Natalie Savona: Who is responsible for health behaviour?

A recent poll showed that almost twice as many people in the United Kingdom would blame the public than the government for a second “wave” of covid-19 cases, shining a light on the perceptions of individual vs others’ responsibility for what may ultimately be individual behaviours. Now, recent government anti-obesity guidelines—driven apparently, by prime minister Boris Johnson’s alarm at the role his body weight may have played in the severity of his coronavirusfocus on “empowering” people to live healthily. This is welcome news but contains decades-old, subtle patterns observed in government policy and corporate practices: to divert responsibility away from those with the most power over the drivers of behaviour such as healthy eating or, now, having a family gathering.

Research on perceptions of responsibility for healthy eating in the United Kingdom shows that individuals are disproportionately burdened with responsibility for healthy eating and other behaviours. Disproportionate because the drivers of such behaviours are complex, often subconscious and if not controlled by others, coloured by their stance on individualism and minimal state interference, or driven by commercial expediency. Expecting individual responsibility is to ignore that many behaviours which affect health—diet, alcohol consumption, smoking, a barbecue with friends—are influenced by commercial practices, geography, biology, culture and other socio-economic or environmental factors, not to mention effects of the covid-19 “lockdown.” As one former British senior civil servant said: “people make their choices but they make their choices only within the prison, the context that they are operating”.

Responsibility for health behaviours is a subjective, ambiguous concept; given that discourse is socially constructed, it is noteworthy then that the emphasis on individual responsibility is now reflected in the public’s opinions on responsibility for behaviour around covid-19 incidence. Government advice on socialising, distancing, shopping, mask-wearing etc. has been far from clear or timely, leaving individuals to “stay alert”. The discursive use of responsibility acts as a smokescreen for the role of government guidance—or lack thereof—on covid-19 and corporate practices in unhealthy eating or other behaviours; and serves to place the responsibility on individuals rather than on government or the companies which sell unhealthy commodities.

It is therefore arguable that the responsibility placed on individuals is inversely proportional to the control they have over factors that influence exercising that responsibility. This discrepancy may be a contributing factor to the flouting of the myriad coronavirus suppression guidelines, as demonstrated by scenes on Brighton and Bournemouth beaches in England. It is also likely to drive “unhealthy” food choices and concomitant ill health.

The mismatch between power and responsibility contributes to dysfunctional expectations of public behaviour related to covid-19, diet and other health-related issues. It is difficult to see how public health progress can be made to inspire adherence to covid-19 guidelines or to improve diets while such difference remains. We need policies that are consistent with  demands made on individuals to improve health and the unequal abilities of them to do so. Individuals’ behaviour cannot be segregated from their tacit relationship with the architects of the environment and the complex determinants of choice—food, or going to the beach. Proposals to change the food marketing environment are therefore welcome but the persistent emphasis on health promotion and information provision, as reinforced in the new obesity guidelines highlights how contested responsibility is; the actions create the impression of government (and industry) fulfilling their responsibilities, while burdening individuals, upon whom it is imperative to use the information to make the “right” choices. 

Regarding unhealthy eating, it has been said, “It just doesn’t stack up as an argument that suddenly there’s this outbreak of irresponsibility and we are just stuffing ourselves stupid.“ So it is worth exploring whether there would be a more level playing field on which individuals could make genuine choices (or not) if responsibility were considered in proportion to the power of different actors over determinants of diet or a social gathering. The notion of ‘proportional responsibility’ offers a theoretical, counterfactual idea that subverts the dominant narrative of ‘ultimate’ responsibility held by individuals despite their minimal influence in complex food, or other systems. 

Proportional responsibility recognises that individual responsibility is not in binary opposition to that of the state or industry, rather that responsibility for health behaviour exists along a continuum. The concept provides a framework for carrying out, in effect, an “impact assessment” on the expectations of responsibility relative to the power any actor(s) has over a given factor. Considering proportional responsibility helps at least challenge the reductionist and opaque characteristics of the covid-19 guidance, and the debate around the role of different actors in diet-related health. By doing so, the normative nature of public health practice, with its expectation of “responsible” choice by individuals, is brought into line with the realities in which those choices are made. 

Natalie Savona is an assistant professor at the London School of Hygiene and Tropical Medicine where she researches health inequalities and diet using a systems approach. 

Competing interests: None declared