’s slide projectors housed in the Brasiliana library, and burned them along with the paintings that had been used as visual aids. Freire spent over a month in prison courtesy of the new regime, followed by 16 years of exile, during which he taught at Harvard University, only returning to Brazil in 1980 (Lownds, 2005). During his exile, he wrote his most wellknown book, Pedagogy of the oppressed, which set out the foundations of his philosophy: the notion that people are incomplete beings, but that each individual has the ability to become fully humanised through critical reflection and dialogue and thus transform the world. He distinguishes between the oppressors and the oppressed, but rather than condemning the oppressors he regards both as victims of a dehumanising and unjust social order. According to Diaz-Greenberg et al (2000), this radical interpretation of participation happens through dialogue and dialectic, which are about creating a ‘space’ for understanding one’s own voice, being willing to listen, and thus developing an awareness of one’s own point of view and its opposite. This radical heritage, based on empathy for what it feels like (or might feel like) to be excluded or oppressed, acts as a reminder of what truly participatory work is supposed to be. It is about taking a very critical perspective on the power dynamics of a situation and attempting to work in a way that aims to allow participants to develop their own voice, to create their own knowledge judged by the criteria that they think are important. True participatory approaches regard

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participants as working at the forefront of social action, rather than complex mechanical objects to be broken down, understood and put back together again with slightly different behavioural patterns. This begs the question of whether participation and ‘behaviour change’ are compatible at all, or whether their foundational principles are in fact opposed. The next section explains why this question is so significant.

The landscape of participation Tandon (2008) situates the emergence of formal participatory approaches in international development in a broad socio-historical context, beginning with what he calls ‘subaltern practices of community organising’ (p 285) expressed through art, music, poetry and drama. He directs our attention to the philosophies of Gurus Nanak and Kabir, the latter whose writing is thought to have particular resonance with oppressed peoples, as a ‘protest against social discrimination and economic exploitation’ (Lorenzen, 1991, p 5). In the late 1960s and 1970s, inspired by the work of Freire and his colleagues, international development organisations began to wake up to the potential of subaltern activities, prompted by mounting concern over the exploitativeness (both politically and in terms of natural resources) of the ‘top-down’ development model. What has been called the ‘language of democracy’ (White, 1996, p 6) began to dominate, leading to an emphasis on participation at the level of individual projects. But while the adoption of more participatory development policies appears on the surface to be a good thing, there were (and remain) concerns that the language of participation failed to match up to the practice. Rather than a genuine sharing of power, it was feared that many participatory initiatives simply represented a change in tactic: instead of seeking control by excluding people, it was argued, participatory approaches sought control by incorporating them (White, 1996) as the following example shows: The Bangladeshi NGO leaders are in a dilemma. They are unhappy with the official agencies’ new plan. Neither social nor environmental questions have been given the consideration they deserve. As happens more and more often, they have been invited to attend a meeting to discuss the plan. Flattered at first by official recognition, they are now uneasy. If they do not go, they have no grounds to complain that the interests of the poor have been ignored. But if they go, what guarantee do they have that their

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concerns will really be heard? Too many times they have seen their discussions drain away into the sand. The plans are left untouched; but their names remain, like a residue, in the list of ‘experts’ whose opinions the scheme reflects. (White, 1996, p 6) In 2001, a book called Participation: The new tyranny? was published, edited by academics Bill Cooke and Uma Kothari. The publication was described as the first to address ‘the gulf between the almost universally fashionable rhetoric of participation, which promises empowerment and appropriate development on the one hand, and what actually happens …’. It was critical, with examples of ritualistic participation undertaken mostly for show or that turned out to be harmful. One of the problems discussed during this ‘backlash’ was the way in which participation had evolved from a revolutionary attempt to encourage popular agency (as envisaged by Freire and other radicals) to a technical, depoliticised process. In essence, this critique is founded on the way that participatory methods have been used, rather than their underlying theory. It recognises first that anyone can use participatory techniques and in so doing has the opportunity to co-opt the moral legitimacy of their heritage; and second, that even if well-intentioned and critically sensitive people adopt a participatory approach, who is to say that their work is not inadvertently oppressive in itself, perhaps because they are unaware of the power dynamics that might be influencing their relations with the other participants? Cooke (2004, p 47) uses the example of the World Bank to show how influential organisations can adopt participatory methods and rhetoric and thus benefit from the power of that discourse, without actually changing anything substantive about the underlying structures: Greater impact on people’s empowerment – in terms of, say their right to life through healthcare, water and education – is made by decisions taken by the Bank and the IMF on debt repayment than can be made by an infinity of face-toface participatory events which have no power over debt. Cooke’s point is that participatory methods can be seen as a way of legitimising the bank’s promotion of its ideology and further, that practitioners of participatory methods who go along with such agendas are complicit in the continued oppression, even suffering, that results.

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Other criticisms of participation emerging from development studies are listed in Box 10.1. Box 10.1: Stop and think: criticisms of participatory methods • A form of methodological hierarchy has been created, with participatory methods at the top (see also Elliott, 2005). • These methods might encourage outsiders to frame people as ‘oppressed’, which means they are cast as subjects requiring intervention who need to ‘perform’ appropriately (Cornwall and Brock, 2005). • While participation is supposed to challenge the power of a remote ‘expert’, there is the risk that the power is not challenged, but simply reformulated from ‘subject expert’ to ‘process expert’ (Mohan, 2006). • There is the danger that an overly simplistic conception by outsiders of what ‘local knowledge’ means will simply strengthen existing power structures, rather than challenge them (Mosse, 1994; Cooke and Kothari, 2001; Sanderson and Kindon, 2004). For these reasons, some commentators argue that participatory methods are not really so different from other, more conventional exercises of power, and therefore they should be resisted (Kothari, 2001; Kapoor, 2005).

Despite these criticisms, Kindon and colleagues (2007) argue for a more moderate perspective. They acknowledge that participation, like any other method, can be used in ways that are oppressive and ways that are not, and suggest that the effects of participation can be different depending on who is deploying the resources. They also point out that there is a difference between power (which can be used for good) and domination (which is more about control and self-interest). Drawing on Allen’s (2008) identification of power’s modalities, they explain that domination might occur when the leaders of a participatory process imposes a particular way of representing local knowledge or manipulate group dynamics to achieve the outcomes they wish to see (Alexander et al, 2007). However, despite the more optimistic perspectives that have emerged from the critique, there is a concern that there are parallels between the early parts of the story of participation and the current field of behaviour change, in which ‘participation’ or ‘co-creation’ have become buzz phrases (see, for example, Desai, 2009; Lawson and Flocke, 2009). Practitioners have noted the capacity that participatory methods have to help design effective interventions and undoubtedly there is an appeal to the democratic principles that participatory approaches seem to embody. But given the critique presented so far in this chapter, what

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can we do, if anything, if we want to use participatory methods in a way that is ethical and fair? The next section explores different ways of conceptualising and categorising forms of participation, as a step towards resolving this dilemma.

Evolution or liberation? Participatory approaches are used on a sliding scale, from consulting on aspects of implementation through to methods that combine the skills of people running the intervention ‘with the knowledge of the researched or grassroots communities, taking them as full partners’ (Fals-Borda, 1995, p 1). A starting point for explaining the difference between these two ends of the scale can be found in the way the word ‘intervention’ is used. For behaviour changers in health service provision, an intervention is very close to its dictionary definition: justifiable interference in someone’s life with a desire to change something for the better. In other words, this kind of intervention seeks evolution within the current system. However, in the language of participatory research, an intervention is an aspiration for radical changes in society; in areas like social and economic structures, employment rights and rights more broadly to property, education and health. These kinds of ‘intervention’ also seek to defy ‘the reactionary position whose aim is to immobilize history and maintain an unjust socio-economic and cultural order’ (Freire, 2000, p 6), thus challenging the system by raising the consciousness of those involved. In this tradition, then, people who are economically disadvantaged or socially excluded (quite often the primary targets of behaviour change programmes) are not thought of as individuals whose behaviour is a problem for themselves – and for society – and who need to change; they are thought of as oppressed groups who are disadvantaged and excluded, even dehumanised, because our social system is unjust and exploitative in some way. Thus forms of participation in this tradition seek liberation from, rather than evolution of, current social and economic structures and differ markedly from traditionally applied behaviour change approaches (such as those explored in Chapter Two) that aim to mobilise individuals to create a change to their own behaviour in some way, such as by giving up smoking, regulating their eating or doing more exercise. The idea that there are more and less radical interpretations of participation is not new and there are various models that attempt to categorise the different sorts, like Arnstein’s ladder (1969) or Pretty’s typology (1995). Both of these have been described as normative (Cornwall, 2008); that is, they imply that there are ‘good’ and ‘bad’

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ways to use participation. White’s typology (1996) on the other hand, is more neutral about the types of participation that exist, ranging from nominal participation, which serves the purpose of including marginalised groups but often merely serves the function of display or performance, through to transformative participation, which leads to consciousness raising and empowerment. A particularly enlightening analytical tool is Arnstein’s ladder, as shown and annotated in Table 10.1. Table 10.1: Ladder of participation Ladder position

Type of participation

Note and examples

1 (bottom)

Manipulation

People are placed on rubberstamp advisory committees or advisory boards for the express purpose of ‘educating’ them or engineering their support. Instead of genuine citizen participation, the bottom rung of the ladder signifies the distortion of participation into a public relations vehicle by powerholders.

2

Therapy

Under a masquerade of involving citizens in planning, the experts subject the citizens to clinical group therapy. Citizens are engaged in extensive activity, but the focus is on ‘curing’ them of their ‘pathology’ rather than challenging the system that helps create their ‘pathologies’.

3

Informing

Informing citizens of their rights, responsibilities and options can be the most important first step toward legitimate citizen participation. However, too frequently the emphasis is placed on a one-way flow of information – from officials to citizens – with no channel provided for feedback and no power for negotiation.

4

Consultation

Inviting citizens’ opinions, like informing them, can be a legitimate step toward their full participation. However, if consulting them is not combined with other modes of participation, this rung of the ladder can be a sham since it offers no assurance that citizen concerns and ideas will be taken into account. The most frequent methods used for consulting people are attitude surveys, neighbourhood meetings and public hearings.

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Placation

It is at this level that citizens begin to have some degree of influence, though tokenism is still apparent. An example of placation strategy is to place a few hand-picked, ‘worthy’, poor on public bodies like a board of education, police commission, or housing authority. If they are not accountable to a constituency in the community and if the traditional power elite hold the majority of seats, the have-nots can be easily outvoted and outfoxed.

6

Partnership

At this rung of the ladder, power is in fact redistributed through negotiation between citizens and powerholders. They agree to share planning and decision-making responsibilities through such structures as joint policy boards, planning committees and mechanisms for resolving impasses. After the ground rules have been established through some form of give and take, they are not subject to unilateral change.

7

Delegated power

Negotiations between citizens and public officials can also result in citizens achieving dominant decisionmaking authority over a particular plan or program. At this level, the ladder has been scaled to the point where citizens hold the significant cards to assure accountability of the program to them. To resolve differences, powerholders need to start the bargaining process rather than respond to pressure from the other end.

8 (top)

Citizen control

Citizens have that degree of power (or control) which guarantees that participants or residents can govern a programme or an institution, be in full charge of policy and managerial aspects, and be able to negotiate the conditions under which ‘outsiders’ may change them.

Source: Arnstein (1969, p 217).

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Box 10.2: Stop and think: participation in public health The challenge with more radical forms of participation for liberation (that is, those at the top of the ladder in Table 10.1) is that in areas like public health, experts frequently do know what the required ‘outcomes’ ought to be, and they do know how these ought to be measured. So, if we are going to avoid being well-meaning tyrants attempting to create a cardboard cut-out co-option of the sort of citizencontrolled participatory movement typified by Focus E15, does that mean we have to ignore the expert knowledge and high-quality research that guides the selection of particular outcomes and methods in disciplines like public health? And if we cannot ignore the expert guidance, is well-meaning tyranny inevitable with any participation initiated within a behaviour change framework? Should we simply avoid it, in that case? This is very destabilising territory.

Using participatory methods It may still be the case that practitioners find the reflections on politics, ethics and language presented in this chapter very interesting, but as long as an intervention works, they are less concerned with the possibility of co-opting a radical heritage. What does it matter if a participatory approach manipulates people into believing they have participated fully when outcomes or ‘behavioural goals’ are achieved? It feels like a difficult tightrope on which to balance. Box 10.3 outlines the benefits and pitfalls of participatory approaches in behaviour change, with the caution that the very things that make participatory methods attractive also make them risky: Box 10.3: Participatory methods in practice On the bright side, participatory methods can: • Give marginalised people a voice by working hard to find ways to include in the process even the most excluded of individuals. • Create enthusiasm and build capacity by giving the people involved genuine opportunities and resources to effect the changes they believe are needed. • Build trust between stakeholders. Especially with marginalised groups, there can be reservations on both sides, and a real participatory process can build bridges. • Help design interventions that meet people’s needs, especially if those needs are likely to be local and specific. • Sensitise researchers (or those initiating projects if not research) to a range of ethical issues, as well as factors like positionality and representation.

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Participation in behaviour change • Encourage empathy and understanding of the whole person, rather than risk creating a one-dimensional picture based on a few behavioural and demographic variables. • Help bring to light structural problems as well as issues with individual behaviour, and provide opportunities to start challenging the system. • Draw on resources in the core economy, thus making fewer demands on a shrinking public purse. • Participatory methods can also: • Allow relatively powerful stakeholders to speak for those who are more excluded, which can further particular agendas, creating tension and maybe making problems worse. • Co-opt participatory rhetoric – that moral stamp of approval – to bring in measures that are not what the people involved would have wanted but are harder to argue against because ‘they participated’. • Let people down and make them feel their efforts were wasted, probably contributing to the original problem and creating some new ones as well. • Betray trust, contributing to exclusion, entrenching existing problems and making it even harder for other people wanting to make things better to overcome these initial barriers. • Ways to increase the chances of ‘doing participation’ successfully and without causing harm: • Recognise that genuine participation requires stakeholders, funders and experts to give up the control that they normally would have over the process and outcomes. • Build in budget and time to give proper feedback to participants and listen to their views. It may not be realistic to promise full participation. Honesty about what is negotiable and what you will retain control over is vital. • Be aware that participation involves some risk. This might be personal risk, for example, in projects involving challenging topics, excluded people or in unsafe locations, but also financial and professional risk, because commissioning systems are often set up to prioritise outcomes and conventional measures, which can be a poor fit with participatory working. • Remember that participation is a social process, not a scientific one. You will not be remote from people’s lives; you will look into their eyes as they tell you their difficult stories. You will be aware that you are making promises to people and if you do not (or are unable to) keep them, it will feel like breaking a promise to a colleague or friend. Participation is emotional as well as practical and intellectual work. • Plan for the end of your process. Who will run things in the long term? How will the initiative be funded? Who will care about it in the future? It is extremely rare for volunteers to continue without at least some support.

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Beyond behaviour change • Be aware of the distinct ethical challenges and incorporate these into the design of the process as far as possible. Keep reviewing the project from an ethical perspective, and make changes where needed. The most important thing to keep in mind is that while a participatory project might be your project, it is the participant’s life. Unlike you, participants do not go home at the end of the day; the issues are with them all the time.

Conclusion It has been discussed that participatory approaches are popular in behaviour change work, which is logical given the seeming political and practical benefits. However, when we strip ‘participation’ back to its core tenets, as this chapter has done, perhaps the conclusion to draw is that behaviour change and participation – at least in the transformatory image created by Freire and his advocates – might be philosophically incompatible. At core, behaviour change appears to be founded on the principle that the current social system we have is broadly acceptable, notwithstanding some challenges that can be met largely by individuals changing their consumption habits and lifestyles, assisted by advances in knowledge and technology. By contrast, the participatory philosophies developed by Freire and other radicals hold that the current social system is not acceptable, because it consists of oppressors and oppressed, haves and have-nots. Consequently, this chapter represents the beginning of a critical conversation about participation and behaviour change, rather than a definitive attempt to sketch out various participatory techniques for behaviour changers to deploy, uncritically. It forms part of a series of chapters in this volume (that is, Chapters Nine to Thirteen) that turn traditional thinking about behaviour change on its head and question (and in some cases present mechanisms for changing) the underlying systems and structures in which individuals live their lives.

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End-of-chapter questions • Do you think that we need evolutionary (broadly in keeping with current social systems) or revolutionary (challenging the current system) approaches to the complex health, environmental and social challenges we face? • Do you think that participatory methods and the more conventional, evidencebased behaviour change methods are compatible? If so, how? If not, why not? • What do you see as the key ethical challenges of attempting to change individual behaviour in general, and what difference might participatory methods make?

References Alexander, C., Beale, N., Kesby, M., Kindon, S., Macmillan, J., Pain, R. and Zeigler, F. (2007) ‘Participatory diagramming: a critical view from North East England’, in S. Kindon, R. Pain and M. Kesby (eds) Participatory action research approaches and methods: Connecting people, participation and place, London: Routledge, pp 112-21. Allen, J. (2008) Lost geographies of power, Oxford: Blackwell. Arnstein, S.R. (1969) ‘A Ladder of Citizen Participation’, Journal of the American Institute of planners, 35: 216-224, http://lithgow-schmidt. dk/sherry-arnstein/ladder-of-citizen-participation.html Arvidsson, A. (2005) ‘Brands: a critical perspective’, Journal of Consumer Culture, 5(2): 235-58. Berryman, P. (1987) Liberation theology: Essential facts about the revolutionary movement in Latin America and beyond. Philadelphia, PA: Temple University Press. Bonsu, S.K. and Darmody, A. (2008) ‘Co-creating second life: Market–consumer cooperation in contemporary economy’, Journal of Macromarketing, 28: 355-68. Burns, C., Cottam, H., Vanstone, C. and Winhall, J. (2006) RED paper 02: Transformation design, London: Design Council. Butler, P. (2013) ‘Young mothers evicted from London hostel may be rehoused 200 miles away’, The Guardian, 14 October. Chakrabortty, A. (2014) ‘For real politics, don’t look to parliament but to an empty London housing estate’, The Guardian, 23 September. Cooke, B. (2004) ‘Rules of thumb for participatory change agents’, in S. Hickey, and G. Mohan (eds) Participation: From tyranny to transformation? Exploring new approaches to participation in development, London: Zed Books, pp 47-61. Cooke, B. and Kothari, U. (2001) Participation: The new tyranny?, London: Zed Books. Coote, A. and Goodwin, N. (2010) The Great Transition: Social justice and the core economy, London: New Economics Foundation.

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Cornwall, A. (2008) ‘Unpacking ‘Participation’: models, meanings and practices’, Community Development Journal, 43(3): 269-83. Cornwall, A. and Brock, K. (2005) ‘What do buzzwords do for development policy? A critical look at ‘”participation”, “empowerment” and “poverty reduction”’, Third World Quarterly, 26(7): 1043-60. Cottam, H. and Leadbeater, C. (2004) RED paper 01: Health: Cocreating services, London: Design Council. Desai, D. (2009) ‘Role of relationship management and value cocreation in social marketing’, Social Marketing Quarterly, 15: 112-25. Diaz-Greenberg, R., Thousand, J., Cardelle-Elawar, M. and Nevin, A. (2000) ‘What teachers need to know about the struggle for selfdetermination (conscientization) and self-regulation: adults with disabilities speak about their education experiences’, Teaching and Teacher Education, 16: 873-87. Elliott, J. (2005) ‘Becoming critical: the failure to connect’, Educational Action Research, 13(3). Fals-Borda, O. (1995) ‘Research for social justice: some North-South convergences’, Plenary Address at the Southern Sociological Society Meeting. Atlanta. Fals-Borda, O. and Rahman, M.A. (1991) Action and knowledge: Breaking the monopoly with participatory action research, London: Intermediate Technology Publications. Ferreira, F. and Proenca, J. (2009) ‘Confronting the IMP network approach and the S-D logic of marketing’, Forum on Service, Naples: University of Naples. Fırat, A.F. and Dholakia, N. (2006) ‘Theoretical and philosophical implications of postmodern debates: some challenges to modern marketing’, Marketing Theory, 6(2): 123-62. Freire, P. (1973) Education for critical consciousness, New York, NY: Seabury. Freire, P. (2000) Pedagogy of the oppressed, London: Continuum International. Gabriel, Y. and Lang, T. (2008) ‘New faces and new masks of today’s consumer’, Journal of Consumer Culture, 8(3): 321-40. Holt, D.B. (2002) ‘Why do brands cause trouble? A dialectical theory of consumer culture and branding’, Journal of Consumer Research, 29(1): 70-90. Junginger, S. (2008) ‘Product development as a vehicle for organizational change’, Design Issues, 24(1): 26-35.

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Junginger, S. and Sangiorgi, D. (2009) ‘Service design and organisational change: bridging the gap between rigour and relevance’, 3rd IASDR Conference on Design Research, Seoul: Korean Society of Design Science, pp 4339-48. Kapoor, I. (2005) ‘Participatory development, complicity and desire’, Third World Quarterly, 26(8): 1203-20. Kemmis, S. and McTaggart, R. (2005) ‘Participatory action research’, in N.K. Denzin and Y.S. Lincoln (eds), The Sage handbook of qualitative research, (3rd edn), London: Sage Publications Inc, pp 559-605. Kindon, S., Pain, R. and Kesby, M. (2007) ‘Participatory action research: origins, approaches and methods’, in S. Kindon, R. Pain and M. Kesby (eds) Participatory action research approaches and methods, Abingdon: Routledge, pp 10-18. Kothari, U. (2001) ‘Power, knowledge and social control in participatory development’, in B. Cook and U. Kothari (eds) Participation: The new tyranny?, London: Zed Books, pp 139-52. Lawson, P.J. and Flocke, S.A. (2009) ‘Teachable moments for health behavior change: a concept analysis’, Patient Education and Counseling, 76(1): 25-30. Lorenzen, D. (1991) Kabir legends and Ananta-Das’s Kabir Parachai, Albany, NY: SUNY Press. Lownds, P. (2005) ‘In the shadow of Freire: popular educators and Literacy in Northeast Brazil’, Doctoral dissertation, University of California. Manzini, E. (2008) ‘Collaborative organisations and enabling solutions. Social innovation and design for sustainability’, in F. Jegou and E. Manzini (eds) Collaborative services. Social innovation and design for sustainability, Milan: Edizioni Polidesign, pp 29-41. Minkler, M. and Cox, K. (1980) ‘Creating critical consciousness in health: applications of Freire’s philosophy and methods to the health care setting’, International Journal of Health Services, 10(2): 311-22. Moggridge, B. and Atkinson, B. (2007) Designing interactions, Vol 17, Cambridge, MA: MIT Press. Mohan, G. (2006) ‘Beyond participation: strategies for deeper empowerment’, in B. Cooke and U. Kothari (eds) Participation: The new tyranny?, London: Zed Books, pp 153-67. Mosse, D. (1994) ‘Authority, gender and knowledge: theoretical reflections on PRA’, Development and Change, 25(3): 497-526. Pettinger, L. (2004) ‘Brand culture and branded workers: service work and aesthetic labour in fashion retail’, Consumption Markets and Culture, 7(2): 165-84.

