Minkler - Personal Responsibility For Health

Health Education & Behavior
http://heb.sagepub.com/ Personal Responsibility for Health? A Review of the Arguments and the Evidence at Century's End
Meredith Minkler Health Educ Behav 1999 26: 121 DOI: 10.1177/109019819902600110 The online version of this article can be found at: http://heb.sagepub.com/content/26/1/121
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Minkler / Personal Responsibility for Health

Health Education & Behavior (February 1999)
Personal Responsibility for Health? A Review of the Arguments and the Evidence at Centurys End
Meredith Minkler, DrPH
This article examines the continuing controversies regarding personal versus social responsibility for health as they are being played out at the turn of the century. Following a brief examination of the contested meaning of personal responsibility for health in recent historical context, attention is focused on the arguments for and against holding the individual to be primarily accountable for his or her health behavior. The paper then makes the case for more balanced, ecological approaches that stress individual responsibility for health within the context of broader social responsibility. The article concludes by briefly summarizing the Canadian approach to health promotion as a useful example of what such a balanced, ecological approach might look like.
As we confront the dawn of a new century, ideological and political controversies continue to surround the fundamental question of whether the individual or the broader society should be held responsible for personal health behaviors. For health education professionals, however, a more useful question involves how we can achieve a balance between individual and social responsibility, so that simplistic either/or positions are replaced by a greater appreciation of the contributions of both personal behavior change and broader 1-3 environmental change in facilitating health improvement. To better articulate the need for a more balanced approach, it is necessary to understand and appreciate the evidence and the strong arguments that exist on each side of the personal-responsibility-for-health question. This article will begin by summarizing these arguments and underscoring the utility of more balanced approaches as we enter a new decade and a new century.
Meredith Minkler is professor and chair of Community Health Education and a member of the Division of Health and Medical Sciences in the School of Public Health at the University of California, Berkeley. Address reprint requests to Meredith Minkler, Professor and Chair, Community Health Education, School of Public Health, University of California, Berkeley, Berkeley, CA 94720-7360; phone: (510) 642-4397; fax: (510) 643-8236; e-mail: mink@uclink4.berkeley.edu. This article is based, in part, on a presentation given at the symposium on Health Promotion and Disease Prevention: Ethical and Social Dilemmas, sponsored by the Hastings Center and the Stanford University Center for Biomedical Ethics. The author gratefully acknowledges Daniel Callahan and other colleagues at the symposium for their feedback and support, and particularly Ann Robertson for her helpful review of an earlier draft of this article. My sincere thanks also to Beth Freedman for her help with referencing and final editing, and the anonymous reviewers whose suggestions greatly strengthened this article. Finally, I wish to acknowledge my friend and colleague, Dr. S. Leonard Syme, whose seminal contributions to our understanding of the personal and social determinants of health have helped countless students, scholars, and practitioners better understand this complex area. For his intellectual stimulation and his continuing support, encouragement, and inspiration, I gratefully dedicate this article to Professor Syme.
Health Education & Behavior, Vol. 26 (1): 121-140 (February 1999) 1999 by SOPHE
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Ecological perspectives on health promotion developed by McLeroy, Bibeau, Steckler, and Glanz2; Stokols3; and others4-5 that stress individual responsibility for health within a context of broader social change then will be presented and examined. The article will close by briefly summarizing the Canadian model of health promotion as a concrete example, at the national level, of a broader ecological approach. Despite recent setbacks experienced as a result of ideological shifts, budget cuts, and difficulties in translating the rhetoric of such an approach into practice, the Canadian model will be seen to remain an important and accessible vision of what a balanced perspective on health promotion might look like. THE CONTESTED MEANING OF PERSONAL RESPONSIBILITY FOR HEALTH: AN INTRODUCTORY NOTE As medical ethicist Daniel Wikler6 has argued, the seemingly simple premise that individuals are responsible for their health means very different things to different people. The self-help or holistic health advocate who calls for taking control of ones health back from the traditional medical establishment thus is likely to hold a very different interpretation from that of the individual for whom personal control over health is fundamentally a moral question of right and wrong. To underscore and clarify these diverse perspectives, Wikler turns to Dworkins7 typology of the several alternative meanings of responsibility in the debate over health promotion and personal responsibility for health. The latter schema differentiates between role responsibility (ones body belongs to oneself), causal responsibility (ones health status is in large part determined by personal behavioral choices), and responsibility based on liability for costs and other undesirable consequences of ones illness. While role responsibility in this schema may imply nothing more than ones role as a biological organism, causal responsibility implicates the individuals choices and actions with regard to diet, exercise, and so forth in helping to determine his or her health status. In the words of the late Rockefeller Foundation president, John Knowles,8 the primary critical choice facing the individual is thus whether to change his [sic] personal bad habits or quit complaining. He can either remain the problem or become the solution to it. Finally, responsibility based on liability would suggest that the unhelmeted cyclist who sustains a head injury, or the smoker who develops lung cancer, bear responsibility for the medical care costs and other undesirable consequences of his or her foolish behaviors. Depending upon which interpretation of personal responsibility for health is adopted, Wikler notes, one may invoke ethical or even judicial notions of paternalism, general utility, communitarianism, or fairness and compensation to, in turn, inform policy choices regarding health and health promotion and disease prevention.6 Although it is beyond the scope of this article to discuss the impact of each of these conceptual orientations, they are introduced here to underscore that even among strong advocates of personal responsibility for health, profound, albeit often unspoken, disagreements may exist in the foundational assumptions concerning the meaning of
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responsibility in relation to individual health and health-related behaviors.
