Healthy Lifestyle: Strengthening the Effectiveness of Lifestyle Approaches to Improve Health

Key Points and Discussion Questions

Introduction

1. Is "healthy lifestyle" a useful concept?

2. What are the determinants of lifestyle choice?

3. What approaches have been used to foster healthy lifestyles and have they
   been effective?

4. How can social and community processes foster healthy lifestyles?

These four questions formed the basis of a discussion paper, Healthy Lifestyle: Strengthening the Effectiveness of Lifestyle Approaches to Improve Health , submitted under contract to Health Canada in April, 2000. The paper was written by a workgroup comprised of members of the Canadian Consortium of Health Promotion Research Centres and staff of Health Canada, with leadership from the Atlantic Health Promotion Research Centre, Dalhousie University. This summary provides an outline of key points raised in the paper and a list of questions to stimulate discussion and to reflect upon policy and practice in lifestyle initiatives.

Background:

Healthy lifestyles are important. Illness is costly. It takes considerable family and state resources to cope with and to ameliorate health problems. The increasing prevalence of chronic illness and disabling conditions, along with greater life expectancy and the rising average age of the population, are substantive contributors to the rising burden of illness.

Many health problems can be prevented or at least their occurrence postponed (US Dept. Of Health & Human Services, 1999; IUHPE, 1999; Stroebe & Stroebe, 1995). We have known for the last 20 years that a sizable proportion of the 10 leading causes of death is due to potentially modifiable social and lifestyle factors (US Dept. of Health & Human Services, 1999).

Lifestyle modification presents substantive challenges. Convincing Canadians that health is a good investment, and creating a culture that fosters health, are complex processes. How do we direct efforts to engage people in becoming and staying healthy? Some health issues are addressed with relative ease (e.g., wearing seatbelts). Many others such as exercise, nutrition, smoking, and substance abuse are integrally linked to culture and to socio-economic status (Kawachi et al., 1996; Labonte, 1998; Lupton, 1994; Marmot et al., 1997; Stewart et al, 1996), and are much more difficult to address.

Strategies developed to improve the health of Canadians through healthier lifestyles must align with the knowledge base about health and its determinants, and the evidence that has been accumulated about the effectiveness of strategies to improve health. As health budgets are squeezed, increased pressure is placed on individuals to live healthier lives. It is incumbent upon practitioners and policy makers to thoughtfully consider their leadership on this issue.

The "Lifestyles" paper was based on the following perspectives:

1. People's lifestyles are significant contributors to their physical health, psycho-social (emotional, psychological, spiritual) health and well-being.

2. Lifestyle, particularly when related to "risk" behaviours such as smoking and physical inactivity, is typically conceptualized as a function of individual choice.

3. The concept of "lifestyle" has considerable value in the analysis of the health of Canadians, but not as it is currently conceptualized.

4. Expanding lifestyle beyond an individualistic notion is a key to fostering healthy people and healthy communities.

5. Understanding the relationship between individuals and their social context will lead to the development of more effective methods to improve the health of Canadians.

6. Opportunities to engage in and change the social context foster health.

7. Partners in population health and health promotion have an important role to play in developing and supporting a new "community-oriented" conceptualization of lifestyle, marketing the idea, and providing a supportive environment to enable it to happen.

Is "Healthy Lifestyle" a Useful Concept?

The WHO concept (WHO 1998a) of lifestyle - a way of living based on identifiable patterns of behaviour which are determined by the interplay between an individual's personal characteristics, social interactions, and socioeconomic and environmental living conditions - provided a broader understanding of the determinants of a healthy lifestyle than earlier definitions. The WHO definition stated that there is no one "optimal" lifestyle, and that many factors determine which way of living is appropriate for each individual. If conceived on the basis of interdependence, a "healthy lifestyle" is understood less as acquiring strictly personal health skills, and more as acquiring competencies and an orientation to creating a mutually supportive environment for healthy living.