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Pongsakornrungsilp, S. and Schroeder, J.E. (2011) ‘Understanding value cocreation in a co-consuming brand community’, Marketing Theory, 11(3): 303-24. Prahalad, C.K. and Ramaswamy, V. (2004) ‘Co-creation experiences: the next practice in value creation’, Journal of Interactive Marketing, 18(3): 5-14. Pretty, J. (1995) ‘Participatory learning for sustainable agriculture’, World Development, 23(8): 1247-63. Sanders, E.B. and Stappers, P.J. (2008) ‘Co-creation and the new landscapes of design’, CoDesign: International Journal of CoCreation in Design and the Arts, 4(1): 5-18. Sanderson, E. and Kindon, S. (2004) ‘Progress in participatory development: opening up the possibility of knowledge through progressive participation’, Progress in Development Studies, 4(2): 114-26. Sangiorgi, D. (2011) ‘Transformative services and transformation design’, International Journal of Design, 5(2): 29-40. Shaull, R. (2005) ‘Foreword’, in P. Freire Pedagogy of the oppressed, London: Continuum International, pp 29-34. Tandon, R. (2008) ‘Participation, citizenship and democracy: reflections on 25 years of PRIA’, Community Development Journal, 43(3): 284-96. Thackara, J. (2007) Wouldn’t it be great if…, London: Design Council. Vargo, S.L. and Lusch, R.F. (2004) ‘Evolving to a new dominant logic for marketing’, Journal of Marketing, 68(1): 1-17. White, S.C. (1996) ‘Depoliticising development: the uses and abuses of participation’, Development in Practice, 6(1): 6-15. Wikström, S. (1996) ‘The customer as co-producer’, European Journal of Marketing, 30(4): 6-19.

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ELEVEN

Values and public expressions of concern Tom Crompton

Introduction This chapter grapples with the evidence for the importance of values in motivating people to express social or environmental concern – whether at the supermarket, the ballot box, or on the streets. This evidence base points to possible new approaches to strengthening such concern. It highlights the importance of appealing to ‘intrinsic’ values in the course of communicating about specific causes (for example, biodiversity loss or disability rights). It also underscores the importance of promoting these values more widely in society – often by working tangentially on issues that may at first seem unrelated to these causes. As such, this chapter presents an approach to strengthening public concern about social and environmental challenges that is an alternative, both ideologically and theoretically, to many of those currently in favour (such as behavioural economics – see Chapter Six) that sidestep changing people’s engagement or relationship with important issues in favour of merely changing their behaviour. Organisations working for positive social or environmental change would do well to incorporate an understanding of values into their work.

Public demand for change Collectively, we confront some very significant challenges, from climate change to human rights abuses, from inequality to malnutrition, from biodiversity loss to various forms of prejudice. It is the contention of this chapter that addressing these challenges will require far stronger public expressions of concern – expressed through the choices that people make about the goods and services that they buy, their use of resources in their private lives, and whether, and how, they engage politically.

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Addressing these challenges will also require significant changes in government and business. It can be seen that these changes themselves require stronger public expressions of concern. In the absence of this, government and business find themselves hopelessly constrained in what they are able to achieve. Of course, some governments prove themselves to be both electable and socially and environmentally progressive. Some businesses turn a profit while achieving significant steps towards social and environmental responsibility. Such change is important, but it is patently not proportionate to the scale of the challenges that we confront, and, as Chapter Nine demonstrates, relying on business for the societal changes we require is a strategy rife with limitations. Today’s political leaders are crucially hobbled in the ambition that they can show. This is partly because they must maintain electoral approval. But it is also because, if they are to pursue ambitious policy changes, this will often be in the face of opposition from powerful vested interests. There is, of course, a crucial role for political leadership and bravery in overcoming these constraints. But the resolve that political leaders show for such leadership and bravery must be stiffened by greater public scrutiny and pressure, another point made in Chapter Nine. Business leaders, however philanthropically motivated, must carry their customers with them. Taking perhaps a more optimistic line than Chapter Nine, the contention here is that there is indeed scope for business leaders to exert positive influences on people’s concern about social and environmental issues. But they are ultimately constrained to working where environmental imperative and competitive advantage can be made to converge. To be sure, assessed on its own terms, this is a space that provides for excitement and innovation. Yet without either profound changes in customer preferences, or otherwise regulatory changes, this space cannot accommodate responses that in any way match the scale of the social and environmental problems we confront. What is missing are ambitious changes in government and business, driven by a concerned, engaged and vocal citizenry that is both accepting of more transformative steps from government and business, and actively demands such steps. Nurturing the emergence of a concerned, engaged and vocal citizenry is something that anyone working for positive social and environmental change should help create – or, at the very least, something that they should not inadvertently undermine. (This imperative is discussed at length in Chapter Ten.) As such, this chapter provides an introduction to the importance of values in underpinning such change – and points to some of the profound

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implications of this understanding for the way in which change is currently pursued. Box 11.1: Tom Crompton’s personal journey I began work on cultural values and their importance in shaping people’s concern about social and environmental problems not as an academic, but as a campaigner working for a large charity. My work on values developed as a result of growing frustration at the disparity between the scale of these problems and the scale of response that organisations working for positive change are currently able to muster. Fifteen years ago, I was employed by WWF-International to lead its trade and investment work: lobbying politicians, civil servants and World Trade Organisation officials to try to reshape global trade and investment regimes such that these might better meet the needs of people and nature. This could have entailed, for example, agreement on cutting subsidies for environmentally destructive industries. I found that some trade negotiators showed a quasi-religious commitment to shoring up the current rules. Others were in total agreement about the need for radical change – but would wring their hands in despair: they were hopelessly constrained, they would say, by the lack of public demand for changes in the international trade regime. This simply was not something on which electoral success or failure would ever turn – and therefore vested interests would always be calling the tune. In responding to either group, I realised, there was a need for far greater public demand for change. And when I turned to colleagues in other charities, working on other causes – from climate change to disability rights, from animal rights to international poverty – I discovered, of course, that this frustration (and corresponding sense of impotence) was commonly experienced. Charities readily turn to natural scientists or economists in crafting their policy proposals and building the political case for change. But they do not have a good track record of working with social scientists to try to understand what motivates public expressions of concern about social or environmental issues. I turned to psychologists – in the US, Tim Kasser at Knox College, Illinois; in the UK, Greg Maio and Netta Weinstein at Cardiff University. These psychologists highlighted the substantial – yet widely overlooked – body of research establishing the importance of values in motivating public expressions of concern about social and environmental causes.

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Values and how they work Values are the aspects of people’s identities that reflect what they deem to be desirable, important, and worthy of striving for in their lives (Rokeach, 1973; Schwartz, 1992). Values are important in thinking systemically about social and environmental problems, because they are understood to reflect higher-order motivations that organise the attitudes and behaviours that constitute many aspects of people’s dayto-day lives (Emmons, 1989). Substantial cross-cultural research has identified a limited number of values that consistently emerge across nations. Moreover, the organisation of these values is remarkably consistent. Figure 11.1 presents a two-dimensional smallest-space analysis of individual value structure averaged across 68 countries and nearly 65,000 people (Schwartz, 2006). Figure 11.1: Individual value-level structure averaged across 68 countries

Source: Schwarz (2011).

This analysis shows that some values tend to be associated with others, such that if an individual holds one value to be important, certain other values are also likely to be held to be important. Thus, it is observed as a statistical likelihood that individuals who attach importance to ‘equality’ (in the top right part of the map) will also attach importance

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to ‘protecting the environment’ (close by, in the same area of the smallest-space analysis). Similarly, individuals who attach importance to ‘wealth’ (bottom left) are also likely to attach importance to ‘authority’. Conversely, individuals who attach particular importance to ‘wealth’ are statistically unlikely to attach importance to ‘equality’, and vice versa. This is not to suggest that it is impossible to hold, simultaneously, both wealth and equality to be important, merely that this is observed at low frequency. This value structure is found to be important in two ways. First, while people may differ widely in the priority that they attach to different values, the relationships between these values – the patterns of compatibility and opposition – have been found to be remarkably consistent: they are found to be broadly replicated across surveys that have now been conducted in more than 70 countries. So, for example, irrespective of the importance that the citizens of a particular nation place, on average, on ‘wealth’ or ‘equality’, the oppositional nature of these values is found to be largely preserved across national samples. Second, the values structure is important for individuals in a dynamic way. It seems that most people – perhaps all – attach some level of importance to each of these values. That is, while individuals seem to be disposed towards placing greater importance on some values than on others, it does not seem to be the case that people are exclusively oriented towards one set of values. Box 11.2: Stop and think: your values It is likely that we all at times place importance on each and every one of the values shown in Figure 11.1. Choose a few values from different parts of the map and give some thought to times over the course of the past week when you have felt each of these to be important.

The values that an individual holds to be important change over time, both temporarily (over the course of a day, for example), and in a more durable or ‘dispositional’ way (over the course of months or years). Such changes reflect, in dynamic fashion, the patterns that are shown in Figure 11.1. So, temporarily ‘engaging’ a particular value will tend to lead an individual to place increased importance on values adjacent to this engaged value in the smallest-space analysis, and diminished importance on values that are distant from the engaged value. Strengthening a particular value in a more dispositional way will tend to lead an individual to place increased importance on values adjacent to this value, and diminished importance on values that are

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distant from it. This point is important for ‘behaviour change’ and is now explored further.

Values and ‘behaviour change’ A wide range of studies have shown that our values influence both our attitudes and our behaviours. They affect our political persuasions, our willingness to participate in political action, our career choices, our ecological footprints, the amount of resources we use (and for what purpose), and our feelings of personal wellbeing (Schwartz, 2011). This chapter refers to a set of ‘intrinsic values’, taken to include both the universalism and benevolence values shown in the top right quadrant of Figure 11.1, and a related set of ‘intrinsic goals’ that include goals such as ‘community feeling’, ‘affiliation to friends and family’ and ‘selfacceptance’1 (Grouzet et al, 2005). These values are consistently found to underpin both concern about social and environmental problems, and action in line with this concern (from day-to-day behaviour, to voting choice, to political activism). These, then, are the values that organisations working to meet these problems must seek to engage and strengthen if they are to step up to the challenge of building public acceptance of, and active public demand for, ambitious change. Drawing attention to intrinsic values, even subtly, has been found to prompt a temporary increase in a person’s concern about social and environmental problems (see Crompton, 2010; Crompton and Kasser, 2010). This is found to be the case even if the intrinsic value that is primed has no obvious relevance to the particular problem discussed. For example, in one study, the authors found that drawing people’s attention to the importance of ‘acceptance’, ‘affiliation’, or ‘being broadminded’ deepened expression of social and environmental concern (Chilton et al, 2012). This effect has been called ‘bleed-over’. The implication is that it may not be necessary to work to directly invoke concern about a specific social or environmental problem in order to nonetheless elicit such concern by engaging intrinsic values in other ways. This is considered in more detail later, in the case study (Box 11.3). Intrinsic values stand in opposition to ‘extrinsic’ values – concern about wealth, social status or image. Drawing a person’s attention to these values diminishes the importance that he or she places on intrinsic values. This has been called the see-saw effect (Maio et al, 2009) and it has predictable behavioural consequences. Because of its effect in diminishing the importance that a person places on intrinsic values, drawing a person’s attention to extrinsic values also reduces motivation

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to express social or environmental concern (Crompton et al, 2014), also a bleed-over effect. It seems that engaging a range of different extrinsic values (in the study mentioned previously, ‘popularity’, ‘preserving public image’ or ‘wealth’) serves to diminish concern about social and environmental problems (Chilton et al, 2012). Such bleedover effects have been demonstrated experimentally by many different groups, although on the whole the effects of such interventions are only examined in the short term. Note, though, that some studies have found that a simple prime can have significant impacts weeks or even months later (Rokeach, 1973; Vansteenkiste et al, 2004). Other work suggests that repeatedly engaging values leads them to be strengthened in a more durable or ‘dispositional’ way. Michael Sandel makes this point powerfully in his book What money can’t buy: The moral limits of markets (previously discussed in Chapter Seven). Sandel (2012, p 130) writes that altruism, generosity, solidarity and civic spirit (attributes closely aligned to ‘intrinsic’ values) are ‘like muscles that develop and grow stronger with exercise’. There is undoubtedly less empirical data on these dispositional effects, but there is both theoretical and experimental support for this perspective (Sheldon and Krieger, 2004; Bardi and Goodwin, 2011). For example, it has been found that law school experience is associated with students coming to place greater importance on extrinsic values, perhaps because of excessive performance and grading pressures. Before embarking on their courses, law students seem to place higher priority on intrinsic values relative to a control group of other undergraduates, but over the first year of their studies the importance that the law students ascribe to these values erodes. In particular, and irrespective of age or gender, they come to place significantly lower value on ‘community contribution’ and significantly higher value on an ‘appealing appearance’ (Sheldon and Krieger, 2004). These basic principles – the association between intrinsic values and heightened social and environmental concern; the association between extrinsic values and diminished social and environmental concern; the see-saw and bleed-over effects; and the probability that repeated engagement of particular values strengthens these values dispositionally – have profound implications for building public concern with social and environmental problems. Before turning to examine these impacts in more detail, this chapter now outlines a study recently conducted by WWF and Scope, which examines these principles further, as they apply to people’s concern about biodiversity conservation and disability rights.

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Box 11.3: Case study: an empirical study of values in social and environmental campaigning Using a large online panel maintained by the Institute of Development Studies (IDS), people were presented with different rationales for supporting the work of either Scope (a disability charity) or WWF (a conservation charity), and then asked about their intention to take action on either disability or environmental issues (Crompton et al, 2014). In the first study, authors presented participants in two separate conditions with one of two primes describing the work of a conservation charity. To ensure external validity, these were written with the help of communication staff in WWF. In one condition, participants were asked to read a text that included the following paragraphs: Text A: WWF (intrinsic) Have you ever paused to think about the importance of the natural world? At WWF, we are working to minimise the loss of nature in the UK – such as plants, animals, woodlands or rivers – by helping people to recognise its real value. The importance of environmental protection is still often overlooked and is not adequately reflected in planning and policy. One reason for this is that people’s inherent appreciation of, and love for, the natural world is often forgotten. Reminding people of the intrinsic importance that they attach to nature can help to address this problem. Here, phrases written to invoke intrinsic values are underlined. In a second condition, participants were asked to read text that also described the work of WWF, but which included the following paragraphs: Text B: WWF (extrinsic) Have you ever paused to think about the contribution that the environment makes to our national wealth? At WWF, we are working to minimise loss of the UK’s natural resources – such as plants, animals, woodlands or rivers – by helping people to recognise their real value. Natural assets, and the benefits that they provide, are still often overlooked and are not adequately reflected in planning and policy. One reason for this is that the financial value of the environment, and the commercial benefits that people derive, is often overlooked. Putting a monetary value on nature can help to address this problem. Here, phrases written to invoke extrinsic values are emphasised with a broken line.

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Values and public expressions of concern Having read one or other of these texts, participants were then asked about their intentions to take action to help WWF; for example, by sending an email to an MP, joining a public meeting, or volunteering. We found that participants who had read text A were significantly more likely to offer to help WWF than participants who read text B. This result was corroborated in a further study where we examined the effects of two different texts describing the work of Scope, each again developed in close collaboration with communications staff working for this charity. Some participants read text including this paragraph: Text C: Scope (intrinsic) Scope works with disabled people and their families at every stage of their lives. We believe that disabled people should have the same opportunities as everyone else, enabling them to live the lives they choose. Yet today, disabled people are more likely to live in poverty, more likely to experience negative attitudes or prejudice, and are more likely to live alone. They still face marginalisation and discrimination. Again, phrases written to invoke intrinsic values are underlined. Other participants read text including this paragraph: Text D: Scope (extrinsic) Scope works with disabled people and their families at every stage of their lives. We believe in giving disabled people the chance to achieve greater success in their lives, so that they can fully contribute to the economy. Yet today, disabled people are more likely to be unemployed and receiving benefits. Again, some of the phrases written to invoke extrinsic values are underscored with a broken line. We found that participants who had read text C were significantly more likely to offer to help Scope than participants who read text D. In a further study, we also tested the effects of texts that combined elements of both the intrinsic and extrinsic frames. So, for example, in another condition we presented participants with the following text describing the work of WWF: Text E: WWF (mixed) Have you ever paused to think about the importance of the natural world? At WWF, we are working to minimise the loss of nature in the UK – such

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Beyond behaviour change as plants, animals, woodlands or rivers – by helping people to recognise its real value. The importance of environmental protection is still often overlooked and is not adequately reflected in planning and policy. One reason for this is that the financial value of the environment, and the commercial benefits that people derive, is often overlooked. Putting a monetary value on nature can help to address this problem. It is also the case that people’s inherent appreciation of, and love for, the natural world is often forgotten. Here, reminding people of the intrinsic importance that they attach to nature can help. In further condition, we presented participants with a ‘mixed text’ describing the work of Scope, combining elements of both texts C and D (this text, text F, is not reproduced here). An understanding of the see-saw effect leads one to anticipate that the effects of intrinsic and extrinsic values will not be ‘additive’. That is, if one’s aim is to elicit expressions of concern about social or environmental issues, it is predicted that intrinsic appeals alone will prove more effective than mixed intrinsic/extrinsic appeals. Our results corroborate this understanding. ‘Mixed texts’ (texts E and F) performed no better than the extrinsic texts (texts B and D) in eliciting intention to help WWF and Scope. In each case, they performed significantly more poorly than the ‘intrinsic texts’ (texts A and C).

The case study results – all corroborated by many other studies – illustrate some of the key principles set out in this chapter. In particular: • Engaging intrinsic values in relation to a cause leads to stronger expressions of social and environmental concern than engaging extrinsic values. • Social or environmental concern is expressed most strongly when intrinsic values are engaged and extrinsic values are avoided. But there is one more important result, which has far-reaching implications. The studies outlined explored the effects of texts describing the work of a disability organisation on participants’ support for a conservation charity, and vice versa. One might not expect an audience’s motivation to support an organisation working on disability to be influenced greatly, if at all, by the way in which a message relating to conservation is framed. Similarly, one might not expect an audience’s motivation to support an organisation working on conservation to be influenced greatly, if at all, by the way in which a message relating to disability is framed. Yet we found that texts that framed the work of either organisation in terms of intrinsic, self-transcendent values were

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just as effective in eliciting support for the other organisation. In other words, texts A and C in the case study were each equally effective in motivating concern about disability, and they were also each equally effective in motivating concern about conservation. Conversely, texts B and D were each equally ineffective in motivating concern about disability, and each equally ineffective in motivating concern about conservation. It seems that engaging intrinsic values in one context (for example, in the context of disability, with no mention of the environment) ‘bleeds over’ to engage intrinsic values in a very different context (for example, in the context of the environment), and that this has predictable consequences, that is, a strengthening of environmental concern. This leads to one more important principle. In seeking to build stronger public concern about social and environmental issues, it may not be necessary to draw an audience’s attention to a specific issue of importance; it may be equally effective to invoke intrinsic values in the context of other issues.

Objections This section addresses two objections to some of the principles outlined so far: one arising from a strategy called ‘values matching’, the other from a perceived disconnect between a person’s values and their behaviour. These objections are encountered more frequently among practitioners than among academics – perhaps because neither bears close scrutiny in the light of theoretical and empirical studies. Values matching One might ask whether the greater effectiveness of intrinsic primes in motivating concern about social and environmental issues is influenced by a participant’s prior value disposition. Some social marketers advance the case for segmenting an audience according to people’s prior values disposition (as discussed in depth in Chapter Seven). This strategy is sometimes called ‘values matching’ and the proprietary approach called ‘value modes’ uses this strategy. According to this strategy, it is assumed that a person for whom extrinsic values are relatively more important is likely to find a communication engaging these values more persuasive (Rose, 2014). On this basis, one would predict that texts B and D in the case study would prove more effective in eliciting support for WWF or Scope among participants for whom extrinsic values were relatively more important.

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However, although this strategy has been forcefully advanced by some social marketers (Rose, 2014), we are aware of no empirical evidence to support this perspective. On the contrary, although it may seem superficially appealing, there are strong empirical and theoretical arguments against this approach (Kasser and Crompton, 2011; Chilton et al, 2012). We sought to test the values-matching strategy further in the study described in the case study (Box 11.3). All participants in this study were asked to complete a values survey three months prior to our experiment. This enabled us to examine whether a participant’s prior values disposition was of importance in determining the effectiveness of intrinsic or extrinsic primes. We found that there was no such interaction – the greater effectiveness of texts A and B was unrelated to a person’s prior values disposition. As such a fourth principle can be added to the list generated throughout this chapter: the greater effectiveness of intrinsically framed communications holds irrespective of a person’s value disposition. The value–action gap There is a widespread perception that a person’s values are a poor predictor of their behaviour, leading to a so-called value–action gap (Maio, 2011). The case study in this chapter outlines in some detail the effect of different primes in influencing participants’ intention to support environmental or disability causes. However, it did not examine actual behavioural outcomes. It is of course true that people routinely behave in ways that are not aligned to the values they hold to be most important. A person may strongly believe in the value ‘protecting the environment’, and hold positive attitudes towards cycling, but nonetheless drive to work each morning, perhaps because she is not a confident cyclist, or because the route is dangerous for cyclists, or because her bike is unreliable. Similarly, a person may attach particular importance to the value ‘protecting the environment’, yet fail to write to his MP ahead of a crucial vote on a piece of legislation related to pesticide use, perhaps because he is not confident in composing a letter, or because he is always just too busy doing other things, or because (despite his wider environmental convictions) he believes that pesticide use is one area where most environmentalists have got things wrong. It is important to recognise that we may each frequently behave in ways that are inconsistent with values to which we attach particular importance. But consider what happens when one begins to aggregate

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across a range of behaviours. Here the barriers that we encounter in embracing particular behaviours consistent with our values begin to average out (see, for example, Weigel and Newman, 1976). Taken overall, a person’s values are likely to be a very important in shaping their behaviour. As Greg Maio (2011, p 5) writes: [I]n working to tackle environmental and social problems, we overlook the importance of values at our peril. It is true that we may be able to overlook values in designing interventions to address specific behaviours in piecemeal fashion. But a thorough-going response to these challenges will require a far more systematic and sustained engagement with the things that we hold to be most important: those things that we value. (Emphasis in original.)