PERSONAL RESPONSIBILITY FOR HEALTH IN RECENT HISTORICAL PERSPECTIVE Notions of personal responsibility for health have surfaced and resurfaced throughout human history. The effects of lifestyle on health were emphasized in ancient Greece and Rome, and the notion that individuals had at least some control over their health continued, to varying degrees, through the Middle Ages and the Renaissance (see Reiser9 for a good historical overview). In the United States, as in other nations, several shifts in the assignment of responsibility for health have been witnessed, with an emphasis on personal control and selfsufficiency emerging in the early 1800s and again toward the end of the 19th century. Despite such shifts, however, a dominant cultural preference for notions of personal responsibility has been noted throughout our history, which is consonant with Jeffersonian democracys emphasis on voluntarism, decentralization, and only limited obligation to the common good.9 The dominant view of health promotion in the United States today emerged in the 1970s in response to a growing disillusionment with the limits of medicine, pressures to contain health care costs, and a social and political climate emphasizing self-help and individual control over health.9-12 It is a vision that sees individual behavior as in large part responsible for the health problems we face as a society. In the words of J. K. Iglehart,13 editor of the journal Health Affairs, this vision suggests that most illnesses and premature death are caused by human habits of living that people choose for themselves (emphasis added). Ironically, this traditional approach to heath promotion has tended to be disease oriented, rather than health oriented. As Wallack and Montgomery14 have pointed out, it defines health primarily as the absence of disease and sees disease as being associated largely with known and controllable risk factors such as cigarette smoking, poor diet, and heavy drinking. The individual is seen as the appropriate focus for intervention to control risk factors, with those interventions typically consisting of providing knowledge and skills for changing unhealthy behaviors. This vision of health promotion was given institutional expression in Canada, with the publication of the Lalonde report15 in 1974, and in the United States, in the surgeon generals report, Healthy People, published in 1979.16 Both of these documents, it should be noted, discussed the role of broader environmental factors in influencing health and did not limit themselves to a discussion of individual lifestyle or personal behavior issues. The surgeon generals report, for example, argued persuasively that we are killing ourselves, not only by our own careless habits but also by polluting the environment and permitting harmful social conditions to exist.16 Despite their efforts to address some of these broader issues, however, the major contributions of both the Lalonde and the surgeon generals reports lay in calling attention to the often substantial role individuals can play in modifying their personal behaviors and in other ways improving their health status.17-19 In the United States, the surgeon generals report was followed by the development of clearly articulated and measurable Objectives for the Nation.20 The listing of activities
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for achieving each objective was extremely thorough and included strategies on the levels of institutional change, legislation, and policy, and not merely in the realm of personal behavior change. In reality, however, implementing this broad vision of health promotion, particularly in an era of fiscal conservatism, proved difficult indeed. Moreover, as former Office of Health Promotion Director Lawrence Green21 noted, the sharp distinction drawn in United States policy between health promotion (focused mainly on behavior and lifestyle issues) and health protection (concerned more with the physical environment) led to a narrower interpretation of health promotion in the United States than in many European nations, which argued that both physical and social environmental factors lay within the purview of health promotion. In Greens21 words:
We Americans allowed our health promotion terrain to be restricted to lifestyle determinants of health, but we also allowed lifestyle to be interpreted too narrowly as pertaining primarily if not exclusively to the behavior of those whose health is in question.
As a consequence, most of the programs that grew out of the renewed push for health promotion and disease prevention in the United States beginning in the late 1970s tended to focus primarily on the level of personal behavior change.22 The programmatic emphasis on individual responsibility for health, in short, frequently was not accompanied by attention to individual and community response-ability,23 or the capacity of individuals and communities to build on their strengths and respond to their personal needs and the challenges posed by the environment.24 Following an examination of the case for and against a predominantly personal responsibility focus in health promotion, I will return to the notion of a more balanced approach that stresses both individual responsibility and broader society action to enhance response-ability.
