Building better health: a handbook of behavioural change



Mickey Chopra

Director, Health Systems Research Unit, Medical Research Council, Parow, South Africa (email:



Author: C. David Jenkins
Publisher: Pan American Health Organization: Washington (DC); 2003
ISBN: 92 75 11590 7; softcover; 395 pages; price Swiss francs 80 (in developing countries, Swiss francs 56);
available free from:

This book was awarded the Highly Commended Certificate in Public Health from the 2004 British Medical Association Book Competition

Professor Jenkins has set himself the ambitious target of empowering "people who generate health" to produce significant behavioural and social change that will promote good health. He has done so by writing a handbook that starts by outlining general principles of health promotion and disease prevention before embarking upon a lengthy exposition of the major causes of illness and death throughout the life-cycle. Each of the major causes of mortality (involving mental health, heart and circulatory system, respiratory system, injuries and violence, and cancer) is then examined in turn in separate chapters before the last section, which focuses upon behavioural change.

This structure allows a wide range of topics to be covered — everything from arthritis and substance abuse to the diffusion theory of behavioural change. For each of the major periods of the life-cycle the reader is provided with a succinct summary of the epidemiology of illness and poor health along with the author's own considered opinion of the most important causes of these conditions. Each chapter is summarized in boxes that highlight twenty or so things that a good health worker should be screening for when conducting a consultation. Similarly, the chapters on the major causes of illness and death are rich in epidemiological detail along with some clinical details. Scattered throughout these chapters are suggested actions that could be taken to reduce the prevalence of risk factors and minimize the impact of various diseases. The final section of the book deals with this more systematically with a clearly written guide on some of the major theories of behavioural change and how these might be applied to reduce the most important risk factors.

The book does address a definite need. The disjuncture between the almost daily medical scientific breakthroughs and the growing burden of disease globally is bewildering to many. A book that combines clinical and epidemiological insights situated within a broader social and behavioural context could play an essential role in initiating effective responses. Unfortunately there are a number of reasons why this handbook does not quite achieve its lofty aims.

The intended readership is not entirely clear. The book's stated aim is to address health challenges in both developing and developed country settings, but the emphasis is clearly on the latter. So, for example, breastfeeding is covered in three paragraphs compared with the three pages dedicated to sudden infant death syndrome. But even for readers in developed countries some important conditions are covered scantly (obesity in childhood, for instance). As someone working in public health in southern Africa, I was especially disappointed to see that HIV/AIDS is reduced to almost a footnote.

One reason for my disappointment may be that much of the book appears to have been written about ten years ago, with very few references dating from after 1994. This feeling is heightened by some of the other omissions in the text. Despite devoting five pages to controlling tobacco use, the book makes no mention of the WHO Framework Convention on Tobacco Control; similarly in discussing childhood undernutrition and breastfeeding no mention is made of the UNICEF Conceptual Framework or of the UNICEF/WHO Baby-Friendly Hospital Initiative (BFHI). The importance of these initiatives is that they draw attention to not just the broader determinants of ill-health but also the central role that organizations and institutions play in determining health behaviour and outcomes. Although individuals can, and do, make a difference in persuading and supporting others to change their behaviour, experience and evidence suggest that initiating sustained behavioural changes for large numbers of people requires changes in the environment, institutions and organizations within which they work and live. This is the major thrust of the BFHI, for example, where the education of health workers and mothers is supported by fundamental structural changes in hospital procedures. Experience in applying the theories of behavioural change to organizations has increased rapidly but is not covered at all in this handbook. The Convention on Tobacco Control recognizes the critical importance of legislation and control of marketing in changing behaviour. To achieve this requires consistent mobilization of advocates for public health. Advocacy skills and insights into achieving changes in policies and legislation that support healthy behaviours are seldom taught to health workers. Unfortunately this handbook represents another missed opportunity to do so.

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