Conclusion Insights from social psychology explored in this chapter, coupled with an appreciation of the scale of the sustainability challenges that we confront, have important implications for strengthening public concern about social and environmental problems. They have implications for the way in which organisations that are seeking to address social or environmental issues work, whether charities, governments or businesses. The first implication relates to the ways in which organisations communicate. Many communications appeal to extrinsic values in attempting to motivate environmental or social concern. For example, many in the conservation movement have enthusiastically embraced approaches that put a financial value on nature (see text B in the case study). Appeals to extrinsic values may sometimes prove to be effective as ways to motivate particular behaviours – although, as we have seen, there is evidence that appeals to intrinsic values can be more effective (see, for example, Bolderdijk et al, 2013). But, crucially, it seems that such strategies are also likely to entail unwanted side-effects. Such effects may be apparent across a large number of people (all those who are exposed to a communication, irrespective of whether or not they act in line with this) and across a wide range of socially and environmentally relevant behaviour. If a brief text highlighting the benefits of assigning a financial value to nature can lead to significantly weaker intention to take action to help promote the rights of disabled people (see Box 11.3), then one would anticipate that this communication will

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have comparable impacts on intention to take action on a very wide range of other social or environmental causes. Of course, this is not to argue that there can be no role for appeals to extrinsic values in promoting social or environmental concern. It seems clear that such appeals will, at times, have their uses, potentially where a campaign can be shown to be effective in encouraging uptake of a behaviour that is in itself particularly socially or environmentally significant, or where it aims to address some of the structural barriers to strengthening intrinsic values at a cultural level. But such communication and campaign strategies should be deployed with great care. Ideally, they would only be deployed in the light of experimental trials demonstrating their effectiveness, and even then only following careful deliberation about unwanted side-effects. Many charities are beginning to respond to an understanding of cultural values, and some have undertaken analysis of their public communications and campaign materials to explore the values that these currently serve to engage, that is, to begin to explore the possible ‘mind-print’ of these communications. Nonetheless, important as it is to examine the values that charities themselves are communicating, the ‘mind-print’ that they exert will be small compared with that of the public and private sectors. An understanding of the ‘mind-print’ of business and government can point to important new ways in which charities can work to help bring intrinsic values to the fore at a cultural level. The second implication of an understanding of values lies with the social and environmental issues on which organisations focus. Charities tend to define their work in terms of specific causes (such as human rights, biodiversity loss or child protection). Yet an understanding of values leads to the conclusion that a focus on specific causes leads charities to overlook many areas of work that are likely of crucial importance in promoting public concern about social and environmental problems. Consider, for example: Economic policies: intuitive politicians are well aware of the importance of economic policy in communicating, and reinforcing, the importance of particular values, through citizens’ lived experience of those policies. Margaret Thatcher, for example, famously commented on the second anniversary of her first election, in The Sunday Times on 3 May, 1981: It isn’t that I set out on economic policies; it’s that I set out really to change the approach, and changing the economics is the means of changing that approach. If you change

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the approach you really are after the heart and soul of the nation. Economics are the method; the object is to change the heart and soul. Economic policies that have little direct material impact on specific social or environmental issues may nonetheless be of profound importance in shaping cultural values, and therefore public concern about a wide range of social and environmental problems. Social institutions: our daily interaction with social institutions is likely to serve to reinforce particular values. In the UK, consider our experience of the National Health Service – both as taxpayers who contribute to its services, and as patients. This experience is likely to reinforce the perception that it is normal and right to live in a society that addresses the health needs of all, irrespective of their ability to pay. This experience is therefore likely to engage, and over time strengthen, intrinsic values (here, values of social justice) that are associated with concern about a wide range of social and environmental issues extending far beyond public health. Media: the media plays a crucially important role in shaping our collective sense of what is important in life, how we perceive ourselves, and how we properly interact with others. Take one, apparently trivial, example. Studies have found that briefly referring to participants as ‘consumers’ rather than ‘citizens’ significantly increases participants’ bias towards extrinsic values, and that referring to them as ‘consumers’ rather than ‘individuals’ leads them to behave more selfishly in a natural resource dilemma game (Bauer et al, 2012). Yet The Times, Guardian and Observer newspapers in the UK increasingly refer to their readers as ‘consumers’ rather than ‘citizens’ (Shrubsole, 2012). Marketing: estimates vary widely, but it is thought that the average UK citizen is exposed to hundreds, perhaps several thousand, marketing messages each day. There is evidence that exposure to these messages, and to photographs of consumer products, increases the importance that a person attaches to extrinsic values (Alexander et al, 2012; Bauer et al, 2012). Irrespective, therefore, of the steps that more progressive advertising agencies and their clients may have taken to reduce their immediate material footprint (for example, the greenhouse gases produced in the course of creating an advertisement), they are likely to have a significant social and environmental impact mediated by their ‘mind-print’. Conditions of employment: most people of working age spend a significant proportion of their waking hours in a social environment that is shaped by their employer’s management culture and employment

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policies. So, for example, a competitive workplace that extends little job security, demands that employees work long hours, provides minimal annual leave, and rewards good performance through pay increases, is likely to engage – and over the course of time strengthen – extrinsic values among its workforce. Education: educational experiences that stress competition and that present education as a prerequisite for more remunerative careers are likely to strengthen extrinsic values. There is also evidence that such approaches may be counterproductive in supporting learning (Ryan and Deci, 2009). Studies have found that simple interventions to encourage primary school children to uncover stories of kindness or love lead to remarkably durable improvements in these pupils’ prosocial and helping decisions (Andrews, 2012). Although not tested, one would anticipate that this would also lead them to express wider social and environmental concern. There is also evidence that encouraging immersion in nature leads a person to attach more importance to intrinsic values (Weinstein et al, 2009). Certainly, organisations working on social or environmental problems do work on some of these issues where there is a direct programmatic link to a specific cause (for example, a charity focused on promoting the health of young people may campaign against advertising of highfat content food to children). But taking a values-led approach would mean that advertising to children is seen as an issue of crucial concern to any organisation working to address social or environmental problems, because of the probable links between exposing children to high volumes of commercial advertising, strengthening the importance these children place of extrinsic values, and eroding social and environmental concern – perhaps well into adulthood (Alexander et al, 2012). This chapter has provided an overview of values, how these develop and interact with one another, and how these contribute to shaping people’s social and environmental concern. Such understanding has crucial, and largely overlooked, implications for any strategy to build systemic public concern about social and environmental problems.

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End-of-chapter questions • The strategy for change outlined in this chapter is very ambitious. It only makes sense in the context of very big challenges requiring systemic changes in people’s behaviour. Do you think that a problem like climate change can be addressed in the absence of such changes? • The perspective outlined in this chapter invites closer collaboration between organisations that currently work on very different social and environmental challenges. Organisations that work to engage intrinsic values (through a focus, for example, on the commercialisation of childhood or education policy) will promote public concern about their specific causes, but they will also help to build people’s concern about a wide range of other social and environmental problems. What do you think the main barriers are to organisations working in this more coherent way? • Can you think of some prominent examples of tactics to promote social or environmental change that simultaneously engage extrinsic values – risking undermining the longer-term basis for change? How would you begin to assess the wider impacts of these tactics?

Note Consideration of the relationship between goals and values is beyond the scope of this chapter. Readers are referred to Crompton and Kasser (2010). 1

References Alexander, J., Crompton, T. and Shrubsole, G. (2011) Think of me as evil? Opening the ethical debates in advertising, Machynlleth: PIRC and Godalming: WWF-UK, www.valuesandframes.org Andrews, T. (2012) ‘Personal communication’, 27 February. Bardi, A. and Goodwin, R. (2011) ‘The dual route to value change: individual processes and cultural moderators’, Journal of Cross Cultural Psychology, 42: 271-87. Bauer, M.A., Wilkie, J.E.B., Kim, J.K. and Bodenhausen, G.V. (2012) ‘Cuing consumer ism: situational mater ialism undermines personal and social well-being’, Psychological Science, published online, 16 March, http://pss.sagepub.com/content/ early/2012/03/16/0956797611429579 Bolderdijk, J.W., Steg, L., Geller, E.S., Lehman, P.K. and Postmes, T. (2013) ‘Comparing the effectiveness of monetary versus moral motives in environmental campaigning’, Nature Climate Change, 3: 413-16. Chilton, P., Crompton, T., Kasser, T., Maio, G. and Nolan, A. (2012) ‘Communicating bigger-than-self problems to extrinsically-oriented audiences’, Godalming: WWF-UK, www.valuesandframes.org

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Crompton, T. (2010) Common cause: The case for working with our cultural values, Godalming: WWF-UK, www.valuesandframes.org Crompton, T. and Kasser, T. (2010) Meeting environmental challenges: The role of human identity, Godalming: WWF-UK. Crompton, T., Weinstein, N., Sanderson, B., Kasser, T. and Maio, G. and Henson, S. (2014) No cause is an island, London: Common Cause Foundation. Emmons, R.A. (1989) ‘The personal strivings approach to personality’, in L.A. Pervin (ed) Goal concepts in personality and social psychology, Hillsdale, NJ: Erlbaum, pp 87-126. Grouzet, F.M.E., Kasser, T., Ahuvia, A., Fernandez-Dols, J.M., Kim, Y., Lau, S., Ryan, R.M., Saunders, S., Schmuck, P. and Sheldon, K.M. (2005) ‘The structure of goal contents across 15 cultures’, Journal of Personality and Social Psychology, 89: 800-16. Kasser, T. and Crompton, T. (2011) ‘Limitations of environmental campaigning based on values for money, image, and status: Eight psychologists reflect on the disagreement between the value modes and common cause approaches’, Common Cause Briefing – August 2011, www.valuesandframes.org Maio, G. (2011) ‘Don’t mind the gap between values and action’, Common Cause Briefing, August, www.valuesandframes.org Maio, G., Pakizeh, A., Cheung, W. and Rees, K. J. (2009) ‘Changing, priming, and acting on values: Effects via motivational relations in a circular model’, Journal of Personality and Social Psychology, 97: 699-715. Rokeach, M. (1973) The nature of human values, New York, NY: Free. Rose, C. (2014) ‘Why values matching is a good idea’, Campaign Strategy Newsletter 90, http://bit.ly/1pGfaHk Ryan, R. and Deci, E. (2009) ‘Promoting self-determined school engagement: motivation, learning, and well-being,’ in K. Wentzel and A. Wigfield (eds) Handbook of motivation at school, New York, NY: Routledge, pp 171-96. Sandel, M. (2012) What money can’t buy: The moral limits of markets, London: Allen Lane. Schwartz, S.H. (1992) ‘Universals in the content and structure of values: theory and empirical tests in 20 countries’, in M.P. Zanna (ed) Advances in experimental social psychology, vol. 25, New York, NY: Academic, pp 1-65. Schwartz, S.H. (2006) ‘Basic human values: theory, measurement, and applications’, Revue Française de Sociologie, 47(4): 249-88. Schwartz, SH. (2011) ‘Studying values: personal adventure, future directions’, Journal of Cross-Cultural Psychology, 42: 307-19.

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Sheldon, K.M and Krieger, L.S. (2004) ‘Does legal education have undermining effects on law students? Evaluating changes, motivation, values and well-being’, Behavioral Sciences and the Law, 22(2): 261-86. Shrubsole, G. (2012) ‘Consumers outstrip citizens in the British media’, Open Democracy, 5 March, www.opendemocracy.net/ourkingdom/ guy-shrubsole/consumers-outstrip-citizens-in-british-media Vansteenkiste, M., Simons, J., Lens, W., Sheldon, K. M. and Deci, E.L. (2004) ‘Motivating learning, performance, and persistence: the synergistic effects of intrinsic goal contents and autonomy-supportive contexts’, Journal of Personality and Social Psychology, 87: 246-60. Weigel, R.H. and Newman, L.S. (1976) ‘Increasing attitude-behavior correspondence by broadening the scope of the behavioral measure’, Journal of Personality and Social Psychology, 33: 793-802. Weinstein, N., Przybylski, A.K. and Ryan, R.M. (2009) ‘Can nature make us more caring? Effects of immersion in nature on intrinsic aspirations and generosity,’ Personality and Social Psychology Bulletin, 35(10): 1315-29.

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TWELVE

Social practices and behaviour change Daniel Welch

Introduction Continuing the theme of this second part of the book, which looks at behaviour change through innovative theoretical and ideological lenses, this chapter considers the role that theories of social practice might play in offering new theoretical perspectives to policy engaged with behaviour change, providing fresh insights about the nature of the problems addressed in such policy and novel targets for intervention. While any domain of activity is in principle amenable to practice theoretical approaches, they have shown particular pertinence to the study of consumption (Warde, 2005) and thus to sustainable consumption (Hargreaves, 2011; Evans et al, 2012; Shove et al, 2012; Warde and Southerton, 2012; Shove and Spurling 2013; Strengers and Maller, 2015; Welch and Warde, 2015) and have been actively adapted to inform policy in this field (Darnton et al, 2011; Darnton and Evans 2013; Spurling et al, 2013; Spurling and McMeekin, 2015). More recently, the pertinence of a practice theoretical approach to transport (Watson, 2012; Spotswood et al, 2015) and health-related policy (Maller, 2015; Blue et al, 2016) has also been advocated and demonstrated. It is worth stressing that theories of practice, in the plural, are heterogeneous. However, their family resemblance lies in the conception that human activity is primarily the performance of social practices. Practices here refer to everything from domestic practices such as doing the laundry, or everyday practices like driving, to specialist practices (such as work practices), and to cultural practices that help characterise different groups (such as going to the opera). Practices are fundamentally social phenomena: ‘their performance entails the reproduction of cultural meanings, socially learnt skills and common tools, technologies and products’ (Spurling et al, 2013, p 3).

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What makes theories of practice distinctive and innovative in the field of ‘behaviour change’, is that the practice itself, rather than the human doing it, becomes the central unit of analysis. So in terms of policy, practice would be the central unit of intervention, rather than individuals (and their attitudes and preferences), or other analytical categories such as norms, values, discourses, or social structures. This perspective reframes the question from ‘How do we change individuals’ behaviours?’ to ‘How do we change practices and their performance?’ Individuals are thus reframed as the practitioners, or carriers, of social practices. It is this reframing wherein lies much of the analytical novelty and strength of practice theoretical approaches, and much of the challenge in terms of its adoption by policymakers. Theories of practice claim to offer a resolution to problematic dualisms such as structure and agency, methodological individualism and holism, and determinism and voluntarism, dualisms that have particular resonance for analysts and policymakers concerned with facilitating behavioural and social change. Moreover, theories of practice ‘undermine the traditional individual-nonindividual divide by availing themselves of features of both sides’ (Schatzki, 2001, p 14). The significance of this for policymakers is that it moves us away from framing problems and interventions in terms of false oppositions or alternatives: the individual or the social context; behaviour or technology.

An overview of social practices Practices are structured nexuses of activity – or sets of ‘doings and sayings’ (Warde, 2005, p 134). A practice can be defined as ‘an organised, and recognisable, socially shared bundle of activities that involves the integration of a complex array of components: material, embodied, ideational and affective’ (Welch and Warde, 2015, p 85). For example, driving as a practice requires the material components of the car and the road transport infrastructure; the embodied know-how of the skill of driving; and the understanding of a host of meanings and ideas, including rules such as speed limits, the symbols used on road signs, and conventions such as flashing one’s headlights, as well as affective and normative engagements such as the equation of driving with autonomy and freedom. The identification of the components that make up practices, their configuration within the practice, and their dynamic relation to other practices, thus becomes a core task of analysis. Two influential schemas that sort this bewildering array into generic categories amenable to

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operationalisation have been offered by Warde (2005) and Shove and colleagues (2012).1 Warde (2005, p 134), adapting Schatzki (1996), defines the categories of practice components as ‘understandings’ (know-how and practical interpretation); ‘procedures’ (rules, principles, instructions); and ‘engagements’ (an array of ends and projects, as well as affective and normative orientations). Shove and colleagues (2012, p 23) offer an avowedly ‘radically simplified’ schema of three types of practice element: materials, competence and meanings. Shove and colleagues’ stress on material elements emphasises how practices are always deeply interwoven with objects, tools, technologies and infrastructures. Competence draws our attention to the skills and know-how necessary for the successful performance of a practice, while meanings include norms, cultural conventions and expectations. To conclude this brief introduction, a useful analytical distinction can be made between practices as ‘performances’ and practices as ‘entities’ (Schatzki, 1996; Shove et al, 2012; Warde 2005). Practices are entities – we can identify driving, for example, as a ‘thing’. As entities, practices have a history as well as a trajectory, or path of development (Welch and Warde, 2015). At the same time practices only exist through their performance – for driving to exist, people have to drive. Performance and entity are therefore recursively related, in a way analogous to agency and structure in Giddens’ theory of structuration (1984). As illustrated in Figure 12.1, from the social practice perspective, behaviour is just the tip of the iceberg of practices conceived in their entirety. We might expect, therefore, that intervening in behaviour Figure 12.1: Observable behaviour is the performance of social practices

Practice as performance: The observed behaviour of individuals Practice as entity: Socially shared ideas and meanings Knowledge and skills Materials and infrastructures

Source: Spurling et al (2013, p 8).

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alone, rather than intervening in that behaviours’ socially embedded underpinning, or practice-as-entity, will have limited results. The social practice approach therefore argues that it is the practice-as-entity that forms the better target for policy seeking behavioural and social change (Spurling et al, 2013). Box 12.1: Stop and think: the implications of practice-as-entity There are several fundamental implications when the practice – and not the carrier of that practice – is the target of intervention. First, ‘behaviour change’ becomes something of a misnomer, because ‘behaviour’ is no longer the primary focus, but rather the practice as an entity. Second, the individual ceases to be the primary focus of intervention. From a social practice perspective, rather than being the expression of an individual’s values and attitudes, ‘behaviour’ is the observable performance of social practices (Spurling et al, 2013). The various constituent elements of the practice-as-entity – socially shared ideas and meanings, knowledge and skills, and materials and infrastructures (Spurling et al, 2013) – become the focus of intervention and study.

The ‘portfolio model’ of behaviour versus practice theory Conventional behaviour change strategies, primarily influenced by social psychology and economics (see Chapter Two), draw on an implicit model of behaviour, which assumes individuals’ capacity to achieve change, and emphasises the deliberative character of behaviour. From the social practice perspective, this model structurally overestimates the role of choice in routine behaviour and fundamentally underestimates the extent to which individuals’ autonomous action is constrained by infrastructures and institutions, by collective conventions and norms, and by access to resources: social, cultural and economic (Southerton et al, 2004; Welch and Warde, 2015). This voluntaristic and individualistic approach is found in a particularly acute form in the figure of ‘the consumer’, to which much sustainable consumption policy is addressed. Shove (2010) has lampooned this dominant policy approach to sustainability as an overly simplistic ‘ABC’ model, which assumes a linear relation between attitude−behaviour−choice, and thus overly focuses on information provision and social marketing for the purpose of attitudinal change. Find a list of further reading covering the ‘ABC debate’ in Chapter Two. Hindess (1988, cited in Whitford, 2002) calls this commonplace, implicit, model of the human subject and behaviour ‘the portfolio model’, wherein the subject is presumed to possess a more or less

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stable portfolio of values, attitudes, norms, interests and desires, and selects from them to decide on the course of action. Seen from the social practice perspective, much of what passes as the ‘value−action’ or ‘attitude−behaviour’ gap − the centrepiece of so much policy analysis and intervention − arises from this widely shared model in which behaviour or social action is assumed to be driven by anterior conditions, variously norms (in classical sociology), attitudes (in social psychology) and preferences or interests (in economics) (Southerton and Welch, 2015; Welch and Warde, 2015). From the perspective of ‘the portfolio model’, in which behaviour is ‘driven’ by values, attitudes, or interests, the obvious assumption is that changing behaviour presupposes changing those things that drive it. Furthermore, the ‘gap’ between people’s professed ‘pro-environmental’ values and attitudes and their less than pro-environmental behaviours therefore appears somewhat mysterious, to be explained by ‘barriers’ blocking the motive force of those values and attitudes that would otherwise enable those behavioural choices. Against this ‘portfolio model’ of the individual, practice theory emphasises routine and habit over conscious reflection, dispositions over deliberation, and constraint over choice (Warde and Southerton 2012; Welch and Warde, 2015). Obviously this is not to deny that people have values or attitudes, nor that they act on them, but it is to challenge that model as the paradigm through which we should understand behaviour or social action in general (Southerton and Welch, 2015). Take, for example, vegetarianism, a clear example of individuals choosing a form of behaviour based on their values or attitudes. Five percent of UK adults report being vegetarian or vegan (ONS, 2002). However, that the other 95% eat meat cannot simply be understood in voluntaristic terms as an aggregation of individual choices. To understand why 95% do eat meat we need to apprehend the widely shared understanding that a ‘proper meal’ contains meat, vegetables and carbohydrates, and the historical, social and infrastructural underpinnings of that cultural convention (Spurling et al, 2013). A social practice perspective asks us to look at the way in which practices themselves enjoin and organise attitudes, values, norms, and even desires and emotions. For example, the range of emotions and desires that are permissible or prescribed to enact within the context of the practice of ‘attending a lecture’ are very different to those enjoined by the practice of a ‘going out for a drunken night on the town’. The ends or projects that practitioners may pursue − ‘engagements’ in Warde’s terminology − such as, for example, the pursuit of profit, or of sustainable consumption, are thus normatively ordered; certain

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things may be obligatory, others acceptable, others still, controversial (Schatzki, 2002). This is not to deny individual agency (not least the agency to engage in some practices and not others), but to contend that agency transpires chiefly through the medium of social practices. From the practice perspective, therefore, the ‘value−action’ gap appears less a mystery to be solved, or a failure of individuals to act on values, than as an artefact of the ‘portfolio model’ of behaviour implicit in much behaviour change policy. Thus environmentally motivated individuals commonly find themselves engaging in suites of ‘environmentally friendly’ behaviour while also engaging in deeply ‘unsustainable’ activities, largely due either to the constraints imposed on them by specific infrastructures of provision or because of the difficulty of prioritising ‘sustainability’ as an engagement within specific practices. One study found that the more people care about the environment, the more they drive (Kollmus and Agyeman, 2002, p 258, fn 6). This is not, of course, because of a causal relationship, but because of a correlation between environmental awareness and affluence: and the bundle of practices through which normal affluent lifestyles are enacted involves higher levels of personal mobility. It is for this reason that Shove has argued that, for sustainability policy, focusing on environmental attitudes is something of a distraction: ‘What counts is the big, and in some cases, global swing of ordinary, routinized and taken-for-granted practice ... [and the] processes underpinning the normalization of consumption and the escalation of demand’ (Shove 2003, p 9). It is thus to the dynamics of social practices that we should look for explanations of the escalating environmental impact of consumption (Shove et al, 2012). Similarly, Warde’s practice theoretical reframing of consumption stresses that most environmentally significant consumption occurs in the pursuit of social practices (for example, sharing a meal, playing sport or gardening), not as consumption per se (Warde, 2005). Furthermore, the inconspicuous consumption of energy and resources in the use of goods and services occurs largely in the accomplishment of everyday routine tasks (for example, doing the laundry, showering or commuting), as opposed to in the conspicuous consumption usually associated with ‘consumerism’ (Shove and Warde, 2002). The focus therefore shifts from the individual choices of ‘the consumer’ or ‘consumerist values’ to the social organisation of practices and ‘the moments of consumption enjoined’ (Warde, 2005, p 146). Seeing values, attitudes, ends, and so on, as embedded in social practices, not individuals, helps us understand the obduracy of much

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everyday behaviour and how particular ‘ways of doing’ become very deeply embedded within our everyday routines. Box 12.2: Stop and think: how theories of practice make us see things differently Taking theories of practice seriously implies a significant shift of perspective away from many commonplace understandings. If human activity can be said to occur chiefly through social practices, a central reframing is to see the ends pursued by human activity – ‘engagements’ in Warde’s terminology (2005) – as the property of the practice, rather than its practitioners. This is to suggest that values, attitudes, ends, and even emotions, are embedded in, or ordered through, social practices. Practices organise the contexts in which people act. Individuals do not disappear in such a perspective, but can be thought of as possessing individuality through the unique intersection of manifold practices that they embody and perform (Warde, 2005).