THE CASE FOR PERSONAL RESPONSIBILITY FOR HEALTH The past three and a half decades have seen the amassing of an impressive body of evidence supporting the importance of individual responsibility for health.15,16,25-30 Indeed, bioethicist Daniel Callahan29 has argued that nothing is more evident in the statistics of public health than the role played by individual health behavior in contributing to accidents, illness and disease. In a now classic series of studies, for example, Breslow and his associates26 revealed that men who followed seven personal health habitseating breakfast, drinking only in moderation, not smoking, and so forthhad lower morbidity and mortality rates than those who followed six; those who followed six of the habits had better health and mortality outcomes than those who followed five; and so forth. Similarly, Kayman, Bruvold, and Stern25 demonstrated that individuals who develop their own diet and exercise plans are more successful at achieving and maintaining weight loss than those who play a more passive role. Finally, when McGinnis and Foege27 calculated the leading causes of death for Americans under 75, not by disease, such as cancer, coronary heart disease and stroke, but rather by putative or actual cause, tobacco, diet, and exerciseall factors directly related to individual behaviorwere found to constitute the greatest causes of premature death. The two most rapidly increasing causes of mortalitysexual behavior and illicit drug usealso were among those with strong behavioral components. The case for a strong emphasis on personal responsibility for health frequently also is built on the fact that there is much room for improvement in the health habits of
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Americans. The United States has record rates of obesity and eating disorders, and fully 35% of all Americans and 21% of teenagers were overweight in the mid-1990s.30 More than 60% of adults are not physically active on a regular basis and 25% lead sedentary lives.28 While smoking rates dropped substantially from 40% in the mid-1960s to about 22% by the mid-1990s,31 tobacco still accounts for more than 400,000 deaths per year, leading the Centers for Disease Control and Prevention to dub smoking the most devastating cause of disease and premature death this country has ever seen.32 Finally, recent evidence suggests that the prevalence of some unhealthy behaviors has significantly increased during the last few years. Among 8th, 10th, and 12th graders, for example, the proportion of youths who smoke daily increased by almost 50% between 1991 and 1996, with 20% of 12th graders now smoking on a daily basis.33 The proportion of adults who are overweight increased by 14% from 1980 to 1994,30 and the proportion of high school students participating in daily physical education classes fell from 42% in 1991 to just 25% in 1995.28 Coupled with these and other indicators of the need for change is some impressive evidence that individual behavior change can work to achieve improved health outcomes. Each year, millions of smokers successfully quit the habit (albeit usually after several attempts), and most who do quit do so on their own.34 For those individuals who need help in making lifestyle modifications, increasingly sophisticated behavior change techniques and interventions have sometimes demonstrated high success rates. The Stanford Coronary Risk Intervention Program (SCRIP), for example, which combined comprehensive lifestyle modification in terms of diet, exercise, and smoking with counseling and medication, reported a 40% lowering in cholesterol consumption, a 23% reduction in lowdensity lipoproteins (LDL), a 20% increase in exercise, and other significant changes during a 4-year period.35 Although both groups in this randomized clinical trial saw some worsening of their heart disease and three died in each group, the SCRIP participants demonstrated 47% less narrowing of their arteries and had only slightly more than half the number of hospitalizations of the controls.35 Numerous smaller scale interventions stressing lifestyle modification, many of them chronicled in the health education literature, also have demonstrated success.28,36-38 Research on successful lifestyle modification programs for the elderly have been particularly important in demonstrating that despite a troubling health profile (70% of Americans over 65 are sedentary, 16% smoke, and 20% are overweight),39 many older Americans both choose to participate in such programs and have low recidivism rates following smoking cessation and other lifestyle changes.40 The Los Angelesbased Medicare Screening and Health Promotion Trial (MSHPT) thus boasted participation rates of more than 70% (N = 1,911) with no significant differences at baseline in the health habits and behaviors of participants and nonparticipants. Although this trial was limited to a largely white middle-class community,40 the finding of comparability in health behaviors between those elders who took part and those who did not suggests that health promotion and disease prevention efforts may effectively reach those for whom personal behavior changes could make a significant difference in terms of risk factor reduction. The above arguments frequently are cited as part of the scientific base for approaches to health promotion that stress personal responsibility. Yet another important part of this case is firmly grounded in ethics, since this perspective acknowledges human agency or individual will and choice in deciding on a course of action. The human agency argument highlights the role of intentional or purposive action in health achievements.6,8 Proponents of the human agency argument, for example, point to dramatic declines in cigarette smoking and consumption of saturated fats from the 1960s through the 1980s, with a
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corresponding decline by about one-third in deaths from coronary heart disease and stroke in that same period.41 Although it is impossible to determine the extent to which these dramatic declines in stroke and heart disease mortality can be attributable to personal behavior changes in diet and smoking, the death rates from both diseases began to fall well in advance of the widespread use of pharmacological agents.42 Examining the evidence in this regard, Farquhar42 has suggested that personal decisions to change health behaviors must indeed be credited with some of the declines observeda perspective that again highlights the human agency argument. As Neubauer and Pratt19 have noted, notions of the freedom to think and to act, to exert control over situations, to gain respect from othersall on ones own terms, are particularly important to Americans and make the human agency component of the dominant approach to health promotion a compelling one. For intimately related to the notion of human agency is the idea that individuals have a fundamental right, based on the principle of autonomy, to choose health-related behaviors. Yet, with this right, so the argument goes, comes a responsibility to make wise choices. A major assumption of the human agency argument, with particular relevance in relation to the responsibility side of this equation, involves the notion that individuals can make choices in relative isolation from the broader social environment of which they are a part. In Larry Churchills43 words, such thinking is embedded in a moral heritage in which answers to the questions what is good?and what is right?are lodged definitively in a powerful image of the individual as the only meaningful level of moral analysis. Yet, as Bellah et al.,44 Sandel,45 and others make clear, the moral actions of individuals (and, I would argue, their health-related actions) can only be understood in a broader social context. It is to this and other critiques of the dominant notion of personal responsibility for health that we now turn.
