This piece is part of HWO’s feature on ‘Apocalypse Then and Now’. The feature brings together radical reflections and historic perspectives on catastrophe and calamity. How have crises (both real and imagined), and responses to them, shaped our world?
Provoking behaviour change is central to the UK government’s response to COVID-19. Members of the public were asked, and are now increasingly required, to alter their ways of living to prevent the virus from spreading. This has included behaviours people are expected to adopt, such as frequent handwashing, and behaviours that should stop, such as going to the pub. Individual and collective behaviour change is seen as crucial to efforts to ‘flatten the curve’, to reduce the number of cases and mitigate the impact on the NHS. Much has been made of the involvement of the Behavioural Insights Team, or the ‘Nudge Unit’, in designing the government’s response. The involvement of this specific group is particular to this moment, but strategies to encourage behaviour change amongst the public have long been central to public health policy and practice.
The organised activity of societies to protect their health has, to some extent, always involved elements of behaviour change. Personal cleanliness, for instance, was promoted as beneficial for individual and collective health in Ancient societies throughout the world. Rapid industrialisation and urbanisation in the West during the nineteenth century facilitated the development of large-scale epidemics of infectious diseases such as cholera. The response to these epidemics involved a mixture of government action, legislation, private enterprise and massive infrastructure improvements, like the building of the sewerage network. Individual behaviour change was less of a concern.
Although the impact of such measures on the public’s health has been questioned, by the early twentieth century rates of infectious disease had declined. Non-communicable conditions, such as cancer and heart disease, made up most of the burden of death and disease. By the 1950s and early 1960s, epidemiological research was starting to show that many chronic conditions were linked to lifestyle. Individual behaviours, like smoking, diet, exercise and alcohol consumption, were shown to be important risk factors for heart disease and some forms of cancer.
The primary response from public health authorities to such a shift was to educate the public about these risks and encourage them to change their behaviour. From the early 1960s onwards, a succession of public health campaigns were launched. Anti-smoking and anti-alcohol campaigns, efforts to get the public to eat more healthily, and to take more exercise, became widespread. By the late 1970s, however, doubts started to creep in. Health educators struggled to demonstrate that their campaigns resulted in widespread behaviour change. Some efforts met with active resistance, but more frequently these were greeted with indifference. On the other hand, members of the public could also actively re-interpret public health messaging to suit their own ends. The 1983 ‘Heroin screws you up’ campaign, for instance, backfired, as some viewers took the posters and put them up on their bedroom walls as an ironic rejection of the anti-drug message. ‘The public’ could respond to health education messages in varied and unexpected ways.
Indeed, for public health authorities, ‘the public’ has long existed as both one thing and many. Like ‘the nation’ or ‘the masses’, ‘the public’ is an imaginary concept. From the 1950s onwards, public health authorities tended to think of ‘the public’ in three ways: as a whole or a mass; as groups; and as individuals. These categories could overlap, intersect and conflict, and they were unevenly applied. Certain groups and individuals, for instance, were singled out for more attention than others. Women, and especially mothers, were often the target of public health messaging. Post-war public health could not shake off older notions about the importance of good motherhood for securing the health of the future nation.
Reflecting on this history of attempts to persuade the public to change their behaviour for the benefit of their own and collective health provides three key insights that may be useful when assessing current efforts to change behaviour in relation to COVID-19.
First, health education campaigns to provoke behaviour change are not always successful, but they can be useful and are often necessary when there are no other options, or these are politically unpalatable. ‘Sensible drinking’ campaigns, for instance, have a limited impact on levels of alcohol consumption, but they are acceptable to a range of stakeholders, including the alcohol industry.
Second, ‘the public’ can respond to health education campaigns in a variety of ways. They may ignore or actively re-interpret messages to suit their own ends. The public may also take the messaging seriously and change their behaviour, especially when there are few barriers to doing so. A good example here is wearing a seatbelt in a car. Although there was some public resistance to this when it became a requirement in 1983, most people now comply, because the opportunity cost of doing so is low, and the benefit – in terms of reducing the risk of death or serious injury – high.
Finally, although public health education campaigns often target a universal ‘public’, the public is rarely thought of as one entity. Targeting specific strategies at certain groups may sometimes be justified, but it can also be motivated by, or exacerbate, deeper prejudices. Efforts to promote safe sex messages for gay men to prevent HIV transmission during the 1980s, for instance, sometimes had a stigmatising effect.
Although COVID-19 presents a unique challenge to public health authorities, the recent history of health education shows that some patterns are likely to be repeated. If mistakes are to be avoided, then a more nuanced approach to communicating about behaviour change needs to be adopted.
Alex Mold is Associate Professor and Director of the Centre for History in Public Health at the London School of Hygiene and Tropical Medicine. She works on the history of public health and especially health education. She is the co-author of Placing the Public in Public Health in Post-War Britain, 1948-2012 (Palgrave, 2019).