Interventions in practice The question remains as to what behaviour change policy informed by a social practice perspective would look like. First, it is worth noting that existing examples of such interventions are as yet extremely limited. However, practice theory has informed public policy in the UK (see Chatterton, 2011; Darnton et al, 2011; Darnton and Evans, 2013). One way we might assess its utility is through its capacity to explain the success or failure of existing behaviour change initiatives, all of which are, of course, themselves interventions into social practice. The key insight is perhaps that interventions should address as full a range of the components of practices as possible (Southerton and Welch, 2015). Most existing interventions address only a limited range of components. Thus social marketing often addresses meanings only, education generally addresses competences only and regulation generally addresses only procedures or the material underpinnings of practice. In an international review of 30 policy interventions for sustainable consumption Southerton and colleagues (2011b, p 118) found that the vast majority were framed by the portfolio model of behaviour and sought to ‘change the behaviour of autonomous consumers – whether by providing economic incentives, correcting information efficiencies, seeking to re-frame attitudes, or removing the barriers’ to individuals’ behaviour change. By contrast, it was those initiatives that addressed the interlinked individual, social and material contexts of social practices

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that had the greatest success. It is worth noting, however, that the successful initiatives examined by Southerton and colleagues (2011a) tend also to be those on a more ambitious scale. Box 12.3: Case study: Cool Biz The Cool Biz initiative in Japan sought to significantly reduce energy use for air conditioning in government buildings. It achieved remarkable success through not only regulating the setting of air conditioners at no lower than 28°C but also through implementing a programme to change the conservative conventions of business clothing away from suit and tie to lightweight, short-sleeved clothes. This was achieved through engaging the fashion industry, media initiatives and other supports for behavioural and attitudinal change. The understandings, procedures and engagements of the everyday practices of office work were simultaneously addressed (see Shove et al, 2012 for a more detailed exploration).

The analytical value of practice theory for behaviour change policy is not, however, limited to prescriptions for ambitious interventions. Hargreaves (2011) conducted a study of a conventional workplace behaviour change programme from a social practice perspective. The programme sought to change attitudes in order to promote pro-environmental behaviours. The programme was relatively successful in changing behaviour. However, Hargreaves found that the ‘environmental attitudes’ of participants were largely unchanged. Rather, habitual behaviours had been changed, for example around turning off lights, but rather than being driven by pro-environmental attitudes these changes to working practices had become invested with meanings of loyalty to company culture. Hargreaves’ practice theoretical analysis of the initiative provided a more robust account of its results than the implicit portfolio model of behaviour that had informed the programme. Similarly, Halkier (2010) found in empirical research into changing eating habits that interaction within social networks and practical procedures were often more important as explanations of change than were changes in individuals’ normative commitments. The analytical value of practice theory can therefore be demonstrated in the context of the conventional territory of behaviour change policy.

Models for policy intervention Recrafting practices Building on Shove and colleagues’ (2012) three elements of practice (meanings, competences and materials – illustrated in Figure 12.2),

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Spurling et al, 2013 (compare Spurling and McMeekin, 2015) suggest three complementary models for policy intervention: recrafting practices; substituting practices; and changing how practices interlock. These models are intended to reframe policy problems in the light of practice theoretical insights. Figure 12.2: The three elements model of practice

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‘Recrafting practices’ suggests changing one or more of the constituent elements of practices and as such is not dissimilar to some existing forms of intervention. However, its starting point is the systematic analysis of the dynamic relation of practice elements to inform where those changes are best made, as illustrated in Figure 12.3. Figure 12.3: Recrafting practices: changing the elements of practice

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An example of recrafting practice can be found in the ‘New Nordic Diet’, a policy programme that aimed to develop a healthy, environmentally sustainable diet based on foods originating from the Nordic region, developed out of a five-year multidisciplinary research project. It addressed all three elements of practice simultaneously. First, it changed the material element of food; second, competences, by offering cookery courses; and third, meanings: it was conceived as an identity movement and promoted by fashionable restaurants, celebrity chefs, and other high-profile supporters (Spurling et al, 2013). Substituting practices The second model, of particular pertinence to sustainability, is ‘substituting practices’. This asks policymakers to think how alternative practices can fulfil the same needs and wants as the unhealthy or unhelpful practice. It draws attention to how different practices compete for time, space and resources, and how infrastructures and conventions lock the evolution of social practices into particular paths. Thus, in recent years we have seen a trend towards the uptake in cycling, based in changes of associated meanings, the spread of competence and material innovations in bicycle technology; however, to scale up this trend and significantly shift commuters from travelling by car to travelling by bicycle requires, as a prerequisite, attention to infrastructural changes (Spurling et al, 2013). ‘Substituting practices’ is illustrated in Figure 12.4. Figure 12.4: Substituting practices: different practices compete for time, space and resources Competences

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Interlocking practices The third model seeks to identify how practices interlock with one another. There is both a spatial and a temporal aspect to this. Crucially, practices interlock through sequence and synchronisation. Our daily schedules are heavily determined by institutions and organisations, and much infrastructure is designed to meet the peak load demanded of it by the synchronised performance of practices, whether rush-hour traffic or putting the kettle on in the same TV advert break. This is illustrated in Figure 12.5. The temporal coordination of practices, their sequencing and synchronisation within collective life, presents novel opportunities for achieving substantial shifts in behaviours by positively harnessing the complex interactions between practices (Southerton et al, 2011a; Spurling et al, 2013). Southerton and colleagues (2011a, p 34) argue that temporality is a particularly important feature of how the elements of practices are configured: ‘the form of duration, periodicity, sequence, tempo and synchronization represent readily identifiable features of the practice as an entity’. They explore this through a comparative study of eating in Spain and the UK, and argue that given the importance of the temporal dimension in distinct cultural patterns of eating practice ‘instruments for changing eating practices should take seriously the interrelated temporalities of related practices’ (Southerton et al, 2011a). Speculatively, they suggest this might include ‘the temporalities of working times, should the target be to encourage people to eat at collectively defined times’ (Southerton et al, 2011a), with possible benefits for sustainability. The ‘sequential ordering of food provisioning (such as shopping, storing, cooking and eating food) in relation to broader everyday temporal rhythms could also be considered if the target is to encourage local sourcing of food, less use of frozen storage, and reducing domestic food waste’ (Southerton et al, 2011a). While such ideas are speculative, they suggest novel empirical questions pertinent to the goal of the policy intervention, and, critically, shift ‘policy orientation away from persuading, influencing and encouraging attitudinal change in the hope that millions of people will simultaneously change their behaviours, and toward a focus on how daily practices are co-ordinated and ordered within collective daily life’ (Southerton et al, 2011a). Furthermore, as many social practices are so interlocked, any form of intervention may produce change that ripples through interconnected practices (Spurling et al, 2013). The social practice perspective

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Figure 12.5: Changing how practices interlock

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enables a more holistic view of these interlocking effects, intended or unintended, than more limited models of behaviour. Box 12.4: Stop and think: implications for evaluation We heard in Chapter Two how important evaluation is for behaviour change. It is essential to demonstrate the effectiveness of any type of intervention and for underpinning decisions from policymakers, particularly where large budgets are involved. However, there are significant implications to evaluation of any intervention given the principle explored here that practices interlock and changes to one will likely have implications on others in the same bundle. Do you think there is a way round this or do you think policymakers will shy away from theories of practice for this (or perhaps other) reasons?

Conclusion The logic of models of behaviour leads to the particular framing of problems, suggesting plausible and possible targets for intervention, while excluding others (Spurling et al, 2013). The portfolio model implicit in so much behaviour change policy promotes interventions that overemphasise individuals’ autonomy, and thus responsibility, and underestimate the social, cultural, economic and material constraints acting on them. Conventional initiatives directed at attitudinal change fit more comfortably into limited budgets and evaluation timescales, but they also reinforce a particular ideology in which responsibility for changing complex social problems is laid at the door of individuals’ behaviour (Shove, 2010; Barr and Prillwitz, 2014; Moloney and Strengers, 2014). Proponents argue that the social practice perspective offers more robust accounts of how social change actually comes about and suggests novel targets for interventions. But arguably a social practice perspective also demands a more ambitious approach to address grand societal challenges such as climate change or obesity − one that explicitly addresses the socio-technical organisation of practices and the systemic causes of those challenges. Writing prior to the recent policy-focused developments cited earlier, Jackson (2005) suggested that theories of practice would lead us to abandon notions of individual agency altogether, locating social action at the collective level. ‘Behavioural change in this view would simply be seen as the evolution of “social practices”’, suggested Jackson (p 63), and as such could offer little concrete to policy. While practice theoretical approaches do not advocate the abandonment of agency (see, for example, Schatzki, 2002), they do suggest the ways in which

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agency is constrained, as well as decentring deliberation and intention as the source of behaviour. While this theoretical move may be a useful corrective to the portfolio model, the pendulum should not swing so far the other way that we argue, with Jackson (2005), that theories of practice imply that social practices simply evolve blindly through their own internal and external dynamics. One trend in contemporary practice theory does emphasise the complex dynamics of practice, and the co-evolution of conventions and competences, on the one hand, and infrastructures and technologies on the other, as the motor of social change, to the exclusion of the role of social struggles, collective action, and the purposive interventions of social and political actors (Welch and Warde, 2015). This trend emphasises ‘that enduring change emerges through the amplification of existing social orientations’ and plays down the role of explicit contestation and discursive processes in the public sphere (Chappells et al, 2011, p 701). I would argue to the contrary, that examples of enduring change occurring through purposive social, economic and political interventions are historically commonplace. Theories of practice emphasise complex causality in processes of change. Whether the evolutionary dynamics of practice or purposive interventions are the dominant cause in specific processes of change is always an empirical question. Recognising the limitations to individuals’ capacities for behaviour change should underscore the necessity of more systemic approaches to complex social problems. However, recognising the complexity of social practices also suggests modesty on the part of policymakers over technocratic approaches to behavioural and social change (Spurling et al, 2013). The complex interconnections between practices suggests that predicting the effects of interventions is hard, and that it is not easy to model processes of change (Evans et al, 2012). Moreover, as practices continually follow their own trajectories of change, they represent moving targets, as it were, and ‘interventions go on within, not outside, the processes they seek to shape’ (Shove, 2010, p 1278). This suggests the need for a programmatic, reflexive and responsive approach to policy that emphasises collective social change over individual behaviour change. Box 12.5: Stop and think: considerations for policy It is important to note that applications of a social practice perspective to policy have thus far been extremely limited, and the importance of some of its key insights for practical policy applications are speculative. Here are some key issues that policymakers might face when trying to apply theories of practice:

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End-of-chapter questions • How might seeing values, attitudes, ends and so on, as embedded in social practices change our approach to behaviour change policy? • How might thinking about the different types of elements or components of practice inform behaviour change interventions? • What are the implications of practice theory for policy? • To what extent is practice theory compatible with, or complementary to, other theoretical approaches? (See the ‘ABC debate’ reading suggested on p xx.) • What is the role of the individual and individual agency within practice theory? • What are the challenges of confronting a policy world dominated by a neoliberal agenda with a radically alternate view?

Note Other foundational definitions include Reckwitz (2002, p 249) and Schatzki (2002, p 77). 1

References Barr, S. and Prillwitz, J. (2014) ‘A smarter choice? Exploring the behaviour change agenda for environmentally sustainable mobility’, Environment and Planning C: Government and Policy, 32, 1-19. Blue, S., Shove, E., Carmona, C. and Kelly, M.P. (2016) ‘Theories of practice and public health: understanding (un)healthy practices’, Critical Public Health, 26(1): 36-50. Chappells, H., Medd, W. and Shove, S. (2011) ‘Disruption and change: drought and the inconspicuous dynamics of garden lives’, Social and Cultural Geography, 12(7): 701-15. Chatterton, T. (2011) An introduction to thinking about ‘energy behaviour’: A multi model approach, London: DECC, www.gov.uk/government/ uploads/system/uploads/attachment_data/file/48256/3887-introthinking-energy-behaviours.pdf Darnton, A. and Evans, D. (2013) ‘Influencing behaviours: a technical guide to the ISM tool’, The Scottish Government, www.scotland. gov.uk/Resource/0042/00423531.pdf Darnton, A., Verplanken, B., White, P. and Whitmarsh, L. (2011) Habits, routines and sustainable lifestyles, Summary Report to the Department for Environment, Food and Rural Affairs, London: AD Research and Analysis for Defra. Evans, D., McMeekin, A. and Southerton, D. (2012) ‘Sustainable consumption, behaviour change policies and theories of practice’ in A. Warde, and D. Southerton (eds) The habits of consumption, Collegium, vol. 12, www.helsinki.fi/collegium/e-series

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Giddens, A. (1984) The constitution of society, Cambridge: Polity Press. Halkier, B. (2010) Consumption challenged, Farnham: Ashgate. Hargreaves, T. (2011), ‘Practice-ing behaviour change: applying social practice theory to pro-environmental behaviour change’, Journal of Consumer Culture, 11(1): 79-99. Hindess, B. (1988) Choice, rationality, and social theory, Boston: Unwin Hyman. Jackson, T. (2005) ‘Motivating sustainable consumption: a review of evidence on consumer behaviour and behavioural change’, Report to the Sustainable Development Research Network, www. sustainablelifestyles.ac.uk/sites/default/files/motivating_sc_final.pdf Kollmuss, A. and Agyeman, J. (2002) ‘Mind the gap: why do people act environmentally and what are the barriers to pro-environmental behavior?’, Environmental Education Research, 8(3): 239-60. Maller, C.J. (2015) ‘Understanding health through social practices: performance and materiality in everyday life’, Sociology of Health and Illness, 37(1): 52-66. McMeekin, A. and Southerton, D. (2012) ‘Sustainability transitions and final consumption: practices and socio-technical systems’, Technology Analysis and Strategic Management, 24(4): 345-61. Moloney, S. and Strengers, Y. (2014) ‘“Going green”? The limitations of behaviour change programmes as a policy response to escalating resource consumption’, Environmental Policy and Governance, 24(2): 94-107. ONS (Office for National Statistics) (2002) ‘The National Diet and Nutrition Survey’, www.ons.gov.uk Roberts, C., Calcutt, E., Draper, A., Hussey, D. and McManus, S. (2014) ‘Eating safe and well: links between nutrition and food safety practices’, Social Science Research Unit, Food Standards Agency, Unit Report 29, www.food.gov.uk Reckwitz, A. (2002) ‘Toward a theory of social practices: a development in culturalist theorizing’, European Journal of Social Theory, 5(2): 24363. Schatzki, T. (1996) Social practices: A Wittgensteinian approach to human activity and the social, New York, NY: Cambridge University Press. Schatzki, T. (2001) ‘Introduction: practice theory’, in T.R. Schatzki, K. Knorr Cetina and E. Savigny (eds) The practice turn in contemporary theory, London: Routledge. Schatzki, T. (2002) The site of the social, University Park, PA: Pennsylvania State University Press.

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Schatzki, T. (2011) ‘Where the action is (on large social phenomena such as sociotechnical regimes)’, SPRG Working Paper 1, www. sprg.ac.uk Shove, E. (2003) Comfort, cleanliness and convenience: The social organization of normality, Oxford: Berg. Shove, E. (2010) ‘Beyond ABC: climate change policy and theories of social change’, Environment and Planning A, 42: 1273-85. Shove, E. and Spurling, N. (eds) (2013) Sustainable practices: Social theory and climate change, London: Routledge. Shove, E. and Warde, A. (2002) ‘Inconspicuous consumption: the sociology of consumption, lifestyles and the environment’, in R. Dunlap, R. Buttel, F. Dickens and P. Gijswijt (eds) Sociological theory and the environment: Classical foundations, contemporary insights, Lanham, MA: Rowman and Littlefield. Shove, E., Pantzar, M. and Watson, M. (2012) The dynamics of social practice: Everyday life and how it changes, London: Sage Publications. Southerton, D. and Welch, D. (2015) ‘A social practice perspective’, in S. Christmas, S. Michie, and R. West, (eds) Thinking about behaviour change: An interdisciplinary dialogue, London: Silverback Publishing. Southerton, D., Diaz-Mendez, C. and Warde, A. (2011a) ‘Behavioural change and the temporal ordering of eating practices: a UK–Spain comparison’, International Journal of Sociology of Agriculture and Food, 19(1): 19-36. Southerton, D., McMeekin, A. and Evans, D. (2011b) ‘International review of behaviour change initiatives’, The Scottish Government, www.scotland.gov.uk/Resource/Doc/340440/0112767.pdf Southerton, D., Warde, A. and Hand, M. (2004) ‘The limited autonomy of the consumer: implications for sustainable consumption’, in D. Southerton, H. Chappells and B. Van Vliet (eds) Sustainable consumption: The implications of changing infrastructures of provision, Cheltenham: Edward Elgar. Spotswood, F., Chatterton, T., Tapp, A. and Williams, D. (2015) ‘Analysing cycling as a social practice: an empirical grounding for behaviour change’, Transportation Research Part F, 29: 22-33. Spurling, N. and McMeekin, A. (2015) ‘Interventions in practices: sustainable mobility policies in England’, in Y. Strengers and C. Maller (eds) Social practices, intervention and sustainability: Beyond behaviour change, London: Routledge. Spurling, N., McMeekin, A., Shove, E., Southerton, D. and Welch, D. (2013) Interventions in practice: Re-framing policy approaches to consumer behaviour, SPRG Report, www.sprg.ac.uk

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Strengers, Y. and Maller, C. (eds) (2015) Social practices, intervention and sustainability: Beyond behaviour change, London: Routledge. Warde, A. (2005) ‘Consumption and theories of practice’, Journal of Consumer Culture, 5(2): 131-53. Warde, A. (2013) ‘What sort of a practice is eating?’, in E. Shove and N. Spurling (eds) Sustainable practices: Social theory and climate change, London: Routledge. Warde, A. (2014) ‘After taste: culture, consumption and theories of practice’, Journal of Consumer Culture, 14(3): 279-303. Warde, A. and Southerton, D. (2012) ‘Introduction’, in A. Warde and D. Southerton (eds) The habits of consumption, Collegium, vol. 12, www. helsinki.fi/collegium/e-series Watson, M. (2012) ‘How theories of practice can inform transition to a decarbonised transport system’, Journal of Transport Geography, 24: 488-96. Welch, D. (2015) ‘Systems, actors, ends, narratives and identities’, in C. Foulds, C.L. Jensen, S. Blue and R. Morosanu (eds) Practices, the built environment and sustainability: Responses to the Thinking Note Collection, Cambridge, Copenhagen, London: GSI, DIST, BSA CCSG. Welch, D. and Warde, A. (2015) ‘Theories of practice and sustainable consumption’, in L. Reisch and J. Thøgersen (eds) Handbook of research on sustainable consumption, Cheltenham: Edward Elgar Publishing. Whitford, J. (2002) ‘Pragmatism and the untenable dualism of means and ends: why rational choice theory does not deserve paradigmatic privilege’, Theory and Society, 31(3): 325-63.

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The emergence of systems thinking in behaviour change: a public health focus Esther Trenchard-Mabere

Introduction This chapter picks up the thread of ‘multidisciplinarity’ that has been running throughout this volume. This time, the focus is on the growing interest among public health practitioners and academics about the relevance of ‘whole systems approaches’ to a number of current behaviour change challenges. This interest comes in recognition of the wide range of social, economic, environmental, psychological, behavioural and biological factors that influence some of the societal problems we face, particularly in health. However, the translation of concepts, approaches and methods from the extensive literature on ‘systems thinking’ to mainstream research and practice of public health in England is still patchy, even though many of the ideas and concepts have a long history. The term ‘whole systems approach’ is used inconsistently; for example, it can refer to a ‘system-wide’ approach that acknowledges the wide range of factors influencing the health of an individual, community or population but addresses the identified factors with an essentially reductionist, mechanistic approach. The term ‘whole systems approach’ can also refer to an approach that uses a radically different methodology that is informed by the emerging understanding of complex, adaptive systems. This chapter focuses on the latter, exploring the academic heritage of systems thinking before applying the approach to the problem of obesity and drawing on the Foresight obesity study to illustrate the case.