LIMITATIONS OF THE PERSONAL RESPONSIBILITY PARADIGM Few, if any, health educators or health psychologists would argue that individuals lack any responsibility for health-related decisions and actions, making the question of individual versus social responsibility for health something of a straw man in these circles. Because this issue remains alive and well politically, however, it is important to review some of the criticisms that have been leveled at what many see as the dangers of an overemphasis on individual responsibility for health. Foremost among these criticisms is the argument that an overriding emphasis on personal responsibility blames the victim, by ignoring the social context in which individual decision making and health-related action takes place.12,19,46-47 In Crawfords words,47 the victim-blaming ideology
both ignores what is known about human behavior and minimizes the importance of evidence about the environmental assault on health. It instructs people to be individually responsible at a time when they are becoming less capable as individuals of controlling their health environment. (p. 671)
Holding the individual responsible for health choices is particularly problematic in the case of the poor, since poverty itself is now widely accepted as among the most significant risk factors for illness and premature death.48 Haan, Kaplan, and Camacho49 thus demonstrated in their study in Alameda County, California, that residence in a poverty neighbor-
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hood resulted in a 40% excess mortality rate. Significant differences in mortality remained, even when smoking, diet, exercise, and other traditional risk factors were controlled for.49 Without discounting the important role of individual risk factors, such as smoking and lack of exercise, in premature morbidity and mortality, this investigation suggested that the nature of poverty itself, with its characteristic combination of high environmental demands and low resources for coping with these demands,50 appeared to play an important causal role. Attention also has been devoted to elucidating those mediating factors that may explain the relationship between personal responsibility and socioeconomic status. Central to much of this theorizing and research is the notion of control as a transcendent concept51 that can help explain health outcomes and health behaviors at both individual and broader population levels. Syme52 has suggested, for example, that people at progressively lower socioeconomic status (SES) levels have correspondingly less opportunity to control the circumstances and events that affect their lives. Conversely, for individuals at higher levels, factors like higher income and greater discretion, latitude, and control over decision making at work may contribute to a more generalized sense of control over destiny, which, in turn, may translate into enhanced health behaviors and health outcomes. Other theorists, while often operationalizing terms differently, have come to similar conclusions. Indeed, as Syme51 has noted, loss of control has been defined in terms of constraints on coping ability, diminished authority over decisions, threats to status and self esteem, lessened opportunity to learn new skills, and inappropriateness of coping. The concept further has been variously used in reference to perceived control and actual control, and to control as a state of being and as a condition under which things are in control. Despite (or perhaps because of) the wide range of definitions and measurement tools employed, the notion of control increasingly is seen as having value in helping to explain the link between unhealthy personal behaviors, poor health, and SES.51 Separate, yet often intimately related to poverty are other aspects of the social context in which individual health behavior takes place that also must be considered in any discussion of personal and social responsibility for health. We have long known, for example, that SES is transformed by racism,53 with significant race differences in such critical areas as the quality of education, income, returns on education, and costs for goods and services including housing, food, and automobile insurance (p. 29).53 Furthermore, as Robinson54 has pointed out, even after controlling for work experience and education, employed African Americans are exposed to more occupational hazards and carcinogens than are whites. We are only beginning to appreciate, however, the more subtle impacts of racism as a risk factor for heart disease, depression, and other illnesses.53,55-58 And only with the advent of a movement for environmental justice have we begun to appreciate the health consequences of such inequities as the fact that people of color have incinerators placed in their neighborhoods at a rate 89% above the national average.59 The implications of such findings are troubling, and they suggest the need for far more serious attention to the racial/ethnic and related aspects of the social environment in which health-related behavior takes place. Finally, the cultural environment in which individuals are expected to take personal responsibility for their health must also be thoughtfully considered. The average American school-age child, for example, watches 10,000 television commercials per year, and in a single recent year, one company spent more than $30 million advertising a single sugar-coated cereal! During that same year, the amount spent by the U.S. government on nutrition education for schoolchildren was just $50,000 per state.60 Americans not only
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are bombarded with advertisements for high-fat, high-calorie foods but consistently are provided large servings of such foods when they eat at most restaurants and fast-food establishments. At the same time, as Robison61 points out, When our culture continues to say to us, why walk when you can ride? when it admonishes us to get every new laborsaving device, and to not even leave our chair to change a TV channel or our computer to send a fax, is it any wonder that the notion of building in 40 minutes three or four times a week for exercise goes against the grain? Without discounting the significant role of genetics in influencing obesity and body size at the individual level, leading geneticists have pointed out that [t]he current increase in obesity has nothing to do with genes and everything to do with how we live,62 including these broad cultural realities. When such environmental factors are taken into account, the limitations of an approach to health promotion based on personal responsibility for health are cast in stark relief. Another important dimension of the victim-blaming potential of an overemphasis on personal responsibility for health involves the fact, noted by Becker,63 that when being ill is redefined as being guilty (p. 19), we may inadvertently stigmatize the disabled, the elders, people who are overweight, and other already devalued groups in our society. The renewed emphasis on individual responsibility for health thus has been accompanied by the reemergence of a Victorian era notion that healthy old age is a just reward for a life of self-control and right living.64,65 In Levins66 words, good health has become a new ritual of patriotism, a marketplace for the public display of secular faith in the power of the will. Within such a