Four social components that may be as important to healthy lifestyle as individual health behaviors are as follows:

1. My health impacts the lifestyle of others

2. My health-related actions are role models for the lifestyle of other people

3. I influence the conditions in my community that contribute to healthy lifestyles

4. We (acting together) influence the health of others

A healthy lifestyle can be thought of as a generalized description of people's behaviour, in three inter-related dimensions: individuals; their social environments (family, peers, community, workplace); and, the relation between individuals and their social environment.

Key Points: Healthy Lifestyles

• Early definitions of lifestyle emphasized nutrition, exercise, smoking, and alcohol use.

• More recent definitions of lifestyle have begun to consider the influence of social, economic, and environmental factors on lifestyle.

• Definitions of "healthy lifestyle" in Canada vary considerably by gender, life stage, geography, culture, and resources.

• There is no one optimal healthy lifestyle.
  A reconstructed notion of "healthy lifestyle" includes individual, community, and "interdependence between individual and community" dimensions.

• A healthy lifestyle is about striving to obtain a reasonable balance between enhancing one's personal health, the health and well-being of others, and the health of the community.

What are the Determinants of Lifestyle Choice?

....health maintaining practices do not stand alone and above other
practices of everyday life, but are incorporated seamlessly into the life-world
of the individual...
(Lupton, 1994, p.117).

Key Points: Determinants of Healthy Lifestyle

• Opportunities and limitations for choice vary considerably.

• Health for most people is not an end in itself.

• Often people make choices that satisfy multiple and competing personal and family needs.

• People maintain lifestyles which they know are unhealthy because they meet certain immediate needs

• There are important Linkages Between lifestyle choice, determinants, and health.

• Lifestyle choices are not random behaviors unrelated to structure and context, but are choices influenced by life chances.

• Five important determinants of lifestyle choice include personal life skills, stress, culture, social relationships and belonging, and a sense of control.

• Support from the social context for healthy behavior is an important determinant of health.

• Choice is influenced by human physiology.

• Personality traits such as optimism and self-efficiency contribute to healthy living and influence lifestyle change

• Today's society provides us with an overwhelming array of choices, and conflicting information about what are the "right" choices

What Approaches Have Been Used to Foster Healthy Lifestyles? Are They Effective?

Approaches for influencing lifestyle can potentially be directed toward changing individual behaviour, changing some aspect(s) of the community, or changing the relationship between the individual and the community. To date, most of the strategies for changing or enhancing lifestyle have been aimed at the individual.

Strategies have included media campaigns/social marketing, incentives and punitive measures (legislation, taxes, fines, insurance, safety standards), training/education, health communications (mass and interpersonal), health promotion/prevention services through public health, community clinics, and health promoting activities in specific settings such as the workplace, school, home, or doctor's office. Which strategies are effective in fostering healthy lifestyles?

Key Points: Fostering Healthy Lifestyles

• Knowledge alone does not usually lead to behaviour change.

• Many short term strategies used to improve health have limited impact on their own.

• Social marketing on its own may increase/steepen the gradient between people with high and low socio-economic levels.

• Lifestyle messages must be associated with health as a resource to achieving ends of relevance to the listener.

• Long-term strategies that create supportive environments can be a valuable investment.

• Specifically focused initiatives that target symptoms or specific negative health behaviors have limited success if the intervention does not attend to "the larger picture" of lifestyle and its determinants.

• Combinations of health promotion strategies (e.g., supportive environments, social marketing, community level initiatives, building healthy public policy) with community "buy in" have the greatest possibility for success.

How Can Social and Community Processes Foster Healthy Lifestyles?

The limited success of earlier attempts to improve health through lifestyle education has shifted the focus for intervention from the individual toward more comprehensive approaches that address health as a social or community (shared) issue, and act on the social processes that influence personal behaviour. Placing the entire responsibility for change on the individual is now understood to be an insufficient response that blames the victim rather than addressing the social circumstances that lead to harmful behaviour. Indeed, social or community responses can
add resources to an individual's repertoire of strategies to cope with change and foster health (Lyons et al., 1998).