Key features of ‘systems thinking’ ‘Systems thinking’ as currently understood emerged in the early 20th century from a number of disciplines including ecology, anthropology,

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psychotherapy, cybernetics, quantum physics and management theory, although arguably has deeper roots in, for example, the thinking of Darwin, Goethe and Aristotle (Capra and Luisi, 2014). There are a number of ways of categorising systems. One classification is that of ‘simple’, ‘complicated’, ‘complex’ and ‘chaotic’ (Plsek, 2003; Rickles et al, 2007). A simple system has very few parts and a complicated system (like a rocket) can have a very large number of parts, but both systems are characterised by linear behaviour, where the behaviour of the system can be understood and predicted by an understanding of the parts and the rules governing the relationships between the parts or between inputs and outputs. In contrast, complex systems not only have many parts, but also show non-linear behaviour; that is, outputs are not necessarily proportional to inputs (Rickles et al, 2007). While it is sometimes argued that with sufficient computational power the behaviour of any system could be predicted, the implications of systems thinking are that the behaviour of complex systems cannot always be explained or predicted by linear or mechanical relationships and needs to be understood as a dynamic and integrated wholes. Complex systems are recognised to have ‘emergent properties’ that arise from the interrelationships between the parts but are not features of the component parts, so that ‘the whole is more than the sum of its parts’ (Christian von Ehrenfels, 1859-1932, cited in Capra and Luisi, 2014). Chapman (2004) argues that while reductionist thinking attempts to understand things by breaking them down into component parts, systemic thinking goes up a level of abstraction to look at the system or sub systems as a whole. Complex systems display ‘self-regulation’ through feedback loops (Meadows, 2008). Negative feedback loops are those where some aspect of the ‘output’ has the effect of reducing the ‘input’ and this provides the basis of homeostasis (Cannon, 1932). Positive feedback loops also operate in complex systems and will tend to amplify processes and can produce runaway exponential behaviours. In self-regulating systems, such as a living organism or an ecosystem, potentially exponential behaviours are held in check by other parts of the system. A complex system such as a living organism or ecosystem is dynamic and in a state of continuous change. Maintaining a stable state requires continuous adaptation to changes in the internal and external environment. The dynamic and adaptive properties of a complex system can also lead to unintended and/or unanticipated consequences as feedback loops compensate for the impact of a change or intervention (Meadows, 2008; Capra and Luisi, 2014). The effects of an impact to

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one part of a system can manifest in other parts of the system that are distant in space and/or time (McMichael, 1999). Regulation via feedback is not unique to complex systems and can be built into a simple or complicated system (such as a thermostat), but in a complex, self-regulating system the feedback mechanisms have ‘evolved’ and do not depend on an external agency defining a set point (Capra and Luisi, 2014). Complex adaptive systems also differ from complicated systems that have been designed by human beings in that they evolve and so importantly have a history (Plsek, 2003b; Capra and Luisi, 2014). Thus, the present state of a complex system is determined by its history. While aspects of the historical development or evolution of a complex system may follow predictable rules or patterns, there is also an important role of chance or contingency so that the historical development of a complex system may be inherently unpredictable (Cohn et al, 2013). It has been observed that ‘hindsight does not lead to foresight’ (Snowden and Boone, 2007). With hindsight, the impact of an unusual or unexpected event that pushes a complex system into a different state can be understood and this can provide useful learning, but it does not necessarily enable the prediction of similar events in the future. Related to the importance of history is what is described as ‘sensitivity to initial conditions’, where a small difference in initial conditions can have a large and unpredictable effect on a later state of the evolving system (Rickles et al, 2007). An example of this effect is the impact of conditions in early life on longer-term health outcomes as described by Barker (1994) and Marmot (2010). Complex systems tend to be made of parts that are complex systems in their own right, which are ‘nested’ in the larger system (such as mitochondria, cells, organs, organ systems, the organism, the community of organisms). At each new level, there are emergent properties that cannot be found in the component parts. There will, however, be complex interactions between the different levels of systems. It has been observed that a ‘complex adaptive system’ cannot be isolated from its ‘environment’ (Best and Holmes, 2010). Living organisms and ecosystems, as self-regulating systems, are in continual interaction with their ‘environment’; they both shape and are shaped by their ‘environment’ in a process of co-evolution. To understand things systemically means to put them into a context, to establish the nature of their relationships (Capra and Luisi, 2014).

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Box 13.1: Stop and think: an example of a complex system A frequently quoted example that illustrates the fundamental difference between the predictability of cause and effect in simple and complex systems is that of kicking or throwing a stone compared with kicking a dog or throwing a bird (Plsek, 2003b; Chapman, 2004). The impact on the stone can be described and predicted in terms of the laws of mechanics, whereas the impact on the dog or bird depends on the particular history and (ever-changing) state of the dog or bird. Plsek describes how, when intervening in a complex system, the ‘disturbing agent’ brings about change simply as a trigger, but the change is determined by the present characteristics and history of the ‘disturbed system’.

Table 13.1 summarises some of the key features of reductionist approaches compared with those of systemic approaches. Table 13.1: Key features of reductionist approaches compared with key features of systemic approaches Reductionist approaches

Systemic approaches

Parts Objects Structures (of components) Measuring Quantities Linear dynamics Independent variables Predicting Objective Machine metaphor Appropriate for simple and complicated systems

The whole Relationships Patterns (connecting components) Mapping Qualities Non-linear dynamics Interdependence of variables Understanding Inter-subjective Living systems metaphor Appropriate for complex, adaptive systems

The point is not that one way of thinking is better than the other; they are both of value and are in fact complementary (Chapman, 2004). The point is to recognise the limitations of linear, reductionist approaches when tackling the complex social systems that have generated the majority of the public health issues that we currently face. This ‘behaviour change’ context is now explored in more depth.

The nature of social systems The focus of public health is on the improvement or protection of population health and therefore needs to be informed by an understanding of social systems. Social systems can be understood as complex systems with emergent properties. An example is meaning

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and language, which are integral to human existence given the social nature of our species. The effect of hearing a pattern of sounds is determined by its meaning to the receiver and not uniquely by its physical characteristics. Meaning and language are therefore emergent properties of the ability of human consciousness to form abstract mental images, concepts, ideas and symbols, and form the basis of culture (Capra and Luisi, 2014). Other emergent properties of social systems arise from the patterns of relationships between individuals and groups, for example social support networks and the power relationships that are key determinants of behaviour and allocation of resources. Culture and social networks evolve in interaction with people’s material and living (biological) environments and in turn generate material structures such as buildings, roads, technologies, texts and works of art. These material elements combine with the biological, social and cultural to form an integral part of the human ‘ecosystem’ (Rayner and Lang, 2012). All dimensions – and their interrelationships – need to be considered to effect change at a population level. How individuals behave within this complex social system is variable. A person’s response depends on their own particular characteristics (as a complex system), including their unique starting point and history, and how they interact with the environment. This points to the importance of recognising difference (Chapman, 2004), and also can throw light on characteristics (such as resilience, self-efficacy, and access to strong social support networks) that enable some people to maintain their health and wellbeing in adverse environments (Kobasa, 1983; Antonovsky, 1987; Kornitzer et al, 1993). Social systems, while showing many features of evolved, selfregulating, complex adaptive systems such as living organisms and ecosystems, also have some features of ‘designed systems’, in that the rules and norms governing acceptable or habitual behaviour are not ‘natural laws’ (as in the ‘laws of physics and chemistry’) but have been created by human beings and so therefore can be changed by human beings. To effect change at a population level, a systemic approach points to the need to focus as much on the behaviours of actors that are driving the system (that is, through wider social and economic policy and commercial economic activity including media and advertising) as on the ‘health behaviours’ that are the (sometimes unintended) consequences of the system (Rayner and Lang, 2012).

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Box 13.2: Stop and think: the role of business and marketing in the system Looking back at Chapter Nine, it is clear to see that business activities have a strong role to play in the complex social systems and contribute to the societal problems that much behaviour change works seeks to influence. Do you think there is enough emphasis in ‘behaviour change’ on parts of the system in which business and marketing dominate? Do you think a systems approach to ‘behaviour’ change might overcome this problem? An example beyond Public Health: One approach that has sought to inject systematic thinking into corporate behaviour for the purposes of sustainability is the Framework for Evolved Marketing that came out of Friends of the Earth’s Big Ideas research programme (Hurth et al, 2015). This situates marketing as being at the heart of how a business decides to use scarce resources to provide social value in the long-term and at the heart of how a business (directly or indirectly) shapes societies, cultures and behaviours. At the same time it recognises that there is little clarity over what ‘sustainable marketing’ looks like, how to get there and what might be limiting progress. The Framework outlines six principles and incremental levels of maturity. This ‘maturity matrix’ allows different organisational levels and other stakeholders to develop a shared language to critically assess where a company is on its journey and help unblock systemic barriers to achieving sustainable business models. To download the report and framework visit https://www.foe. co.uk/sites/default/files/downloads/reforming-marketing-sustainability-fullreport-76676.pdf.

Theories of change in complex, adaptive systems Much of the thinking about how to achieve change in complex, adaptive social systems has come from ‘management science’ and theories of organisational change. Observation of the features of highperforming organisations, successful change processes and also ‘systems failure’ has led to the identification of effective approaches to change in complex organisational systems (Senge, 1990; Plsek, 2003b; Chapman, 2004) that are increasingly being applied in a variety of health and social care settings (Pratt et al, 1998; 2005; Plsek, 2003b; Plsek and Greenhalgh, 2001; Hudson, 2006; de Savigny and Adam, 2009). The next section explores these levers for change.

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A collaborative definition of boundaries In classical systems theory, definition of the boundary of the system is emphasised. Living organisms are examples of complex systems that have clear boundaries. Definitions of the system and its boundaries can be more difficult in social systems, and have been described as ‘fuzzy’ boundaries (Plsek, 2001) due to the nature of influence between wider systems in which ‘lower-level systems’ are nested and differing perspectives of actors in the system. One approach for managing change within such fuzzy sets of boundaries is for the key stakeholders or actors in the system to agree on a definition of the system and change they wish to achieve. This can clarify scope and focus action on arenas that the actors can more readily influence (Chapman, 2004) but can sometimes also rule out potentially more effective interventions at a higher system level (Meadows, 2008). Box 13.3: Stop and think: an example of using boundary definitions to change the focus of activities An example of a shift in the definition of a system in order to achieve more manageable outcomes was the scope of the National Institute for Health and Care Excellence (NICE) programme development group that was originally convened to produce guidance on ‘whole systems approaches’ to preventing obesity. The group was later instructed to change its remit to ‘working with communities’. Interventions at a national policy level were ruled as out of scope. To what extent do you think this change of definition made the guidance more useful? What potential interventions at a higher system level were ruled out?

Leadership Due to the dynamic and inherent unpredictability of a complex system, where changes to one part of the system can have unintended effects (positive or negative) in another part, it is necessary to have leadership distributed across and at all levels in the system in order to achieve effective change. Traditional approaches to leadership based on command and control, delegation and positional authority are seen to be most appropriate for managing change in the context of problems where there is a high degree of certainty and agreement about what needs to be done (Plsek, 2000). See Figure 13.1 for Plsek’s explanatory diagram. However, as a system becomes more complex, there is a need for an adaptive, distributed or transformational leadership style that uses facilitation, empowerment, participatory action and

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continuous evaluation and learning to respond to the inherent unpredictability of the system in change and to engage and motivate others to participate in the change process (Senge, 1990; Chapman, 2004; Pratt et al, 2005). Engaging actors across the system The engagement approach to system change embraces ‘partnership’ working (Pratt et al, 1998) or a ‘system-wide’ approach and utilises participatory methodologies (such as Open Space, World Café, Appreciative Enquiry, scenario-based forecasting) that engage the ‘collective intelligence’ of diverse actors or stakeholders to create new interconnections and patterns (Brown and Isaacs, 2005). To successfully engage a wide range of different actors, it is important to recognise and embrace a diversity of views (Chapman, 2004) and acknowledge that nobody knows the answer (Meadows, 2008). One such mechanism for achieving this is through a ‘social movement’ approach (Bibby et al, 2009). Figure 13.1: Certainty–agreement diagram

Degree of agreement

Low

Chaos Zone of complexity

Plan and control

High

Degree of certainty

Low

Source: Plesk (2003a).

The importance of a shared vision A ‘shared vision’ among a group working towards systemic change is also frequently cited as important – to give focus and alignment of goals and actions. Different actors or agencies may have different primary goals, but if they can identify areas of overlapping interest and

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agreement, system change becomes possible (Chapman, 2004; Hudson, 2006). Some key stakeholders can be hard to engage and influence; for example, the overconsumption of unhealthy foods and drinks is driven by commercial interests and powerful marketing techniques. However, without engagement with the private sector, building true cooperation towards a common goal, progress on tackling obesity will continue to be slow (Jebb, 2014). Recognition of the informal structure and culture of organisations The formal structure in an organisation will usually be a ‘designed system’ with an emphasis on positional authority, clear lines of accountability and decision making. Observations of failed change management processes have pointed to the importance of also recognising and working with the informal organisational structures and cultures. In this informal, emergent, complex system, key players are defined by their networks, interconnections and informal influence rather than positional authority (Senge, 1990; Oliver et al, 2013). Change is more likely to be achieved if the priorities and concerns of all key players are recognised and taken into account (Chapman, 2004), so it is imperative to take into account the informal structures in which organisation members exist. Reflective learning processes When operating in a complex adaptive and inherently unpredictable environment it is important to build in flexibility, adaptability and responsiveness and to utilise iterative approaches with continuous evaluation, feedback and learning both from ‘what works’ and also from ‘mistakes’ and unintended consequences. Senge (1990) has written extensively on the characteristics of the ‘learning organisation’ that is based on systems thinking. Key features include creating an organisational culture that encourages new ways of looking at issues, seeing the bigger picture as well as the parts, and allowing for the emergence of creativity. Similarly, Chapman (2004) highlights that aversion to failure and pressures linked to command and control, uniformity, efficiency, timing and concerns about status are factors that can prevent organisations learning from what has not worked.

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Where to intervene in a complex system Meadows (2008) describes 12 leverage points to intervene in complex dynamic systems, through various aspects of relationships, feedback loops and information flows to the underlying goals and paradigms. She argues that interventions at the paradigm level (that is, the underlying culture, beliefs, values and norms shaping a complex social system) are likely to be the most effective, but that these can be difficult to implement because of power relationships and vested interests. Interventions at ‘lower’ levels will be less effective as the system, driven by the higher levels, will adapt and resist change and so many more interventions will be required to achieve change that will also be harder to sustain. She and others argue that that by looking at the ‘bigger picture’ – the underlying drivers of the system – there is a greater likelihood of identifying leverage points for system change, but in practice it will often be necessary to intervene at multiple levels (Senge, 1990; Meadows, 2008; de Savigny and Adam, 2009).

Implications of systems thinking for research and the practice of public health For public health it can be argued that the need to embrace systemic approaches is even more critical than for organisational change in business, health and social care services. Public health has a much wider focus, across socioeconomic and biological/living systems, as opposed to the working of a particular organisation or group of organisations and their interactions with a complex environment. For public health there are important questions about ‘what’ are the key influences on health outcomes as well as ‘how’ to intervene to improve health. The following sections explore some areas of development and debate about achieving systemic change in public health. Traditional reliance on epidemiology Increasingly sophisticated epidemiological, statistical and qualitative mapping approaches (Greenland and Brumback, 2002) have greatly increasing our understanding of the complex interplay of environmental, social, economic, behavioural and biological factors affecting health outcomes. Epidemiology – based primarily on a quantitative, deterministic methodology – is the study of factors that determine the occurrence and distribution of health and disease in a population and it has traditionally been used as the basis for much

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public health insight and intervention. Epidemiologists study the social or community origins of health and disease such as environmental, social, nutritional, behavioural and psychological factors as well as the effectiveness of interventions. However, McMicheal (1999) has argued that to better understand the wider determinants of population health there is a need to adopt a social-ecologic systems perspective rather than rely on epidemiology. He identified four main constraints of epidemiology that limit engagement in issues of wider context. Epidemiology tends to: • be preoccupied with proximate risk factors that are close to the individual in time or space; • focus on individual as opposed to population influences on health; • focus on a narrow time window (such as the life-stage as opposed to a life-course model); • lack engagement with scenario-based forecasting methodologies to explore the potential health consequences of future large-scale social and environmental changes. There is, however, increasing engagement by epidemiologists with ecological, dynamic, interactive, life-course models of the accumulation of risk factors for disease and more extended spatial-temporal frames of reference, for example exploring effects of environmental exposures across generations and across the life course. This enables deeper insights into the complex social and environmental systems that are the context for health and disease (Susser and Susser, 1996; McMichael, 1999). Box 13.4: Stop and think: widening the focus Shifting the focus from a specific disease or behaviour to the wider social context can give a very different picture. It has long been noted that that the relationship between social class and disease holds for the majority of major causes of death and this has been explored in relation to the concept that social deprivation may cause a ‘general susceptibility’ to disease (Cassel, 1976; Berkman and Syme, 1979; Najman, 1980; Marmot, 1986). From a systemic perspective the impact of social deprivation could be described as the primary risk factor with different individual responses influenced by their specific histories and interactions with the environment.

From ‘evidence to knowledge’ It has been recognised that there can be great practical difficulties in applying the randomised controlled trial (RCT) methodology to the

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evaluation to public health interventions involving social systems, due to the difficulty in achieving the level of control and randomisation required (also discussed in Chapter Five of this volume). A systems approach also raises questions about the underlying assumptions of the RCT and ‘evidence-based’ interventions or policy. For example, RCTs presume: • linear relationship between cause and effect; • the possibility of ‘controlling’ for environmental and contextual factors; • predictability of the effects of an intervention; • the validity of a ‘linear transfer’ of knowledge from researchers to practitioners to implement universally applicable evidence-based interventions with only minor adaptations to local conditions (Chapman, 2004; Best and Holmes, 2010; Best and Saul, 2011; Livingood et al, 2011). A systems approach is interested in the unintended effects (both positive and negative), as well as the intended effects, which tend to be the focus of RCTs. A systems approach gives particular focus to the interactions and synergies between different factors, and looks more widely across the system at distant and longer-term consequences of more immediate or shorter-term changes (McMichael, 1999). Rutter (2014) has argued that at times the symbolic importance of an intervention in engaging participants in a longer-term change process can be as important as any short-term impacts of the intervention. Rutter has also argued that it can be more important to try to minimise harmful unintended consequences than to demonstrate short-term impacts. Thus, reductionist approaches to evaluation are sometimes not only inappropriate for the complex social systems that are the central concern of public health, but can also tend to distort policy towards interventions focusing on short-term individual behaviour change that are more easily measured and testable in an RCT (Livingood et al, 2011). The evaluation of interventions in complex social systems requires a more collaborative approach between researchers and practitioners that integrates research and practice and is based on continuous learning at the application level, pooling practice-based evidence across contexts and learning from ‘natural experiments’. To support such an approach, there is a need to train both researchers and practitioners in the use of tools such as systems dynamics modelling, social network analysis and concept mapping and to further develop tools that are appropriate

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for understanding complex social systems (Best and Holmes, 2010; Livingood et al, 2011). There is also a need for researchers and policymakers to work closely together to change the culture within policymaking that takes RCT-style ‘evidence’ as its baseline. The desire by policymakers for ‘certainty’ in their evidence is understandable, but the contention here is that there are many types of evidence and also that science does not produce certainty – empirical knowledge will always be subject to revision, as these quotes attest: The argument that we should wait for certainty is an argument for never taking action – we shall never be certain. (Marmot, 1986, p 898) Knowledge is reached when a sense of uncertainty is reduced sufficiently to take action. (Rayner and Lang, 2012, p 331) Finally, Rayner and Lang (2012) make the important point that ‘evidence’ and ‘proof ’ in public health needs to be based on interdisciplinary knowledge. Socio-ecological approaches to public health The term ‘ecological public health’ is not used consistently and can refer to an approach that emphasises the wider environmental and social determinants of health without necessarily recognising the features of a complex adaptive system. However, ecology is one of the source disciplines for the understanding of complex adaptive systems and any approach that is genuinely based on ecological thinking will implicitly embody systemic principles (McLeroy et al, 1988; Cohn et al, 2013). Bronfenbrenner’s ecological model (1977) is widely cited – and illustrated in Figure 7.2 of this volume – and has influenced other models that represent different influences by concentric rings (such as that by Dahlgren and Whitehead, explored in Chapter Three). Marmot’s model of the social determinants of health incorporates systemic thinking in both the analysis of the issues (for example, focus on social context, life course and links to wider environmental issues) and recommends taking a ‘whole system’ approach to addressing the issues (Marmot, 2010). However, even when operating with an ecological model, action directed at higher levels of the ‘whole system’ are less common than ‘system-wide’ action addressing structural elements (Malhi et al, 2009;

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Meadows, 2008). To this end, Rayner and Lang (2012) have criticised many widely used socio-ecological models that subtly present politics, economics and ‘the environment’ as distant and ‘out there’, when in fact they argue they closely infuse intimate reality. They put forward a model of ecological public health that is informed by a historical perspective of public health addressing a continuous world in dynamic transition. They argue that human bodies cannot exist apart from the natural environment and highlight the central importance of sustainability as the single greatest challenge of our time with health at the heart of it. In their conclusion, Rayner and Lang argue that ecological public health is about shaping the conditions for good health for all, creating a society that takes all people’s health seriously, but add that: This will not happen in a world driven by consumerism, where ceaseless pursuit of material goods is a substitute for wellbeing, and now the basis for economic activity. (Rayner and Lang, 2012, p 352) Behaviour and the environment It is widely recognised that factors in the physical and social environment are important determinants of individual behaviour (for example, overeating and sedentary behaviour in response to the ‘obesogenic environment’). Investigation into the development and maintenance of habits has shown that behaviour is often not under conscious control and can be triggered by cues that have become associated with rewards (Cohen and Babey, 2012; Duhigg, 2012). Thus it follows that there is a tendency for individuals who have successfully changed their behaviour (such as quitting smoking, losing weight, cutting down on alcohol or giving up a criminal lifestyle) to relapse when exposed to the ‘old environment’. Also, there is evidence that even highly addictive behaviours such as opiate use are less likely to relapse if, following quitting, the person moves into a different environment (Spiegel, 2012). Where groups of people display similar behaviours this points to an underlying systemic cause and in such cases it is important to look beyond individual behaviour to the underlying structures that shape individual actions in order to create the conditions where different types of behaviours become likely (Senge, 1990). A systemic approach would suggest that focusing on specific behavioural cues without addressing the wider context or system that is generating these cues is likely to

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have limited sustainable impact on behaviour at a population level. A similar point is also made strongly in Chapter Ten. Community development approaches Most of the features of community development approaches to public health and health promotion are consistent with systemic approaches, addressing engagement, participation, networks, multiple perspectives and challenging power relationships. NICE (2008) defined community development as follows: Building active and sustainable communities based on social justice, mutual respect, participation, equality, learning and cooperation. It involves changing power structures to remove the barriers that prevent people from participating in the issues that affect their lives. (p 41)

Box 13.5: Stop and think: examples of ‘systemic’ community development and social movement approaches There are many examples of community development and ‘social movement’ approaches (Brown and Zavestoski, 2004) that explicitly embrace aspects of systems thinking, for example, the Royal Society for the encouragement of Arts, Manufactures and Commerce (RSA) Connected Communities action research programme, which uses co-production approaches to map and strengthen social networks,1 the work of the Health Complexity Group, a multidisciplinary team offering professional and academic research, teaching and consultancy services based on complexity theory,2 and the Transition Town movement, a bottom-up social movement that builds local action to create a more sustainable, low carbon economy.3 However, to achieve a ‘whole system’ approach also requires genuine engagement from statutory and commercial organisations. Chapter Ten discusses in full the darker side of participatory approaches such as these.