vision, where is there a place for the 85-year-old man with a disabling respiratory ailment or the obese and severely arthritic elderly woman in a wheelchair? Wang67 similarly has demonstrated how health promotion approaches to injury prevention that stress personal responsibility and carry the implicit or explicit message, Dont let this happen to you! often inadvertently stigmatize people with disabilities, suggesting that they are inherently flawed and undesirable. She poignantly quotes a paraplegic who, on viewing a series of ads depicting people in wheelchairs with scareprovoking captions said, It feels like I should be preventing myself! In cases like these, an overemphasis on individual responsibility for the state of ones body or health may inadvertently contribute to messages that reinforce ageism, prejudice against people with disabilities, and other stigmatizing attitudes. Another widely held criticism of the heavy emphasis placed on personal responsibility for health involves the argument that such a perspective lets government off the hook by assigning blame for premature morbidity and mortality and the like to the individual. Frequently underlying this criticism is the fact that conservative governments have used the rhetoric of personal responsibility for health to justify cutbacks in needed health and social programs.12,19,46,47 The 1996 Welfare Reform Act, for example, which repealed Americas 60-year-old commitment to welfare entitlement for the poor, contained numerous sanctions against undesired individual behaviors (such as becoming a teenage mother) and was, in fact, named the Personal Responsibility and Work Opportunity Reconciliation Act.68 Although the long-term effects of this measure will be very difficult to gauge, in part as a result of its coincidence with a booming economy, initial estimates suggest that it could throw more than 1 million additional children into poverty.69 The political use of the language of individual responsibility to support programs and policies like this one may be significant in their human costs and consequences.70,71 Critics of an overemphasis on personal responsibility for health also frequently invoke an epidemiological argument, pointing out that encouraging individual behavior change can have only limited impact on the distribution of disease in communities.48 Two factors contribute to this reality. First, as health education professionals are painfully aware,
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getting people to maintain behavioral changes over time, like cutting back their intake of high-fat, high-calorie foods or sustaining an exercise regimen, is difficult. Half of all individuals who begin an exercise regimen quit within 6 months.61 This discouraging statistic may reflect in large part ineffective prescriptions based on faulty theory and/or unrealistic hopes for bodily composition changes that cannot be guaranteed by even the most faithful adherence to an exercise regimen. Regardless of the specific reasons, however, the high rates of nonmaintenance of exercise regimenslike the high recidivism rates for smoking cessation and weight lossunderscore the complexity of the behaviors that must be altered if people are to achieve desired health outcomes. As one researcher put it, personal responsibility approaches that liken giving up smoking and other unhealthy behaviors to just saying no to a scone at a tea party trivialize the difficulty of such sustained actions.72 In addition to the difficulty of behavior change maintenance, epidemiologists point out that the sheer prevalence of diseases such as lung cancer, heart disease, and stroke mean that solutions focused on individual responsibility for change are unlikely to have much effect. Each year, for example, several million people are newly diagnosed with coronary heart disease in the United States;73 each day, 6,000 teens smoke their first cigarette and another 3,000 enter the ranks of regular smokersthose who smoke at least one cigarette daily.74 Given such realities, a personal responsibility approach does little to alter the distribution of disease in the population because new people develop disease even as sick people are cured and because new people enter the at riskpopulation as others leave it (pp. 496-497).73 Critics of the personal responsibility approach to health promotion also point to the limited effectiveness of many of the large well-funded programs that have focused on individual behavior change. In the Multiple Risk Factor Intervention Trial (MRFIT), as Syme52 points out, men who were highly motivated and were in the top 10% risk category for coronary heart disease, and who had access to an intensive intervention in a 6-year period, were able to make only modest changes in their eating and smoking behavior. Similarly, the widely touted Community Intervention Trial for Smoking Cessation (COMMIT) project, which represented the most ambitious and sophisticated antismoking program ever attempted, achieved only modest results.75 It is important to note that many of the key architects of these ambitious efforts, which focused heavily on individual behavior change, are now among the most articulate spokespersons on the need for a broader environmental or societal responsibility focus. Stanford Heart Disease Project founder Jack Farquhar42 thus strongly advocates increased excise taxes on cigarettes, which, he argues, could reduce smoking rates far more effectively than individual change approaches. Similarly, a lead researcher in the MRFIT program now advocates approaches that stress community empowerment and increased social responsibility.52 Increasing evidence suggests that macro-level or environmental interventions, grounded in notions of social responsibility for health, can exert a powerful effect in changing behaviors on a broad scale. A 10% increase in the price of cigarettes, for example, has been shown to decrease teen smoking by 14%, and it is projected that a $2 per pack tax would decrease adolescent tobacco use by almost 46%.42 Similarly, reductions in the speed limit to 55 have had a dramatic effect on auto safety, and mandatory seat belt laws cut automobile fatalities by more than 75,000 from 1992 to1995 alone.76 Such facts and figures are compelling, and they bring us back to the epidemiological argument that only by focusing on broader environmental forces, rather than on individual behavior change, can we hope to have much impact on the distribution of disease in society.
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A final dimension of the case against too strong an emphasis on personal responsibility for health involves the argument that through such an emphasis we risk establishing a tyranny of health, in which personal health goals are substituted for more important, humane, societal goals.63 It is beyond the scope of this article to examine in detail the dangers inherent in healthism, which places health itself at the center of a new morality and elevates it to the level of a primary virtue.77,78 But the cautions that have been raised against health becoming the paramount value of our society63 should be seen as constituting another important rationale for broadening the focus of our health promotion approaches in ways that more fully acknowledge and attend to the larger environmental forces that must be addressed if we are to attain healthier societies.