The authors of this paper are not arguing for elimination of the notion of individual lifestyle, but for striking a balance between individual and social orientations toward this concept. Community level interventions modify the entire community through organization and activation, as distinct from interventions that are community based, but aimed at modifying the behaviour of individuals (Lomas, 1998). Enhancing the scope for interdependence involves individuals interacting within their community as they address particular types of issues, and assist others in their community. In fact, a healthy lifestyle might involve the acquisition of coping skills, the accumulation of coping resources, and the development of coping strategies from an interdependence perspective (See Lyons et al., 1998, for a fuller discussion of these concepts; also Israel et al, 1994, for a model of empowerment from the individual and community perspective).

Key Points: Lifestyle as a Collective Process

• Learning effective team skills should be an important feature of "lifestyle" training; e.g., leadership, cooperation, communication, social support strategies, collective coping and problem-solving strategies.

• Healthy lifestyles will be encouraged by providing opportunities to develop coping strategies and fostering resilience (individual and community).

• A healthy lifestyle incorporates a balance between individual autonomy and contributions to community.

• Community processes include providing training in skills that will help to build social capital.

• Social ecological approaches focus on building community capacity and citizen empowerment.

• A goal of healthy lifestyles is to enhance the scope for interdependence: freedom and opportunity within community.

• Resource optimization is important. Enhancing the scope for interdependence includes identifying the level of collective action needed to effectively address an identified issue

Summary and Conclusions

By addressing the determinants of health in a systematic manner, it has been demonstrated that individuals can live longer and healthier lives. To achieve these goals, individuals need personal knowledge and skills plus a facilitative social environment where these skills can be put to effective use. This latter point recognizes the need to institute measures that will address health and healthy lifestyles from a "systems" or "community" perspective, if health gains are to be achieved and sustained.

Action is needed in the following areas: reframing "healthy lifestyle", approaches to foster
healthy lifestyles, research and policy.

Reframing Healthy Lifestyle

• as a resource for quality of life.

• as an individual and a social construct (helping others and the community to be healthy).

• to provide support to those at high risk.

• to improve basic living conditions.

• as a collective effort.

Modifying Approaches to Fostering Healthy Lifestyles

• reward positive health behaviors, community improvements

• link current health and social development initiatives to lifestyle

• carefully devise social marketing strategies.

• portray a culture that support healthy people in healthy communities.

• support well developed community level projects.

• address challenges to roles, operational funding and sustainability.

• support skills training on community participation and leadership.

Research

• clarify strategies that work and those that have limited success.

• systematic reviews of effectiveness/

• identify indicators of success for the health of collectives, communities.

Some Public Policy Options

• apply a healthy lifestyle lens to policy.

• address constraints to health of the most needy/vulnerable populations

• increase understanding of the factors in families and communities that influence healthy living.

Discussion Questions:

Concepts of Healthy Lifestyles: One's own and policies....

• What are one's own perceptions of a healthy lifestyle?

• What constitutes healthy lifestyles from a policy perspective? Where is the emphasis? Why?

• What changes should occur in how lifestyle/wellness are used?

Determinants of Healthy Lifestyles

• Where should the emphasis be placed and with whom?

Fostering Healthy Lifestyles

• What are the approaches to fostering healthy lifestyles? What would be the most effective contributions to healthy lifestyle choices

• What do we need to change about the approaches to effect change? With whom?

• What types of indicators would suggest advances/declines in healthy lifestyles?

• How do we effectively integrate the social spin/orientation? Are people moved by this orientation?

• Do the social/community approaches work? With whom?

• What would a "healthy lifestyle lens" look like?

• What needs to be done..at indivdual, family and community levels?

• Are there characteristics of program grants that promote or impede change?.

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