Policy and regulatory approaches One approach changing wider social and physical environments is through policy and regulation, and this can also be very effective in achieving behaviour change at a group or population level. However, regulation can be experienced as coercive (as discussed at length in

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Chapter Four) and it has been argued that a higher level of evidence is needed for such interventions (Nuffield Council on Bioethics, 2007) – clearly problematic if the type of evidence required is harder to get (Swinburn et al, 2011). Box 13.6: Stop and think: public support for regulation The case study in Chapter Four explores in depth the regulation that prevents people from smoking in public places. Evaluation has shown that a significantly higher number of smokers in England made a quit attempt as a result of this smokefree legislation (and the tobacco advertising ban) (Bauld, 2011). However, political support for this legislation was only achieved when a high level of public support was also achieved, demonstrating the type of public support for policy and regulatory intervention that is necessary in a democratic society. This was achieved through a long process of awareness raising, advocacy and lobbying, led from the voluntary sector with support from a wide range of professionals.

Making the case for a similar comprehensive approach to issues such as obesity and alcohol misuse is more difficult, as the underpinning evidence is inherently more complex. However, there is growing evidence to support a regulatory approach to sugar consumption including the regulation of price promotions on sugary snacks, restrictions on marketing to children and increasing the price of sugary foods through a ‘sugar tax’ (Tedstone et al, 2015). This will again require public support before it is likely to be translated into legislation. It can sometimes be easier to take forward policy and regulatory approaches when working with smaller ‘sub systems’ such as through health-promoting schools, workplaces, hospitals, towns and cities where there is a more defined group of stakeholders to engage with and more scope to develop and implement policy. However, the effectiveness of such programmes will be influenced by the wider systems in which they are embedded.

A whole system approach to obesity The Foresight report Tackling obesities: Future choices (Butland et al, 2007) significantly raised awareness of obesity as the outcome of a highly complex system. The authors used a systems mapping approach to identify the factors influencing whether an individual or group will be in energy balance, and produced the well-known ‘spaghetti diagrams’ illustrating the complex interconnections between these factors. They argue that interventions are needed across all areas of the system map, and describe how the complex interrelationships

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Source: Butland et al (2007).

For a clearer view please go to https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/287937/07-1184x-tackling-obesities-future-choices-report.pdf [page 84]

Figure 13.2: The systems map of obesity

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Beyond behaviour change

between variables means that interventions in one area can produce compensatory adjustments in other areas, which needs to be taken into account. For example, intervening in ‘food consumption’ can have an impact on ‘physical activity’ and ‘individual psychology’. The map is shown in Figure 13.2. However, the Foresight report was stronger in describing the problem than identifying how to tackle it. The authors recommended that, as there were currently no realistic short- or medium-term solutions to curtail the projected increase in obesity, it is important to build the foundations for long-term sustainable change. They identified the following core principles for tackling obesity: • taking a system-wide approach, redefining the nation’s health as a societal and economic issue; • setting a higher priority for the prevention of health problems, with clearer leadership, accountability, strategy and management structures; • engaging with stakeholders within and outside government; • developing long-term sustained interventions; • prioritising ongoing evaluation and a focus on continuous improvement. The Foresight report provided the basis for the national obesity strategies of two successive administrations. In mid-2008, the CrossGovernment Obesity Unit, on the basis of a competitive bidding process, provided funding for nine ‘Healthy Towns’ to pilot approaches to tackle the environmental drivers of obesity. The initial indication that funding would be extended for successful areas was not fulfilled and so the programmes were only funded for two years, plus an initial three- to four-month set-up period, which is insufficient time to achieve system change. However, there is a wealth of important learning from these pilots that needs to be more widely shared, some of which was incorporated into NICE guidance (2012). In the case of the Tower Hamlets ‘Healthy Borough’ programme (one of the Healthy Towns initiatives), evaluation of the cultural and strategic impact of the programme confirmed that it incorporated many of the features of a systemic approach (Hayden et al, 2011), with some initial evidence of system-wide change and impact on child obesity levels (Williams et al, 2011). The challenges and barriers faced during the Tower Hamlets project, and within systems approaches more generally, are described in the following vignette.

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Box 13.7: Stop and think: challenges and barriers to the implementation of systemic approaches in public health In one of a series of literature reviews on whole systems approaches and obesity prevention, Pearson et al (2011) identified the following challenges and barriers, some of which were experienced in the Tower Hamlets example referred to earlier, particularly when extending the programme beyond the initial externally funded phase: • a lack of explicit recognition of the public health issue as a ‘whole system’; • the detrimental impact of existing power relations between organisations; • a lack of recognition of community concerns, which may not be the same as those of the project workers involved in public health programmes; • previous poor experiences of partnership working, which may have a lasting legacy; • difficulties in maintaining momentum for specific public health activity in uncertain political times; • tension between funding that is attached to specific projects in the short term, and the long-term vision required for a whole system approach; • a lack of trust between partners, preventing open discussion of failed activities. Hunter and Perkins (2012), in a three-year study of public health partnerships in nine localities across England, described how less formal, more organic partnerships were more effective than more formal strategic partnerships that were driven by targets. They described how many partnerships were facades with a prevailing ‘silo mentality’, and observed that while the focus tended to be on the structures of partnerships, relational factors such as trust and goodwill were more important for a well-functioning partnership needed to tackle complex, systemic public health issues.

Conclusion The recent move of English public health departments into local authorities presents significant opportunities but also challenges for whole systems approaches to public health. Local authorities have a historic responsibility for public health, a new duty to promote wellbeing, and are well positioned to influence local social, economic and physical environments. The culture of local authorities, based on political accountability to the community, is also potentially more open to collaborative, applied approaches to research and ‘evidence’. However, local authorities are facing massive financial pressures that are forcing a retreat to provision of only the most essential, statutory

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services. The danger is that this can lead to a reactive, risk-adverse culture that focuses on short-term pressures and neglects prevention, despite the evidence that only a long-term ‘fully engaged’ scenario that prioritises prevention is likely to alleviate the predicted public funding crisis (Wanless, 2004; Butland et al, 2007). The challenge for public health departments newly located in the local authority is to influence the larger organisation to adopt a more flexible, responsive organisational culture, to break down silos across the local authority, work with local politicians and develop genuine, inclusive, engaged partnerships at both local and wider levels. Whole systems approaches require both ‘top-down’ strategic and policy approaches linked to and informed by ‘bottom-up’ engagement with action at multiple levels and across the system. There is a need to foster systems thinking and transformational, adaptive, distributed leadership at local and national levels across statutory, community, academic and private sectors. The recent training for future Directors of Public Health, (provided by Public Health England in partnership with the Society for Local Authority Chief Executives [SOLACE]), does incorporate features of transformational leadership and working in complex systems but does not extend systemic thinking to the research and practice of public health. To address the complex public health challenges facing us will require a long-term perspective, and genuine partnership across sectors to achieve system change and create a more sustainable and health-enhancing economy and environment. Notes See www.thersa.org/action-research-centre/community-and-public-services/ connected-communities/reports

1

2

See www.healthcomplexity.net/content.php?s=c2andc=c2_background.php

3

See www.transitionnetwork.org

References Antonovsky, A. (1987) Unravelling the mystery of health: How people manage stress and stay well, San Francisco, CA: Jossey Bass. Barker, D.J.P. (1994) Mothers, babies and disease in later life, London: BMJ Publishing Group.

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Bauld, L. (2011) The impact of smoke free legislation in England: Evidence review, Report submitted to Department of Health, Bath: University of Bath, https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/216319/dh_124959.pdf Berkman, L.F. and Syme, S.L. (1979) ‘Social support networks, host resistance and mortality: a nine year follow up of Alemda County Residents’, American Journal of Epidemiology, 109: 186-204. Best, A. and Holmes, B. (2010) ‘Systems thinking, knowledge and action: towards better models and methods’, Evidence and Policy, 6(2): 145-59. Best, A. and Saul, J.E. (2011) ‘Systems thinking: a different window on the world of implementation and global exchange of behavioral medicine evidence’, Translational Behavioral Medicine Practice, Policy, Research, 1(2): 361-3. Bibby, J., Bevan, H., Carter, E., Bate, P. and Robert, G. (2009) The power of one, the power of many, London: NHS Institute for Innovation and Improvement. Bronfenbrenner, U. (1977) ‘Toward an experimental ecology of human development’, American Psychologist, 32(7): 513-31. Brown, J. and Isaacs, D. (2005) The World Café: Shaping our futures through conversations that matter, Oakland, CA: Berrett-Koehler. Brown, P. and Zavestoski, S. (2004) ‘Social movements in health: an introduction’, Sociology of Health and Illness, 26(6): 679-94. Butland, B., Jebb, S., Kopelman, P., McPherson, K., Thomas, S., Mardell, J. and Parry, V. (2007) Foresight. Tackling obesities: Future choices – project report, London: Government Office for Science, www. gov.uk/government/publications/reducing-obesity-future-choices Cannon, W. (1932) The wisdom of the body, New York, NY: Norton. Capra, F. and Luisi, P.L. (2014) The systems vew of life: A unifying vision, Cambridge: Cambridge University Press. Cassel, J. (1976) ‘The contribution of the social environment to host resistance’, American Journal of Epidemiology, 104: 107-23. Chapman, J. (2004) System failure: Why governments must learn to think differently (2nd edn), London: Demos, http://www.demos.co.uk/ files/systemfailure2.pdf Cohen, D.A. and Babey, S.H. (2012) ‘Contextual influences on eating behaviors: heuristic processing and dietary choices’, Obesity Review, 13(9): 766-79. Cohn, S., Clinch, M., Bunn, C. and Strong, P. (2013) ‘Entangled complexity: why complex interventions are just not complicated enough’, Journal of Health Services Research and Policy, 18(1): 40-3.

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de Savigny, D. and Adam, T. (eds) (2009) Systems thinking for health systems strengthening, Geneva: World Health Organization, http://apps. who.int/iris/bitstream/10665/44204/1/9789241563895_eng.pdf Duhigg, C. (2012) The power of habit, London: William Heinemann. Greenland, S. and Brumback, B. (2002) ‘An overview of relations among causal modelling methods’, International Journal of Epidemiology, 31: 1030-7. Hayden, C., Harrison, J. and Granville, G. (2011) Cultural and strategic impact of the Tower Hamlets Healthy Borough Programme, Final Evaluation Report, London: Borough of Tower Hamlets. Hudson, B. (2006) Whole systems working: A guide and discussion paper, London: The Integrated Care Network, http://lx.iriss.org.uk/sites/ default/files/resources/ICN_Whole_Systems.pdf Hunter, D. and Perkins, N. (2012) ‘Partnership working in public health: the implications for governance of a system approach’, Journal of Health Services Research and Policy, 17(Suppl. 2): 45-52. Hurth, V., Peck, J., Jackman, D. and Wensing, E. (2015) Reforming marketing for sustainability: Towards a framework for evolved marketing, London: Friends of the Earth. Jebb, S. (2014) ‘What is needed to tackle obesity, why is progress slow and what needs to be done?’, Position Paper One, ESRC Behaviour Change Seminar Series, Seminar Two: Obesity, Food and Physical Activity, www1.uwe.ac.uk/bl/research/bsmc/esrcseminarseries.aspx Kobasa, S.C. (1983) ‘The hardy personality: towards a social psychology of stress and health’, in G.S. Sander and J. Suls (eds) Social psychology of health and illness, Hillsdale: Erlbaum. Kornitzer, M., Beriot, I., Kittel, F. and Dramaix, M. (1993) ‘Psychosocial factors in perspective’, in N. Poulter, P. Sever and S. Thom (eds) Cardiovascular disease: Risk factors and interventions, London: Radcliffe, pp 231-350. Livingood, W.C., Allegrante, J.P., Airhihenbuwa, C.O., Clark, N.W., Windsor, R.C., Zimmerman, M.A. and Green, L.W. (2011) ‘Applied social and behavioural science to address complex health problems’, American Journal of Preventive Medicine, 41(5): 525-31. Malhi, L., Karanfil, O., Merth, T., Acheson, M., Palmer, A. and Finegood, D. (2009) ‘Places to intervene to make complex food systems more healthy, green, fair and affordable’, Journal of Hunger and Environmental Nutrition, 4(3-4): 466-76. Marmot, M. (1986) ‘Epidemiology and the art of the soluble’, The Lancet, 19 April: 897-900.

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Marmot, M. (2010) Fair society, healthy lives: Strategic review of health inequalities in England post 2010, London: The Marmot Review, www.instituteofhealthequity.org/projects/fair-society-healthy-livesthe-marmot-review McLeroy, K.B., Bibeau, D., Steckler, A. and Glanz, K. (1988) ‘An ecological perspective on health promotion programmes’, Health Education Quarterly, 15: 351-77. McMichael, A.J. (1999) ‘Prisoners of the proximate: loosening the constraints on epidemiology in an age of change’, American Journal of Epidemiology, 149(10). Meadows, D.H. (2008) Thinking in systems: A primer, London: Chelsea Green. Najman, J.M. (1980) ‘Theories of disease causation and the concept of a general susceptibility: a review’, Social Science and Medicine, 14A: 231-7. NICE (National Institute for Health and Care Excellence) (2008) Public Health Guidelines (PH9). Community engagement, 27 February, London: NICE, http://www.nice.org.uk/guidance/ph9/resources/ community-engagement-55462554565 NICE (2012) Public Health Guidelines (PH42). Obesity: Working with local communities, 28 November, London: NICE, http://www.nice. org.uk/guidance/ph42/resources/obesity-working-with-localcommunities-1996354580677 Nuffield Council on Bioethics (2007) Public health: Ethical issues, London: Nuffield Council on Bioethics, http://nuffieldbioethics. org/wp-content/uploads/2014/07/Public-health-ethical-issues.pdf Oliver, K., de Vocht, F., Money, A. and Everett, M. (2014) ‘Who runs public health? A mixed-methods study combining qualitative and network analyses’, Journal of Public Health, 35(3): 453-59. Pearson, M., Garside, R., Fry-Smith, A. and Bayliss, S. (2011) ‘Preventing obesity using a “whole system” approach at local and community level: barriers and facilitators to effective whole system approaches’, Systematic review undertaken by the Peninsula Technology Assessment Group (PenTAG) for NICE, London: NICE, http://www.nice.org.uk/guidance/ph42/evidence/ review-3-barriers-and-facilitators-to-effective-whole-systemapproaches-430265485 Plsek, P. (2000) Spreading good ideas for better health care: A practical toolkit. Tools, perspective and information for healthcare providers, Volume 2. Texas, Irving: VHA, pp.1-54. http://www.chcanys.org/clientuploads/ downloads/Clinical_resources/Leadership%20Articles/GoodIdeas. pdf

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Plsek, P. (2003a) An organization is not a Machine! Principles for managing complex adaptive systems, Roswell, GA: P.E. Plsek and Associates, Inc. Plsek, P. (2003b) ‘Complexity and the adoption of innovation in health care. Accelerating quality improvement in health care: Strategies to accelerate the diffusion of evidence-based innovations’, Washington, DC: National Institute for Healthcare Management Foundation and National Committee for Quality in Health Care, https://www.niatx. net/PDF/PIPublications/Plsek_2003_NIHCM.pdf Plsek, P.E. and Greenhalgh, T. (2001) ‘The challenge of complexity in healthcare’, British Medical Journal, 323(15): 625-8. Pratt, J., Gordon, P. and Plamping, D. (2005) Working whole systems: Putting theory into practice in organisations (2nd edn), Oxford: Radcliffe. Pratt, J., Plamping, D. and Gordon, G. (1998) Partnership: Fit for purpose?, London: King’s Fund. Rayner, G. and Lang, T. (2012) Ecological public health: Reshaping the conditions for good health, London: Earthscan from Routledge. Rickles, D., Hawe, P. and Shiell, A. (2007) ‘A simple guide to chaos and complexity’, Journal of Epidemiology and Community Health, 61(11): 933-7. Rutter, H. (2014) ‘The puzzle of public health evidence’, Position Paper Two, ESRC Behaviour Change Seminar Series, Seminar Two: Obesity, Food and Physical Activity, www1.uwe.ac.uk/bl/research/ bsmc/esrcseminarseries.aspx Senge, P.M. (1990) The fifth discipline: The art and practice of the learning organization, London: Random House Business Books. Snowden, D.J. and Boone, M.E. (2007) ‘A leader’s framework for decision making’, Harvard Business Review, 85(11): 68-76. Spiegel, A. (2012) ‘What Vietman taught us about breaking bad habits’, NPS Shots, 2 January. Susser, M. and Susser, E. (1996) ‘Choosing a future for epidemiology: II. From black box to Chinese boxes and eco-epidemiology’, American Journal of Public Health, 86(5): 674-7. Swinburn, B.A., Sacks, G., Hall, K.D., McPherson, K., Finegood, D.T., Moodie, M.L. and Gortmaker, S.L. (2011) ‘The global obesity pandemic: shaped by global drivers and local environments’, The Lancet, 378(9793): 804-14. Tedstone, A., Targett, V. and Allen, R. (2015) Sugar reduction: The evidence for action, London: Public Health England, October 2015 https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/470179/Sugar_reduction_The_evidence_for_ action.pdf

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Wanless, D. (2004) Securing good health for the whole population. Final report, Department of Health, London: The Stationery Office. Williams, K., Trenchard-Mabere, E. and Shaw, C. (2011) ‘Becoming a healthy borough: tackling the social and environmental causes of obesity in Tower Hamlets’, Tower Hamlets Healthy Borough Programme, Phase 1 Progress Report, September, London: London Borough of Tower Hamlets.

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FOURTEEN

Conclusion: what is the future of ‘behaviour change’? Fiona Spotswood and Alex Marsh

Introduction This book has provided insight into a range of areas that all come under the umbrella of ‘behaviour change’. The contributing authors come from a range of fields, including both academia and policy, and their expertise covers a variety of topic areas such as public health, energy, environmental management and transport. Some authors focus on tackling a specific societal problem and others are interested in policy or ideology more broadly. All, in one way or another, are involved in developing the ideas around ‘behaviour change’, but other than that they have little in common. In fact, some of the contentions within chapters clash or contradict each other. There are ideological, ethical, and theoretical disparities across this volume and as such it can be argued that far from this suite of chapters representing a cohesive behaviour change discipline, it has highlighted the fragmented nature of the field. If ‘behaviour change’ is ever to be considered a cohesive field, it has a long way to go. On the one hand, like Cox and colleagues’ (2012) conclusions about strategic management, it can be argued that diversity in research simply represents the characteristic evolution of a discipline on its way to cohesion, and that through its maturity and refinement a field with such diverse roots has the potential to generate immense creativity and innovation. On the other hand, it may be that the nature of the disparity between potential members of this field will always prevent cohesion, and that this in itself – in a productive form – would form a particular route towards innovation and creativity. Either way, for the sake of improving our capability to tackle the momentous societal problems of our age, it is innovation and creativity that must be the goal of ‘behaviour change’ community members. As such, this concluding chapter argues for three shifts required in ‘behaviour change’ work on our way to achieving greater innovation and subsequent success.

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The first is a move towards more systematically considering the interrelationship between broader societal forces – like the actions of business – and individual behaviour: a culturalist perspective. The second is a move towards a more blended, truly transdisciplinary focus, where disciplines focus not on their own priorities and achievements, but on the shared goal of making sustainable changes in society. The third is a move towards the more enthusiastic consumption by policymakers of insight and evidence which has a broader range of methodological and theoretical underpinnings. This, as is explored at length later, would require changes in the relationship between academic and policymaking.

A ‘culturalist’ perspective The thrust of much discussion in behaviour change has traditionally revolved around the best ‘techniques’ or ‘mechanisms’ to change behaviour. This includes research to test these techniques, evaluate their effectiveness and use the resulting knowledge in the systematic creation of replica interventions. These discussions are predominantly based on an individual-level, psychological paradigm. This is important work with a well-established and much-respected research base. We need to know what works and it is undeniable that the way people behave – eating too much of the wrong food, using up too much of the planet’s resources and not exercising enough to counter their sedentary lifestyles – needs to change. Policymakers and practitioners have keenly embraced this rich evidence base, this implementation science, so they can take account of the latest and best insights when they make decisions and allocate funding. But arguably the energy exerted in this direction has eclipsed the broader forces involved in creating the conditions in which problem behaviours exist. The focus in all this activity is primarily on the individual ‘doers’ of the behaviours. Even when issues of a ‘social’ and ‘cultural’ nature are considered (like in the theory of interpersonal behaviour – see Chapter Two), the emphasis is still on how they might influence individual-level behaviour. Such is the inherent nature of psychology-based theory. Although it is individuals who are the ones eating themselves into obesity or choking the planet, struggling with their habits and willpower and self-regulation, these individualist approaches cannot – and do not attempt to – question why we crave junk food, why we believe that driving is our fundamental right or why we find it hard to imagine a world in which many teenagers do not drink to excess as a rite of passage. Individualist approaches provide

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support mechanisms for bolstering willpower and encouraging a move along the stages of change – and they can do this with considerable success (Wing et al, 2006). They can help people evolve within existing structural limitations, but they do not allow for people to liberate themselves by questioning the very nature of the structures that limit them (Collins, 2015). Shifting our focus towards an examination of ‘culturalist’ phenomena is difficult, because it involves questioning our own ingrained cultural ways of knowing. We are all subject to a culture that guides our hand at every turn, with which various theorists have attempted to grapple. One such examination is Bourdieu’s concept of habitus. Bourdieu (1977) explains how the habitus is a ‘structuring structure’ that provides the ‘rules of the game’ for us (Bourdieu, 1985), that is, it comes about as the result of structures such as the capital endowment of a person and their physical environment that are ‘embodied’ (that is, subjectified) to produce a set of dispositions, or a ‘way of seeing the world’. Bourdieu emphasised that ‘people are not … isolated individuals each deciding a course of action by making individual economic calculations’ (Ovenden, 2000). The rules dictated by our society – lived and embodied by us – dictate what behaviour is ‘normal’ and what will be accepted by our group or social class. We know how to avoid deviation from the rules and can recognise those who fail to do so. Despite considerable criticism to the contrary (Jenkins, 1992; King, 2000), habitus was not intended as a structuralist phenomenon or contextual variable that simply influences attitude, but rather a cultural system of thinking, being and doing: individual decisions and behaviours exist and reproduce the culture. Other theories, such as Giddens’ (1984) structuration theory, also seek to explain the quiet but forceful guiding hand that culture has on our behaviour, and the role of agency in its reproduction. Habitus has been criticised for its obscurity (DiMaggio, 1979; Wacquant, 1987), with some justification. However, theories of practice (the subject of Chapter Twelve), which are based in part on Bourdieu but also Taylor (1971), Giddens (1984) and others, have been viewed as having more potential for application to changing societal problems. They make a significant contribution to the behaviour change field for two reasons. First, they provide a new framework for understanding the origin of problematic behaviours and how we might change them. Shove and colleagues’ (2012) three elements model has possibly the best chance of being adopted in policy circles – which is the target of this first suggested shift – for its simplicity and compactness. It comprises three linked elements that constitute any practice (such as ‘eating’ or

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‘travelling to work’): materials, meanings and competences. When the links between these interrelated elements change – or are changed – then the practice evolves. The three elements model has been used to explain changes in car driving (Rettie et al, 2012), showering (Hand et al, 2005), DIY (Watson and Shove, 2008), Nordic walking (Shove and Pantzar, 2005) and cycling (Spotswood et al, 2015) among others. It is appealing for its implication that there are multiple facets to a practice, so a multitude of approaches will be required to change it. For example when examining the problem of childhood obesity, the role of business in producing and heavily marketing the ‘materials’ (products) and ‘meanings’ associated with children’s unhealthy snacking might be considered alongside the loss of family cooking skills, evolving after school parenting priorities and the increase in TV viewing. However, the model remains untested in a policy context and was not developed with intervention design in mind. Nonetheless its potential is enormous and it remains at the forefront of new thinking in some fields of policy and research such as energy use and sustainable consumption (Hargreaves, 2011; Shove, 2011; SPRG, 2012), although has yet to make a significant impact in public health (although see Maller [2015] and Blue et al [2016]). The second key contribution of theories of practice are their conceptual focus on the practice – as an entity – and not the individual ‘performer’ of the practice. As has been described, there has been a tendency among much behaviour change commentary, and particularly policy activity, to focus on the ‘doers’ of the behaviour. Perhaps this comes from the neoliberal political preoccupation with avoiding regulation (of business, for example – and see Chapter Nine for more on this) and legislation (for fear of the ‘nanny state’ criticism); it feels more comfortable to hold individuals responsible. Perhaps the focus on such ‘downstream’, individualist research in the behaviour change arena has influenced this preoccupation – the jury is out. In contrast, theories of practice implicitly accept what Bourdieu and Giddens emphasise through their sociological ‘culturalist’ theories – that ‘behaviour’ is the result of, and constrained by, structures that are ingrained and reproduced and adapted by our actions. We are not ‘free agents’ whose cognitions and decisions are necessarily the most significant factors for altering the course of our lives. Rather, the emphasis in theories of practice – and thus in ‘behaviour change’ (or rather ‘practice change’) approaches that employ practice theories – is on changing these structures and not on attempting to directly influence the decision making of individuals.