OVEREMPHASIZING SOCIAL RESPONSIBILITY FOR HEALTH: SOME FINAL CAUTIONS In casting this article in terms of the arguments and the evidence for and against primary attention to personal responsibility for health, I have necessarily focused on the individual side of the personal versus social responsibility equation. It should be stressed, however, that legitimate concerns also have been raised concerning health promotion approaches and mind-sets that focus too exclusively on the social determinants of health. First and foremost, for example, such approaches often ignore the fact that many individuals, despite often highly adverse environmental circumstances and constraints, do manage to quit smoking, dramatically change their diet and exercise patterns, and in other ways act effectively to improve their health. Too exclusive an emphasis on social responsibility for health ignores human agency and may, as a consequence, downplay the important role of individuals, health educators, and other practitioners who may assist individuals in making these important lifestyle changes. Second, as Stokols79 has noted, Environmental analyses of health promotion give little or no attention to the varying behavioral patterns and sociodemographic characteristics of the people occupying particular places and settings (p. 285). By failing to acknowledge individual and group differences in how people respond to their environments, such approaches may miss the fact that environmental interventions, such as policies promoting smoke-free workplaces, may vary substantially in their health impacts with the behaviors and life circumstances of individuals and groups. The health benefits of a policy creating smoke-free workplaces, for example, may be far less for employees whose behavior includes smoking at home or during breaks and similarly may be reduced for those groups of employees who face greater stressors due to low income and educational levels.79 A third criticism of health promotion approaches stressing too exclusively the social responsibility side of the equation involves the lack of precision with which social determinants of health often are defined, which, in turn, poses great difficulties in measuring and evaluating the effectiveness of macro-level interventions.4 In the case of substance abuse prevention, for example, when one moves beyond such environmental factors as alcohol availability and advertising and into the realm of variables like social inequality and racism, operationalizing terms and measuring impacts becomes far more challenging.80 While the importance of focusing on these underlying factors cannot be denied, health promotion efforts to address social determinants of health that do not clearly identify which social factors are being targeted and how they are being defined and measured
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may do a disservice in making it impossible to determine whether such interventions do, in fact, have an impact. Finally, as Green, Richard, and Potvin4 have noted, complexity breeds despair, and too exclusive an emphasis on the multilevel environmental determinants of health can lead health promotion practitioners to the fatalisticand spuriousconclusion that nothing they can do will be of any consequence. The continued strong need for programs that help individuals take control over, and change, unhealthy personal behaviors make such fatalism an attitude we can ill afford. In sum, a single-minded preoccupation with social responsibility for health tends to carry its own set of problematic consequences. What is needed, instead, and what most health educators advocate, is a more balanced approach. It is to the latter that we now turn, with special attention to the ecological models for health promotion that provide useful conceptual frameworks for research and practice in this area.
BALANCING INDIVIDUAL AND SOCIAL RESPONSIBILITY FOR HEALTH: ECOLOGICAL MODELS FOR HEALTH PROMOTION Epidemiologist S. Leonard Syme,81 one of the worlds leading experts on the risk factors associated with coronary heart disease, once wrote the following:
No one would [question] that, as individuals, we are responsible for our health. In the final analysis, we are the only ones who can change our behavior. We are the only ones who lift fork to mouth, who inhale smoke, who plant feet on sidewalk. And we are the only ones who can decide to do these things. . . . [But] we dont live in a vacuum. Whether we like it or not, our thoughts, ideas, wishes and behaviors are influenced and conditioned by the people around us, by the environments in which we find ourselves, and by the customs, traditions, fads and fashions to which we are continuously exposed. . . . Effective behavior change therefore requires that we do our best as individuals, but also that we work together with one another to create more healthful and supportive social environments. (p. 56)
The notion of doing our best as individuals while attending to the broader environmental determinants of health is nicely captured in the ecological perspectives on health promotion that have gained increasing currency in recent years.2-5,79 Individual behavior is the outcome of interest in most of these ecological models, and as will be noted later, they include an emphasis on intrapersonal change as well as on transformations on the interpersonal and broader community, institutional, and policy levels. A key attribute of such approaches, moreover, involves their appreciation of the human agency perspective that changes at the individual level can, in turn, influence the broader systems of which individuals are a part. As Wallerstein and Bernstein82 have noted, for example, the very process of planning and carrying out a health promotion program can shape individual consciousness about responsibility and causal factors in health. Such perceptions in turn may play a critical, empowering role as individuals and their communities are enabled to better address health-related problems. Although ecological models for health promotion do tend to place their greatest emphasis on those causal factors influencing health and health behavior that are environmental rather than individual in nature, the focus of these models on reciprocal relationships between people and their environments should be underscored.
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The application of social ecological thinking to health and health behavior dates back several decades (see, e.g., May83 and Catalano84,85) and is well-grounded in early health education approaches. Green et al.s86 PROCEDE/PROCEED model, for example, which was developed as a planning and evaluation tool more than 30 years ago and has been applied in several hundred published accounts, has a distinct ecological flavor. By helping health educators work systematically backward from a desired outcome, such as quality of life, through various epidemiological, behavioral, educational, organizational, administrative, and policy determinants, the model aids in planning multilevel interventions consistent with ecological thinking.86,87 Similarly, Banduras88 social cognitive theory, although widely identified as the leading personal agency perspective, has, in fact, evolved into an ecological model. In his recent book, Self Efficacy: The Exercise of Control, Bandura thus sought a balance between individual efficacy and broader political and other collective forms of action for social change, concluding with a call for social initiatives that build peoples sense of collective efficacy to influence the conditions that shape their lives and those of future generations (p. 525). A more explicit ecological model for health promotion was developed by McLeroy, Bibeau, Steckler, and Glanz,2 who, in turn, built on the work of Brofenbrenner89 and others.90 McLeroy, Bibeau, Steckler, and Glanzs model emphasized five nested levels of influence: intra- and interpersonal factors, community and organizational factors, and public policies each were seen as intimately interdependent levels of analysis that must be considered if we are to better understand both health-related behaviors and interventions that may be appropriate at each level. Individuals developmental histories and their social support systems; the organizational structures and processes that can positively or negatively affect health behavior; community-mediating structures such as schools, neighborhoods, and churches; community networks and power structures; and both the content of our public policies and the role of participation, advocacy, and other processes in their formation thus all were described as key components of a broad ecological perspective. Subsequent work by Stokols;3,79 Green, Richard, and Potvin;4 Sallis and Owen;5 and others87 has further developed and refined the social ecological framework for health education and health promotion research and practice. It has underscored, for example, the need to (1) examine the joint or cumulative effects of personal and environmental factors in designing health promotion programs; (2) take into account the linkages between various settings and levels, and how change at one level affects others; (3) use a multidisciplinary perspective, integrating knowledge and methods from a variety of fields; and (4) look for and address the unanticipated consequences of intervention strategies.4-5,79,87 Green, Richard, and Potvin4 further have stressed the need to carefully differentiate between health promotion settings and health promotion targets and have elucidated the many difficulties inherent in evaluating ecological health promotion programs, which by definition do not lend themselves to either experimental or quasi-experimental design. Finally, and in response to the latter concern, Richard et al.87 have devised and tested a framework for assessing the integration of the ecological approach in health promotion programs, leading the way for more careful analysis of the effectiveness of such efforts in the future. Numerous examples of approaches to health promotion that implicitly or explicitly apply an ecological approach can be found in the health education literature in such diverse areas as substance abuse prevention,81,91 nutrition,92 work site health promotion,9395 physical activity,96 HIV/AIDS prevention,97,98 school health,99 tobacco control,100 and homelessness.101
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On a broader scale, the World Health Organizations (WHO) vision of health promotion102,103 and the ways in which that vision was crafted into a conceptual framework for health promotion policy in Canada104 provide examples of the usefulness and the challenges of an approach that truly balances concerns with individual and broader social responsibility for health. Outlined in the Ottawa Charter,103 which was released at the First International Conference on Health Promotion in the mid-1980s, the new WHO notion of health promotion defined it as a process of enabling people to increase control over, and to improve their health. It went on to state that health promotion represented a mediating strategy between people and their environments, synthesizing personal choice and social responsibility in health. Underlying this alternative vision of health promotion (which came to be called the new public health) were principles including acting on the determinants or causes of health, eliciting high-level public participation, and using a variety of approaches that go well beyond lifestyle education and include legislation, organizational change, and community development.102,103 Efforts like the Healthy Cities Movement, through which some 6,500 municipalities around the world have selfidentified as healthy communities and engaged in processes such as multisectoral planning and public participation in decision making, represent concrete examples of the WHO philosophy of health promotion in action.105,106 The new WHO approach has not been without its critics, with Caplan107 asserting, for example, that the Ottawa Charter attempts to be all things to all people, and because of that, is unlikely to provide the means for a strategy of action. As will be noted below, moreover, both the strengths and the limitations of the WHO approach also have been described with respect to Canadas efforts to apply this philosophy at a national level.
HEALTH PROMOTION IN CANADA: PROGRESS AND CHALLENGES IN THE APPLICATION OF AN ECOLOGICAL FRAMEWORK AT THE NATIONAL LEVEL The Canadian approach to health promotion, which developed alongside, and often in tandem with, the WHO approach, provides an illustration of how such a broadened vision may be translated into a national framework for action. After a period of considerable preoccupation with healthy lifestyles and individual responsibility for health, the Canadian government undertook a massive restructuring of its approach to health promotion. As elucidated in the now classic document Achieving Health for All: A Framework for Health Promotion,104 two important points stand out in the Canadian approach. First, the number 1 challenge set forth for health promotion was reducing inequities between lowand high-income groups, and this was not framed in terms of individual responsibility but of broader societal responsibility. Second, three levels of concern were set forthhealth challenges, health promotion mechanisms, and implementation strategiesand at each of these levels there was attention to the role of broad institutional or environmental change. Self-care, for example, was advocated within a framework that devoted considerable attention to the creation of healthy environments within which positive personal health behaviors could flourish.104 Canadian legislation on cigarettes thus is among the toughest in the world, with many provinces having developed healthy public policies on tobacco, which have included changing their policies on marketing, crop substitution, and smoking in the workplace, at the same time that they urge individuals to quit the habit.