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Other volumes are better placed to explore in greater depth what a specifically practice-based approach to behaviour change would look like (Spurling and McMeekin, 2015; Strengers and Maller, 2014; Vihalemm et al, 2015). Here it is sufficient to conclude that a culturalist approach would be ‘revolutionary’ rather than ‘evolutionary’ – in that it would seek to change socio-cultural structures rather than just persuade and encourage individuals to change within the existing structures. It is the first suggested answer to the question posed by this chapter about where the future of behaviour change lies: the future must be less dominantly about ‘behaviour’ and more about behaviour within and a part of ‘culture’. It is arguably here that the greatest gains are to be had for overcoming vast health and social inequalities and for sustainably tackling associated health, societal and environmental problems. Individualist approaches should not be discarded, but rather expanded and integrated alongside culturalist perspectives.

A transdisciplinary future Closely related to the argument that we need to develop the culturalist agenda in ‘behaviour change’ (so called here for simplicity, although the limitations of this language are now clear), is the second answer to this chapter’s lead question: the future must see disciplines combining forces. The House of Lords Science and Technology Committee concluded from its Behaviour change review (2011) that it was imperative to move beyond working within individual disciplines. In other fields this combining of approaches has been considered the ‘mantra of science policy’ (Robertson et al, 2003). Indeed, it has been noted that moving beyond a system based on single disciplines is required if we are to become ‘more adept at reassembling the unity of knowledge and coping with problems that are too large for any discipline to tackle alone’ (Robertson et al, 2003). The heart of the House of Lords’ critique was the government’s over-focus on ‘nudge’ techniques, and the same critique can be applied to any of the disciplines represented in this volume, whether social marketing or behavioural economics or urban planning or downstream legislation, a point also made in Chapter Seven. To put the importance of this shift in sharp focus, we have only to look at the Foresight ‘spaghetti’ map (see Figure 13.2) of the underpinnings of obesity (Butland et al, 2007), formulated using a ‘systems approach’ (and discussed at length in Chapter Thirteen). A brief glance shows how complex and interrelated the ‘system’ of obesity is. It is impossible to expect any one approach to overturn such a Goliath. Downstream

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interventions like weight management support groups cannot tackle the corporate and political structures that underpin the power of the ‘sugar lobby’, for example, and fail to question the powerful influence that expert corporate ‘stakeholder marketers’ have over policymakers (see Chapter Nine for more on this). However, not only is the range of disciplines working under the loose umbrella of ‘behaviour change’ both vast and heterogeneous, but there are also many reasons why these disciplines are unlikely to join forces. For example, academic research is still largely conducted in silos, fuelled by a publication system that is still predominantly based around historical disciplinary boundaries (Gilbert, 2008). Despite the efforts of the research councils to encourage interdisciplinary projects, without ‘quality’ outlets (itself a loaded term that cannot be explored here for lack of space) for the resulting articles, researchers are likely to continue to plough dead-straight furrows in their own disciplinary field and often – understandably, given that their reputations and careers are built on it – fiercely protect the supremacy of their particular approach. Another key difficulty is the practical problems faced when attempting interdisciplinary projects. Different disciplinary cultures and language, approaches and standards often make it hard for true ‘transdisciplinarity’ to be reached, where disciplines set aside their own differences and work in a truly blended fashion towards the same goal and where, in ideal cases, a new discipline or field results (Nash et al, 2003; Jordan et al, 2005). We are far from this situation in most ‘behaviour change’ work. However, the consideration by individual fields of their role within an interdisciplinary agenda (like that of the social marketers writing in Chapter Seven and see also Spotswood, 2015) is a welcome development. In addition, it is notable that applying a systems (Chapter Thirteen) or practice theoretical approach (Chapter Twelve) would simply necessitate interdisciplinarity at the very least. This is why they are recommended for consideration by policymakers, who could play an important part in demanding if not leading a future shift towards transdisciplinarity.

The ‘evidence’ conundrum As noted, one of the key difficulties facing disparate disciplines when attempting to move towards inter- or transdisciplinarity is their particular disciplinary cultures, and in particular their methodological foundations. Public health has its own set of quantified standards for what constitutes ‘valid evidence’, for example, and this has little in common with social marketing, which is often based on evidence

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from rich qualitative insights drawn from focus groups and depth interviews. The criteria to judge the rigour of a positivist experiment or randomised controlled trial conducted within the former would have little relevance to that used to judge the credibility of a series of qualitative interviews in the latter (see Tracy, 2010). Although methodological pluralism could be highly valued for the range of knowledge available about behaviour and how to change it, in fact these differences have had important implications for the way in which each discipline has been embraced by policymakers, key consumers of behaviour change research and evidence. Simply put, evidence produced by disciplines that use quantitative methodologies – such as behavioural economics and implementation science – has been embraced far more readily than those that produce ‘less scientific’ qualitative data. Perhaps quantified data feels like solid evidence that can be put into models and monetised and on which difficult policy decisions can more confidently be based, whereas, despite their potential richness of insight, the small sample sizes of qualitative work are perceived to render findings that are incapable of being generalised, are anecdotal and of questionable value. On the one hand, it is positive that in the world of policy and practice the value of ‘evidence’ has become extolled and broadly endorsed, a fairly recent enthusiasm in the UK borne out of the early Blair governments’ interest in rationalist, technocratic policy. Since then, there has been much talk of improving analytical skills in government and the virtues of policy pilots (Cabinet Office, 1999; 2003). Using evidence and learning lessons have now become perceived as essential skills for policymakers and many of the tenets of evidence-based policy continue to be influential in the current era of ‘open policymaking’ in Whitehall. These tenets have been supplemented by further injunctions regarding the need to increase the perceived robustness of the evidence base for policy – such as the desirability of basing policy pilots on randomised controlled trials (RCTs) (Haynes et al, 2012). On the other hand, this bias towards positivist evidence – and RCTs in particular (discussed in more depth in Chapters Three and Five) – has significant implications. First, it leaves disciplines based on qualitative methodologies at a disadvantage. Academic researchers are under pressure not just to achieve highly ranked journal publication to prove their contribution to ‘knowledge’, but – a recent development – also to turn their minds to the applied ‘impact’ of that knowledge (Bastow et al, 2014). In the UK, as elsewhere, we see research funding at the individual project level increasingly made contingent on plans for delivering impact beyond the academy and, at the institutional

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level, funding is partly contingent on a track record of demonstrable impact on policy, practice or popular audiences.1 Second, the partiality towards positivist methodologies becomes dangerously misleading when it comes to addressing complex social problems in which value positions can shape both the questions asked by researchers and the conceptual and empirical frameworks deployed. Policymakers may be seeking unanimity where there is none to be found and to cut through any uncertainty by constructing persuasive narratives, and, in the process, they ‘silently silence’ some perspectives while promoting others (Stevens, 2011). The inherent biases here lead to a stronger link between policies and practice and individualfocused theories of behaviour change compared with evidence based on research not fitting this paradigm. Consider the earlier discussion of the relationship between culturalist structures and behaviour: if research is aiming to explore the nature of a particular practice, or the constituency of a group’s habitus, the research design will inevitably be richly qualitative (see Hargreaves, 2011; Spotswood and Tapp, 2013). As important as these findings might be for understanding a complex and challenging societal problem, in the light of prevailing understandings of robustness they are unlikely to be considered valid evidence by policymakers. An associated implication is that this bias towards positivist methodologies tends to skew the perception of what ‘works’ in behaviour change. If the evidence most readily accepted by policymakers relates to individualist interventions, then these are the interventions most likely to be funded. Similarly, as Chapter Six explores, the Behavioural Insights Team has generated considerable research into the effectiveness of interventions based on behavioural economics (amongst other approaches), but the media attention on the work of the ‘nudge unit’ has arguably led to a pervasive view that behavioural economics specifically is the most likely approach to achieve the results. The danger here is that policymakers are potentially failing to tackle the real bases for problematic behaviour – perhaps rooted in industry, trade or social welfare (Jones et al, 2013; Rutter, 2014) – because these changes cannot be tested in randomised controlled trials, viewed as the pinnacle of hierarchies of evidence (Nutley et al, 2013). Thus, the third factor in the ‘future’ of behaviour change has to be an expansion in the nature of evidence that is commissioned, considered, accepted and acted on at a policy level.

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Box 14.1: Stop and think: the scope of policy ‘evidence’ Policymakers and practitioners draw on a range of evidence when making decisions. Mulgan (2005) identifies eight types of evidence. In addition to scientific knowledge, these include statistical knowledge, professional knowledge, public opinion, practitioner views and insights, and political knowledge such as the balance of opinion in the ruling party and hence the likelihood that particularly policies will be agreed. All of these types of knowledge are potentially relevant – on pragmatic and democratic grounds if no other – to policy decisions. We can distinguish between the direct and indirect influence of research on policy. Direct research use can be thought of as instrumental and is sometimes referred to the ‘engineering model’ of research use – knowledge applied to directly address a particular social problem. Indirect research use can be more subtle and complex. It can be about sensitising policymakers to issues or providing a vocabulary or conceptual framework through which to make sense of a particular set of issues, without necessarily offering directly applicable recommendations for action. This is sometimes referred to, in contrast to the engineering model, as the ‘enlightenment’ model (Janowitz, 1972).

Talking to policymakers It is not our intention in this chapter to attack policymakers for not embracing the full range of evidence available from academic research. It is the responsibility of both academic researchers and policymakers to work together in partnership to improve the flows of communication between their – at times – alien worlds. There are immense challenges involved in moving ’evidence-based policy’ from the realm of normative models of the policy process to the realm of practical policymaking. However, members of academic communities are being encouraged – some might argue compelled, due to the new ‘impact’ imperative – to reorient our thinking. The walls of the ivory tower must be breached. Academics are being challenged to consider that simply contributing new theoretical or empirical insights to an academic literature leaves our task half done. Yet, far from being warmly received, academic research frequently gets the cold shoulder from policymakers. Whereas some behaviour change research has achieved a high profile in policy circles, attention is selective and as we have discussed, only certain types of research seem to make an impression on policy thinking. When researchers have considered the question of direct research use – how researchers and policymakers can engage in more fruitful knowledge exchange – it has led to the identification of a range of barriers and facilitators and

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generated a range of prescriptions for how to improve the situation (Duncan and Harrop, 2006; Nutley et al, 2007; Williams, 2010; Oliver et al, 2014). The broad messages emerging from this literature are relatively consistent. Problems can arise when policymakers are not sufficiently clear in their requirements from research or when the policy agenda moves on while the research is underway and requirements change. Policymakers are looking for evidence that is, in Duncan and Harrop’s (2006) terms, rigorous, accessible and usable. The evidence needs to be relevant to the problem in hand and it needs to be methodologically robust, but it also needs to be presented in terms that are accessible to policymakers. Important insights can often be lost in a thicket of academic jargon. Thus usable evidence is evidence that is available when it is needed but also evidence that comes with clear implications. These can both be challenging requirements. The rhythms of policymaking often do not articulate well with the research process – from a policy perspective, research often takes too long to deliver results and often arrives with results that are hedged with qualifications and caveats as to its broader applicability. Overcoming the timeliness problem requires policymakers to think ahead and commission research early so that its results arrive on time, while Duncan and Harrop (2006) suggest that researchers need to be bolder in drawing implications from their work. This can present challenges to researchers, who are often rightly cautious in drawing conclusions that take them beyond the evidence. On the other hand, researchers may feel that they need to be part of this process of drawing implications from the research in order to maximise the fidelity to the evidence and minimise the scope for misinterpretation or misuse. A key finding of the literature on evidence-based policy is that improving the quality of relationships between researchers and policymakers, creating greater mutual understanding and appreciation of the others’ priorities and requirements, can facilitate the flow of research evidence into the policy process (Oliver et al, 2014). There is a growing recognition that to look at this relationship as one of supply and demand is perhaps not the most fruitful approach. Recent discussions have sought to explore the issue from the perspective of coproduction and examine the role of knowledge brokerage arrangements (Caswill and Lyall, 2013). Similarly, the role of intermediaries such as think-tanks and special advisers in facilitating, or inhibiting, the translation of robust research evidence into useable policy knowledge is being increasingly recognised (Gains and Stoker, 2011). Here again, issues of networks, access and the quality of relationships are important.

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Box 14.2: Stop and think: the political uses of research Weiss (1979) provided one of the most well-known attempts to identify the range of reasons why policymakers might seek to commission or use research as part of the policy process (see also Nutley et al, 2007, for a later review). Weiss (1979) provided a seven-part typology of models of research use. The typology includes direct, instrumental uses of research – the knowledge-driven and problem-solving models – and interactive models of research use in which policymakers draw on research alongside other types of knowledge to support their work. But Weiss also highlights more politically infused uses of research. These include the political model, in which research is used to buttress existing political positions rather than to guide action, and the tactical model, where research is commissioned as a way of appearing to be active either without the intention of taking policy action or with the intention of shifting blame to researchers. Research can provide ‘concepts and theoretical perspectives … that permeate the policy-making process’ (p 429). This is the enlightenment model noted earlier. Finally, research may be seen as part of the intellectual enterprise of society: researchers may be drawn to study emerging social phenomena and, as a byproduct of this, thinking within both policy circles and society more broadly may be reshaped.

Finally, it is also important to consider the ‘fit’ of particular policy ideas or proposals with an existing policy landscape when considering how different types of research are received and acted on. That is, policy ideas may survive and thrive not because of their intrinsic merits, but because they ‘fit’ with existing priorities and interests. Stevens (2007) argues that the take-up of evidence in the policy process is selective in systematic ways; there is a tendency for attention to be paid to ideas that favour the interests of those with social power. In contrast, Rayner (2012) draws attention to the limits of knowledge and the way in which ignorance can be used strategically within policymaking. He argues that organisations deploy four strategies – denial, dismissal, diversion and displacement. The key point is that while much of the ‘evidence-based policy’ discussion is of how to increase the role of evidence in at least informing, if not determining, policy, we should not lose sight of the sometimes powerful social forces working in entirely the opposite direction.

Conclusion This chapter has sought to answer the challenging question about where the future of behaviour change lies. It has suggested that the ‘field’ is fragmented, disparate and conflicted. This might pose a problem

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when considering a desired shift towards transdisciplinarity, one of the three ‘future shifts’ for which the chapter argues. Another is the need for policymakers to shift towards incorporating a stronger focus on a holistic, culturalist perspective such as that rooted in theories of practice. Focusing predominantly on an individualist perspective is unlikely to enable policymakers to achieve the scale of change required. Related to these first two shifts is the final recommendation: for policymakers to adopt a broader recognition of the validity and contribution of research evidence that comes from a range of methodological perspectives. Preoccupation with positivist methodologies is limiting; it inhibits the development of an adequate understanding of the key causes of behaviour. However, as the final section of this chapter has pointed out, there needs to be an improvement in the relationship between policymakers and academic researchers for such a progression to occur. These shifts are undoubtedly challenging and ambitious, but necessary if academics and policymakers are to improve their contribution to improving the lives of citizens and society. End-of chapter-questions • Should behaviour change be considered a distinct ‘field’? • What are the limitations of an individualist perspective of behaviour for behaviour change? • Which of the three shifts suggested by this chapter is, in your view, the most important and why? • What kinds of research evidence do policymakers prefer and why? • What kinds of evidence do policymakers use when they make decisions?

Note 1

See www.ref.ac.uk

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Wacquant, L.J.D. (1987) ‘Symbolic violence and the making of the French agriculturalist: an enquiry into Pierre Bourdieu’s sociology’, Australia and New Zealand Journal of Sociology, 23(1): 65-88. Watson, M. and Shove, E. (2008) ‘Product, competence, project and practice’, Journal of Consumer Culture, 8(1): 69-89. Weiss, C. (1979) ‘The many meanings of research utilization’, Public Administration Review, 39(5): 426-31. Williams, A. (2010) ‘Is evidence-based policy making really possible? Reflections for policymakers and academics on making use of research in the work of policy’, in H. Colebatch, R. Hoppe, and M. Noordegraaf (eds) Working for policy, Amsterdam: Amsterdam University Press. Wing, R.R., Tate, D.F., Gorin, A.A., Raynor, H.A. and Fava, J.L. (2006) ‘A self-regulation program for maintenance of weight loss’, New England Journal of Medicine, 355: 1563-71.

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Index

Index Note: page numbers in italic type refer to figures and tables.

4Ps of marketing 138

A ABC theory 44, 240 Abraham, C. 49 accountability 184–6, 189–90 Action on Smoking and Health (ASH) 82–3 actors see stakeholders adaptation see complex adaptive systems Adkins, S. 187 advertising 136–7, 182 see also marketing affect 36 affordances 161 agency and social practices 242, 249–50 and social structures 21–2 Ajzen, I. 32–5 Alameda County study 49–50 alcohol by volume (ABV) 190 alcohol duty escalator 192 alcohol education 150–1 alcohol industry benefits of stakeholder marketing for 192 CSR and accountability 189–90 lower ABV products 190–1 and public health policy 195 alcohol regulation 14, 15, 78–9, 189–90 Amnesty International 185 amplification of behaviour 158, 160–1, 164, 167–8 Andreasen, A.R. 142 anti-smoking measures 13–14, 82–4, 272 Arnstein’s ladder 208–9 ASH (Action on Smoking and Health) 82–3 attitudes in portfolio model 240, 241 in psychological theories 33, 34

automatic processes and environment 270 automatic system 19–20 interventions targeting 54, 56–7 in portfolio model 241 targeted in marketing 137–8 in TIB model 37

B baby milk 185–6 Bandura, A. 55 Banister, D. 90–1 barriers 42–3, 241 Barton, H. 37–8, 92 behaviour impact on health 49–50 impact of technology on 157–63 influences on 50 as performance of social practices 239–40 portfolio versus practice model 240–3, 249–50 relationship with environment 270–1 see also built environment theories of see theories of behaviour behaviour change comparing approaches to 139–40 and concepts of participation 207 disciplinary history 28–31, 288 diverse perspectives on 1–2, 135–6, 283 evidence base 91, 251, 267–9, 288–91, 292 future shifts 284–93 as growing field 1, 113 interdisciplinary model of 148–51, 287–8 interventions changes to environment see built environment communications and extrinsic values 229–30

299

Beyond behaviour change designing 51–8, 64–5 effectiveness of 50, 77–9, 125, 145–6 ethics and morals of 75–6, 146–8, 212 evaluating see evaluation of interventions; evidence levels of influence 50–1 participation see participatory approaches role of social marketing 141–3, 144, 148–50 smart technology 163–5, 166, 167 targeting regulatory processes 54–8 see also road safety; social marketing; weight loss interventions politics of see politics of behaviour change psychological and sociological insights 19–23 research-policy relationship 291–3 socio-cultural context 284–7 technology as means of 163–70 theories of see theories of behaviour through regulation see state regulation and values 222–7, 228–9 behaviour change techniques habit-breaking 56–7 motivation-building 55 selecting 52–3, 57–8 used by state 12 behavioural ecology 29 behavioural economics 74, 122, 162 compared with social marketing 119–21 rise of 114–17, 138, 290 Behavioural Insights Team (BIT) 117–21, 125 behavioural sciences criticisms of policy application 121–6 emergence and growth of 28 interest in policy application 116–17, 126 behavioural skills 56 Belloc, N.B. 49–50 biases 114, 121–2, 290 bleed-over effect 222, 223, 226–7 boundary definitions 263 Bourdieu, P. 285 Brand, C. 104 breastfeeding services 144 Breslow, L. 49–50 Bronfenbrenner, U. 143, 269 Buehler, R. 105

built environment cycle paths 105–7, 148–9 and multidisciplinary model 151 permeable street networks 99–104, 108 relationship with travel behaviour 89, 90–9 urban intensification 95–9, 107–8 business see commercial interests; corporate sector; stakeholder marketing Butland, B. 272