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Efforts also have been made to end the tobacco company sponsorship of cultural and sporting events.108 In several Canadian provinces, Premiers Councils on Health have been established, through which government leaders in the different sectors provide advice on health promotion and work together in jointly setting goals for helping to address the social determinants of health.108 Throughout Canada, hundreds of cities have designated themselves healthy communities, stressing intersectoral planning, high-level community participation, and reciprocity between the individual and the broader society. Finally, in the Northwest Territories, land claims, and the development of First Nations Peoples rights have been discussed as part of a broadly defined health agenda.109 Despite these encouraging examples, however, substantial difficulties in translating the Canadian rhetoric into reality also have been noted. A recent analysis of close to four dozen health promotion programs funded by the Ministry of Health, for example, revealed that although many included activity at the interpersonal and organizational levels, communities and political systems were not frequently targeted.87 The authors indeed concluded that it remains relatively rare to encounter multi-target, multi-setting programs that fully integrate an ecological approach toward health promotion interventions (p. 326). Although the use of a convenience sample in this study precludes the generalization of its findings, the results underscore the need for more systematic research into the extent to which ecological models are, in fact, being attempted and with what success. Critical analysis also is warranted as one moves to the broader level of federal policy. In this regard, Berkowitzs110 recent examination of fitness policy in Canada is noteworthy. Taking a softer approach toward involving Canadians in physical activity (e.g., by stressing the health benefits of gardening and walking rather than a proscriptive exercise approach), the government-promoted Active Living programs literature is replete with the new health promotion language of empowerment, community development, and participation. Yet, as Berkowitz notes, the programs accent on doing more with less is being used to justify cutbacks in formal exercise programs and services, as well as fitness research and development,110 and the ecological approach espoused in documents like Achieving Health for All104 is not much in evidence. Even for programs that do more actively embrace an ecological model, hard outcome data that would indicate whether this approach has resulted in actual declines in morbidity and mortality tend not to be available. In part, as Robertson111 suggests, this may reflect the real difficulties many practitioners have faced in moving from the ecological health promotion rhetoric to concrete guidelines for program implementation and evaluation. In addition, as Rootman112 and Green113 predicted, cutbacks in social spending have greatly constricted the implementation of health promotion, which, in turn, has hampered evaluative efforts. Finally, as Robertson114 and others115 have pointed out, the shift from health promotion to population health as a guiding discourse for public health policy and practice in Canada, particularly given the latters emphasis on an epidemiological and evidence-based notion of health, has mitigated against broader ecological programming efforts. Although population health, like health promotion, stresses the social determinants of health, the language of population health has been used by conservative policy makers to provide powerful justification for major cutbacks in health care and in more broadly defined health promotion efforts.114 To be sure, the new public health discourse continues to have strong support in many quarters. Canadas community health centers, for example, continue to hire community developers (the rough equivalent of community organizers in the United States), and ecological approaches to health promotion remain popular in provinces such as Quebec,
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Ontario, Saskatuan.116 The Canadian Public Health Associations117 recent Action Statement for Health Promotion in Canada also reaffirmed the importance of continuing to use the Ottawa Charter as the framework that defines health promotion in Canada and laid out as well an explicit value base, in keeping with the Charter. Respect for individual choice but priority to the common good in cases of conflict, popular participation in policy making to determine what constitutes the common good, and the pursuit of social justice to prevent systemic discrimination and reduce health inequities were among the principles identified. Yet, the Action Statement, too, lamented the current climate of increasing poverty and cutbacks in the very health and social service programs that, it argued, historically have defined Canadians as a caring people.117 Within such a climate, the importance of translating the rhetoric of an ecological framework for health promotion programs into concrete and measurable policy and program objectives cannot be overstated. For despite its current difficulties and unresolved problems, the Canadian framework for health promotion, and the values and principles underlying it, remain an important example of a vision that offers a balanced concern for personal behavior change within the context of broader social change.
CONCLUSION As the 20th century draws to a close, the health promotion landscape in the United States is filled with images, policies, and proscriptions that exemplify the continuing tensions between health promotion approaches stressing personal responsibility and those calling for a much heavier emphasis on broader social responsibility. As this article has attempted to suggest, strong arguments can be made on both sides of the question about personal responsibility for health, which is itself more a battle of ideologues and politicians than of serious health education scholars and practitioners. For the latter groups, a more prudent and realistic course of action has been to work for a more balanced approachone that ensures the creation of healthy public policies and health-promoting environments, within which individuals are better able to make choices conducive to health. Ecological approaches to health education and health promotion were seen in this article as providing a helpful conceptual framework for action as we attempt to more systematically integrate this balanced perspective. Finally, the Canadian model of health promotion was put forth as an example of how an ecological framework ideally can guide health promotion thinking and action at the national level. Problems confronting the Canadian model, and in particular the difficulties inherent in transforming the rhetoric into measurable criteria and outcomes, were seen as substantial, as were the budget cuts that have had the effect of severely constricting program efforts. Furthermore, even if one ignores temporarily the implementation problems that have sometimes confronted health promotion efforts in Canada, it should be recognized that such an approach may not be entirely feasible within the constraints and ideological realities of the United States. As Canadian health promotion expert Ronald Labonte118 is fond of pointing out, the national credo of the United States, with its individually oriented life, liberty and the pursuit of happiness, bespeaks a very different worldview than that of Canada with its parallel call for peace, order and good government! As a consequence, when the notion of public or community good is invoked in the United States in arguments, for example, for mandatory motorcycle helmet use, common good often is operationalized in terms of the economic rights of law-abiding citizens. Public or
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common good, in short, is defined as my right not to pay for your foolish or risky behavior.11,12 Broadening our concept of the common good to embrace a sense of our intimate interdependencea notion that we are indeed all in this togetheris just one of the ways in which the worldview of Americans would need to change if the full meaning of the Canadian approach to health promotion were to be captured in U.S. policy and practice. Yet, while acknowledging that such changes are unlikely, and keeping in mind as well the limitations of the Canadian approach, this framework, and the broad WHO vision of health promotion which it reflects, still can provide useful visions of efforts at the national and international levels to balance the need for personal responsibility with an equal emphasis on social responsibility. It is perhaps only by appreciating the validity of the arguments and the evidence on both sides of the question about personal versus social responsibility for health, and crafting an ecological approach to health promotion that truly integrates both, that we can hope to achieve our health promotion goals at the dawn of a new century.
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and the Stanford University Center for Biomedical Ethics, San Francisco, CA, December 12, 1997.

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