C Cao, X. 92 capacity building 210 car use and permeable street networks 99–102 and urban intensification 96, 97–8 see also road safety Cartesian dualism 28 causal mechanisms of interventions 62 causal model of behaviour change 17–18, 19 causality, environment-behaviour link 91–5, 98 cause-related marketing (CRM) 183 Chakrabortty, A. 199 change in complex systems 262–6 public demand for 217–19 see also behaviour change Changing behaviour, improving outcomes (Department of Health) 121 Chapman, J. 258, 265 charity organisations 219, 224–6, 229–30 Chatterton, T. 27, 40 children, values of 232 choice 44 choice architecture 116, 121 Christian Aid 185 citizens control of participation 209 see also public Clean Air Act (1956) 72, 79–80 CMC (computer-mediated communication) 160 co-creation 52–3, 148–9, 201–2 co-option of critical analysis 186–7, 190–1, 194

300

Index of participatory approaches 204–5, 211 co-production 202 Coca Cola 186 collective creativity 201 Collins, K. 199 commercial interests as barrier to regulation 79–80 and impact of social marketing 145 and social systems 262 see also corporate sector; stakeholder marketing commitment, to social media 168 community development approaches 271 competences, as element of practice 22–3, 239, 244–6, 248 competition 141 complex adaptive systems 258–60 engaging stakeholders 264 leadership 263–4 organisational structure and culture 265 points of intervention 266 reflective learning 265 shared vision 264–5 social systems as 260–1 system boundaries 263 theories of change in 262–6 complicated systems 258 compound practices 251 computer-mediated communication (CMC) 160 Connect 2 programme 104 consensus, and stakeholder marketing 183–4, 190 Conservative Party 116 consultation 208 consumer marketing 181–2, 187, 193, 194 consumers and co-creation 201 in portfolio model 240 see also customers consumption, and social practices 242 context see environment/context control groups 59 see also RCTs Cooke, B. 205 Cool Biz initiative 244 corporate identity 183 corporate sector fiduciary imperative 181, 186, 190, 191, 193, 195 and public health policy 195–6

role in environmental and social change 218 see also commercial interests; stakeholder marketing corporate social responsibility (CSR) 183, 184 business thinking on 188–94 Coca Cola 186 Shell 184–5 cost-effectiveness evaluations 59, 146 critical analysis, co-option of 186–7, 190–1, 194 critical marketing 194 critical pedagogy 202–3 CRM (cause-related marketing) 183 Crompton, T. 147, 217, 219 CSR see corporate social responsibility cultural norms 81 see also social norms culturalist perspective 284–7 customers customer insight 142 orientation of social marketing 140–1 see also consumers cycle paths 105–7, 148–9 cycling 99–104, 142, 246

D Dahlgren, G. 50 de Andrade, M. 181 decision making (rational) 29–33, 39, 114–15, 121–2, 137 defaults 161–2 delegated power 209 Denford, S. 49 density of dwellings 95–6 density of population 97, 98 Department of Energy and Climate Change 45 Department of Health 121 Descartes, R. 28 design co-creation in 201–2 of interventions 51–8, 64–5 designed systems 261, 265 development policies 204–5 Diaz-Greenberg, R. 203 disempowerment 123–4 domination 206 downstream social marketing 139 drama workshops 53 drink driving regulation 78–9 Drucker, P. 140 drug misuse 80–1

301

Beyond behaviour change dualisms 19–21, 238 Duncan, S. 292

E e-cigarettes 84–5 EAST framework 158–9 eating practices 244, 247 Echenique, M.H. 99 Eckles, D 168 ecological approaches 142, 143, 267, 269–70 ‘economic man’ 31–2 economic policies, and social and environmental concerns 230–1 economic theories of behaviour 31–2, 114–15 see also fiduciary imperative education, and social and environmental concerns 232 education approach in education-marketing-law model 139, 151 in multidisciplinary model 150–1 see also information effect size 59 emergent properties, of complex systems 258, 261 emotion 36 empathy 211 employment regulations 72, 73 and social and environmental concerns 231–2 engagements, as element of practice 239, 241, 243 engineering model of research use 291 enlightenment model of research use 291, 293 entities, practices as 239, 240 environment/context assessment of 62 of complex systems 259 neglected in theories of behaviour 32, 43 recognised in theories of behaviour 29, 37, 38–9 relationship with behaviour 270–1 see also built environment; structure; systems environmental concern areas related to 230–2 problems of extrinsic values 229–30 public demand for change 217–19

social practice perspective 242, 244, 246 and structure of values 220–1 value-action gap 228–9 values and behaviour change 222–7, 228–9 and values matching 227–8 environmental regulation 72–3, 79–80 epidemiology 266–7 ethics and morals and marketing 146–8 of participatory methods 212 and state regulation 74–6 see also co-option evaluation of interventions 58–9 behavioural sciences 118–19, 121, 125–6 interlocking practices 249 outcome evaluations 59–60 process evaluations 59, 60–4 social marketing 120–1, 146 systems approach 267–9 use of RCTs 59–60, 118, 124, 267–8, 269, 289–90 see also evidence evaluation tools 268–9 evidence 91, 251, 267–9, 288–91, 292 evolutionary approaches 207 exchange 141, 146–8 executive function 20 exercise/fitness interventions 141–2 smart technology 163–5, 166 see also cycling; weight loss interventions expectancy-value model (EVM) 32–3 extension of behaviour 158, 159–60, 167 extrinsic values case study 224, 225–6 and education 232 and media 231 principles of 222–3 problems of appealing to 229–30 and values matching 227

F Facebook 162, 168, 169, 170 facilitating conditions 37 Factory Acts 72 fear appeals 56 feedback 163–4, 211 feedback loops 258–9 female genital mutilation (FGM) 81

302

Index fiduciary imperative of corporations 181, 186, 190, 191, 193, 195 filtered permeability 102–4, 108 Fishbein, M. 32–5, 55 fitness see exercise/fitness interventions Focus E15 group 199 Fogg, B.J. 159, 168 Foresight report 272–4, 287 Forum Theatre 53 Framework for Evolved Marketing 262 Frank, L.D. 104 freedom of individual 14, 74, 82 Freire, P. 202–3 Friedman, M. 181

G ‘Game On: Know Alcohol’ 150–1 Garsten, C. 184 Gibson, J. 161 goal orientation 32–3 Goodman, A. 104 Google Maps 165 governance see regulation Grant, M. 37–8 Greek mythology 19 Guy, S. 39

H habits and environment 270 interventions targeting 56–7 in TIB model 37 see also automatic processes habitus 285 Halkier, B. 244 Hallsworth, M. 113 Hargreaves, T. 244 harm principle 75 Harrop, A. 292 Hastings, G. 146, 181 Hawkins, D. 104 health impact of behaviour on 49–50 see also public health health checks 18 Health Complexity Group 271 Health and Safety at Work Act (1974) 73 healthy eating interventions 81, 142–3, 246, 272 see also weight loss interventions Healthy Lifestyles Programme (HeLP) 51, 52, 53, 58

Healthy Towns programme 274–5 heuristics 114, 124 Hickman, R. 90–1 Hindess, B. 240 historical perspective discourse of risk 15–17 regulation and public health 71–4 history of complex systems 259 HIV 16–17 human rights 82 Hunter, D. 275

I ‘idealised man’ 31–2 ‘if then’ plans 57 implementation, evaluation of 61–2 individualist approaches 41–2, 240–1, 249, 284–5, 286, 290 individuals freedom of 14, 74, 82 impact of structure on 285, 286 within social systems 261 see also agency; citizens; consumers; customers; public infection 15–16 information impact on behaviour change 55, 78, 139 personalisation of 164–5 see also education approach information-motivation-behavioural skills model 55 informing type of participation 208 intention-pledge status 169–70 intentions 34 interactive model of research use 293 interdisciplinary understandings and future of field 287–8 multidisciplinary model of behaviour change 148–51 synthesis of psychology and sociology 19–23 interests 241 interlocking practices 247–9 intervention concepts of 207 points in complex systems of 266 whole system approach to obesity 272–5 see also behaviour change interventions intervention mapping (IM) 51–3, 58 intrinsic goals 222

303

Beyond behaviour change intrinsic values case study 224, 225–7 principles of 222

J Jackson, T. 249 Jacobsson, K. 184 James, W. 20–1 Jepson, R.G. 50 Joinson, A.N. 157, 162 Jones, R. 116

K Kelly, M.P. 11 Kiesler, S. 158 Kindon, S. 206 knowledge impact on behaviour change 78 and systems thinking 267–9 see also information knowledge driven model of research use 293 Kothari, U. 205 Kotler, P. 137 Krieger, L.S. 223 Kvaavik, E. 50

L Lang, T. 270 Lansley, A. 120 law-based approach see state regulation leadership 218, 263–4 legislation 14 anti-smoking 272 commercial interests as barrier to 79–80 drug misuse 80–1 history of public health 72–3, 74 road safety 73, 78 liberation, and participation 207 libertarian paternalism 116 libertarianism 74 life-course models 267 lifestyle self-monitoring 160, 163–5 Litman, T. 90, 91 Lloyd, J. 49 lobbying 80, 192 local authorities 275–6 localism 95 logic models 61 low alcohol (ABV) products 190 Luszczynska, A. 57

M MacKerron, G. 167 McMichael, A.J. 267 Maio, G. 229 management process 144, 145, 150 manipulation in participatory approaches 208 manipulative policies 123 manipulative techniques 138 Mappiness Project 167 market exchanges 141, 146–8 market orientation 141, 149 marketing philanthropic activities as form of 181–2, 183 role in social systems 262 and social and environmental concerns 231 see also social marketing; stakeholder marketing Marmot, M. 269 Marsh, A. 283 Maryon-Davis, A. 71 materials, as element of practice 22–3, 239, 244–6, 248 Mead, G.H. 20–1 Meadows, D.H. 266 meanings, as element of practice 22–3, 239, 244–6, 248 media 231 see also social media Melia, S. 89, 104 methodological individualism 41–2 methodology 288–91 see also evidence Mill, J.S. 31–2 MINDSPACE report 116–17 Misuse of Drugs Act (1971) 80–1 mixed methods approach 63–4 morality see ethics and morals Morgan-Trimmer, S. 49 motivation 55, 139 motivation-building techniques 55 motivational theory 32–3 Mourato, S. 167 Mulgan, G. 291 multidisciplinary model 148–51 see also interdisciplinary understandings

N nanny state 74, 78, 120

304

Index National Institute for Health and Care Excellence (NICE) 50, 263 needs assessment 51–2 neoliberalism 113 network connectivity see permeable street networks New Nordic Diet 246 NHS 73, 231 Niger Delta, Shell’s activities in 184–5 Nike+ 164 Norman, D. 161 norms 34, 81, 170, 241 Nudge 116 nudge techniques growing interest in 146 origins of see behavioural sciences as preferred method 120 and technology 161 Nuffield Council on Bioethics 75

O obesity Coca Cola campaign 186 comparing approaches to 139–40 concern about 49 individualistic view of 42 range of interventions 50 and social practice model 286 whole system approach to 272–5, 287–8 see also weight loss interventions organisational change 262 organisations, structure and culture of 265 outcomes evaluations 59–60 Oxford Implementation Index 61

P participation, concepts of 207–9 participatory approaches 200 co-option of 204–5, 211 community development approaches 271 in complex systems 264 heritage of 202–4 terminology 201–2 participatory methods benefits and pitfalls 210–11 criticisms of 205–6 tips for successful 211–12 participatory research 202–3 partnerships 209, 264, 275 paternalism 74, 116, 121–2

Pearson, M. 275 pedometers 141, 166 perceived behavioural control 35 performance, practice as 239 Perkins, N. 275 permeable street networks 92, 99–104, 108 personal responsibility and changing behaviour 116 personalised information 164–5 persuasion 120 philanthropic activities as form of marketing 181–2, 183 see also stakeholder marketing physical sciences 28 physical-technical-economic model (PTEM) 38–9 pilot studies 53, 274 Piwek, L. 157 placation type of participation 209 policy application of social practices approach to 250–1 Behavioural Insights Team 117–21, 125 changes to environment see built environment criticisms of behavioural science in 121–6 evidence base of 289–91 interest in behavioural sciences 116–17, 126 relationship with research 291–3 and traditional theories of behaviour 45 unintended consequences 99 see also behaviour change interventions; social marketing; state regulation policymakers marketing aimed at see stakeholder marketing relationship with researchers 291–3 political economy 31 political model of research use 293 politics of behaviour change 11–13 advocacy and regulation 82–4 commercial interests 79–80, 218 discourse of risk 15–19 public health 13–15 pornography 162 portfolio model 240–3, 249–50 Portman Group 189–90 positivism 28, 289–90 see also RCTs

305

Beyond behaviour change power, compared with domination 206 power dynamics in participatory approaches 202–3, 204–5, 211 and stakeholder marketing 184 ‘Power Play’ intervention 142–3 practice theories see social practices predictability in systems 258, 259, 260 presentation of options 162 prevention 17–18, 276 privacy 170 problem-solving model of research use 293 process evaluations 59, 60–4 profits see fiduciary imperative psychological theories of behaviour criticisms of 39–43 dual systems 19–21 expectancy-value model 32–3 individualist basis of 284 shifting concepts in 115 theory of interpersonal behaviour 35–8 theory of planned behaviour 34–5 theory of reasoned action 33–4 psychotherapy 28 PTEM (physical-technical-economic model) 38–9 public acceptability of state regulation 81 demand for change by 217–19 see also citizens; consumers; customers public awareness campaigns 78–9, 83 public health as aspect of marketing 186–7 history of regulation and 71–4 implications of systems thinking for 266–75 organisational changes 275–6 political nature of 13–15 see also healthy eating interventions; weight loss interventions Public Health Acts 72 public health policy, relationship with corporate sector 195–6 Public Health Responsibility Deal 190 public opinion 83, 272 Pucher, J. 105

R randomisation 59 randomised controlled trials (RCTs) 59–60, 118, 124, 267–8, 269, 289–90

rational decision-making 29–33, 39, 114–15, 121–2, 137 Rayner, G. 270 Rayner, S. 293 recrafting practices 245–6 reductionist approaches 260 reflective processes 54–6, 265 reflective system 19, 20 regulation by state see state regulation voluntary codes 183–4, 185–6, 189–90 regulatory processes see automatic processes; reflective processes relationship marketing 144 religion 28 research relationship with policy 291–3 to gain customer insight 142 researchers relationship with policymakers 291–3 sensitisation of 210 ‘responsible drinking’ 189, 191 revolutionary approaches 207, 287 rights 14 risk degrees of 17 discourse of 15–19 of participatory methods 211 risk behaviours 16–17 risk prevention 17–18 road safety 73, 77–9, 146, 149–50 Road Traffic Acts 73, 78 roles 36 Rothschild, M.L. 139, 148, 150 Royal Society for the encouragement of Arts, Manufactures and Commerce (RSA) 271 Rundle-Thiele, S. 135 Rutter, H. 268

S Sandel, M. 146–7, 223 Sanders, M. 113 Save the Children 185–6 Scope 224, 225, 226 seat belts 77–8 see-saw effect 222, 226 segmentation 142–3, 227 self, the 20–1 self-concept 36 self-efficacy 55 self-monitoring tools 160 smart tracking technology 163–5

306

Index self-regulation in complex systems 258–9 voluntary codes 183–4, 185–6, 189–90 self-selection, and travel behaviour 92, 96 Senge, P.M. 265 sensitisation of researchers 210 sensitivity to initial conditions 259 sequencing of practices 247 service delivery 143–4 shaping of behaviour 158–9, 161–2, 165, 168–9 shared vision 264–5 Sheldon, K.M. 223 Shell 184–5 short-cuts 102, 104 Shove, E. 44, 239, 240, 242, 285–6 simple systems 258, 260 simplicity, and smart technology 165 Skinner, B.F. 29 smart tracking technology 163–5 ‘smarter growth’ policy 91 smartphones 165–7 Smith, J.R. 49 Smokefree Action Coalition 83–4 smoking as risk factor 16 see also anti-smoking measures; vaping social behaviour, impact of technology on 158–63 social class 267 social concern areas related to 230–2 problems of extrinsic values 229–30 public demand for change 217–19 and structure of values 220–1 value-action gap 228–9 values and behaviour change 222–7, 228–9 and values matching 227–8 social deprivation 267 social housing 199 social institutions 231 social marketing compared with behavioural economics 119–21 as component of multidisciplinary model 148–51 and critical marketing 194 criticisms of 145–8 education-marketing-law model 139–40, 151 key concepts 138–40 ‘mythunderstandings’ about 136–8

principles of 140–5 values matching 227–8 social media 136, 161, 162–3, 167–70 social movement approach 264, 271 social norms 170, 241 see also cultural norms social practices defining 251 overview 22–3, 238–40 synchronisation of 247 social practices approach analyses of interventions 243–4 intervention models 244–9 potential of 285–6 theoretical applications 237 to behaviour change 238, 240, 249, 250 versus portfolio model 240–3, 249–50 social sciences 28 social systems boundaries of 263 nature of 260–2 and public health 266–72 role of business and marketing in 262 see also systems thinking socio-cultural perspective 284–7 socio-ecological approaches 142, 143, 267, 269–70 socioeconomic factors and disease 267 and travel behaviour 91 sociology concept of self 20–1 structure, agency and practice 21–3 Southerton, D. 243–4, 247 SPLATT effect 136–7 Spotswood, F. 1, 283 Spurling, N. 245 stakeholder marketing business thinking on 188–94 to co-opt critical analysis 186–7, 190–1, 194 dangers of 194–5 to enhance business performance 187–8, 192–3 principles of 182–4 to reduce accountability 184–6, 189–90 stakeholders co-creation of interventions 52–3, 148–9 engaging across complex systems 264 marketing aimed at 182, 187–8, 191 shared vision of 264–5

307

Beyond behaviour change state use of violence by 11–12 see also policy; politics of behaviour change state formation 11 state regulation benefits of 77–9 CSR to avoid 185, 189–90 in education-marketing-law model 139, 151 effectiveness of 77 ethical issues 74–6 historical perspective 71–4 and individual freedom 74 pitfalls of 79–85 and public health 13–15, 71–4 and systems approach 271–2 Steele, R. 90, 91 Stern, P. 44 Stevens, A. 293 stewardship model 75 street networks see permeable street networks structural change 207, 211, 286–7 structure impact on individuals 285, 286 relationship with agency 21–2 see also environment/context; systems subjective norms 34 see also social norms substituting practices 246 Sunstein, C. 116 sustainable business models 262 synchronisation of practices 247 system boundaries 263 systems categorisation of 258 and future public health 275–6 nature of social systems 260–2 theories of change in complex systems 262–6 systems mapping 272, 273 systems thinking concept of whole systems approach 257 implications for public health 266–72 key features 257–60 and transdisciplinary future 287–8 whole system approach to obesity 272–5

T tactical model of research use 293 Tandon, R. 204

Tapp, A. 135, 149 targeting 142 technology impact on behaviour 157–63 as means of behaviour change 163–70 smart tracking technology 163–5 smartphones 165–7 see also social media temporal coordination of practices 247 Thaler, R. 116 theories of behaviour ABC debate 44, 240 criticisms of 39–43 disciplinary history 28–31 economics 31–2, 114–15 physical-technical-economic model 38–9 and policymaking 45 psychological 19–21, 32–8, 115, 184 social marketing use of 142 techniques based on 27, 54 see also social practices approach theories of change 61–2 theory of interpersonal behaviour (TIB) 35–7 theory of planned behaviour (TPB) 34–5 theory of reasoned action (TRA) 33–4 therapy type of participation 208 Tidwell, L.C. 160 touchscreen devices 165 tracking technology 163–5 transdisciplinarity 287–8 see also interdisciplinary understandings transformative effect of technology 158, 159, 162–3 Transition Town Movement 271 travel behaviour impact of cycle paths on 105–7 impact of environment change on 89 impact of permeable street networks on 99–104, 108 relationship with built environment 90–9 Trenchard-Mabere, E. 257 Triandis, H. 35–7 trust in participatory methods 210, 211 and stakeholder marketing 182, 187, 193 tunnelling 162 Twitter 169, 170

308

Index

U understanding, in participatory methods 211 . unintended consequences 99, 268 upstream social marketing 139 urban environment see built environment urban intensification 95–9, 107–8

V

White, L.T. 157 Whitehead, M. 50 whole system approach see systems thinking Williams, B. 168 Wilson, C. 40 World Bank 205 World Health Organisation (WHO) 73, 195 WWF (World Wide Fund for Nature) 219, 224–6 Wyatt, K. 49

value co-creation 201 value modes 227–8 value-action gap 33–4, 228–9, 241, 242 values and behaviour change 222–7, 228–9 beyond focus on causes 230–2 Crompton’s work on 219 nature of 220–2 in portfolio model of behaviour 241 problems of appealing to extrinsic 229–30 values disposition 221–2, 223, 227–8, 232 values matching 227–8 vaping 84–5 Vasalou, A. 168 victim blaming 42 violence 11–12 voice 210 voluntary change 77–8 voluntary codes 183–4, 185–6, 189–90

W walking 99–104 Walther, J.B. 160 Wanless, D. 73–4 Warde, A. 239, 242, 243, 251 weight loss interventions Healthy Lifestyles Programme 51, 52, 53, 58 targeting regulatory processes 56, 57, 58 to tackle obesity see obesity use of smart technology 166 see also healthy eating interventions WeightWatchers 138 Weiss, C. 293 Welch, D. 237 ‘Wheels, Skills and Thrills’ intervention 149–50 Whitbread, J. 185–6

309

“This book shines a much-needed multidisciplinary light into the corners of the fast-emerging field of behaviour change. An important read for policymakers, business people and academics alike.” Agnes Nairn, Hult International Business School, USA

‘Behaviour change’ has become a buzz phrase of growing importance to policymakers and researchers. There is an increasing focus on exploring the relationship between social organisation and individual action, and on intervening to influence societal outcomes like population health and climate change. Researchers continue to grapple with methodologies, intervention strategies and ideologies around ‘social change’.

•

Multidisciplinary in approach, this important book draws together insights from a selection of the principal thinkers in fields including public health, transport, marketing, sustainability and technology. The book explores the political and historical landscape of behaviour change, and trends in academic theory, before examining new innovations in both practice and research. It will be a valuable resource for academics, policy makers, practitioners, researchers and students wanting to locate their thinking within this rapidly evolving field.

Beyond Behaviour Change

“This excellent text provides multiple perspectives and important syntheses which should help unify ideas in the growing field of ‘wicked’ problems.” John Parkinson, Bangor University, UK

Edited by

GOVERNANCE / SOCIAL STUDIES

www.policypress.co.uk PolicyPress

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@policypress

Fiona Spotswood

DR FIONA SPOTSWOOD is a critical marketer based at Bristol Business School, University of the West of England. Her research uses practice theory to explore the impact of marketing on ’wicked’ problems.

Beyond Behaviour Change Key Issues, Interdisciplinary Approaches and Future Directions Edited by

Fiona Spotswood 12/02/2016 10:16