The difficulty of making healthy choices and "health in all policies"

Pricivel Melendez Carrera About the author

Healthy choices are difficult choices. On a Sunday afternoon, how many people would choose the exertion of jogging around the neighbourhood for an hour over the immediate gratification of watching a football game? Similarly, someone having to choose between buying foods that are healthful but hard on the budget and foods that are less healthy but make the budget stretch is likely to end up with a cart low on fruits and vegetables but high on dairy and meat products.1Rahkovsky I, Gregory CA. Food prices and blood cholesterol. Econ Hum Biol 2013;11:95–107.
Why are healthy choices so difficult? An overlooked, yet fundamental explanation is that we humans are only an approximation – not a perfect example – of the homo economicus that, in standard economic theory, rationally chooses whatever optimizes his well-being.

Far from holding time-consistent preferences, being forward-looking and maximizing utility, individuals exhibit intertemporal preferences and bounded rationality. These tendencies lead them – or us, rather – to make suboptimal decisions.2Jolls C, Sunstein CR, Thaler R. A behavioral approach to law and economics. Stanford Law Rev 1998;50:1471–550.
“Bounded rationality”, as defined by behavioural health economics, refers to those limits of human cognition that lead to judgment errors or poor decision-making; “intertemporal preferences” undermine individual self-control and bring adverse results in the long run. “Bounded willpower”, on the other hand, refers to the propensity of individuals to choose mitigating losses over acquiring gains and to engage in hyperbolic discounting – i.e. to prefer a smaller, more immediate reward to a larger but more distant one.

Even if the healthy choice is obvious to us, our bounded rationality and bounded willpower steer us away from it. Rather than give up smoking because it is harmful and costly, people continue to smoke or turn to “light” cigarettes or electronic cigarettes.3Schober W, Szendrei K, Matzen W, Osiander-Fuchs H, Heitmann D, Schettgen T et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. Int J Hyg Environ Health 2013;Dec 6:S1438–4639. Individuals compensate for eating ultra-processed foods by consuming artificially sweetened “light” sodas and snacks.4Chiuve SE, McCullough ML, Sacks FM, Rimm EB. Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications. Circulation 2006;114:160–7.
,5Dinsa GD, Goryakin Y, Fumagalli E, Suhrcke M. Obesity and socioeconomic status in developing countries: a systematic review. Obes Rev 2012;13:1067–79.

Acknowledging the limitations of human cognition in the design of health policies and interventions can make these more effective, if not cost-effective.2Jolls C, Sunstein CR, Thaler R. A behavioral approach to law and economics. Stanford Law Rev 1998;50:1471–550.
This is particularly crucial for the “health in all policies” (HiAP) paradigm, defined by the Helsinki Statement as “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies and avoids harmful health impacts in order to improve population health and health equity”.6World Health Organization [Internet]. The Helsinki Statement on Health in All Policies. Helsinki: Ministry of Social Affairs and Health; 2013. The success of the HiAP approach depends on the extent to which it makes healthy choices less difficult, as much as it does on getting people to put their health first. In this regard, the plain packaging of cigarettes in Australia is a good example of the application of the HiAP approach in efforts to influence human behaviour.7Plain cigarette packs in Australia. Lancet 2010;375:1580.

Behind the plain packaging lies the theory, based on behavioural health economics, that making the relevant message more conspicuous (i.e. “Smoking kills”) modifies the “reference point” attached to smoking (i.e. “Smoking [this brand] makes you look cool”) and changes the weight that people assign to its temporal benefits (i.e. “This is what smoking does to your lungs, mouth, skin, etc. over time”).8Wakefield MA, Hayes L, Durkin S, Borland R. Introduction effects of the Australian plain packaging policy on adult smokers: a cross-sectional study. BMJ Open 2013;3:e003175.
,9Wakefield M, Germain D, Durkin S, Hammond D, Goldberg M, Borland R. Do larger pictorial health warnings diminish the need for plain packaging of cigarettes? Addiction 2012;107:1159–67.
It took decades of information, education and communication campaigns about the hazards of smoking, as well as the mobilization of key stakeholders, to make plain packaging a priority and garner the multi-sectoral co-operation and political will that eventually led to the measure and to a complementary increase in the price of cigarettes.1010 Borland R, Hill D. The path to Australia’s tobacco health warnings. Addiction 1997;92:1151–7.
,1111 Dunlop SM, Perez D, Cotter T. Australian smokers’ and recent quitters’ responses to the increasing price of cigarettes in the context of a tobacco tax increase. Addiction 2011;106:1687–95.

There are also fun ways of nudging individuals into making healthy choices. In the “piano staircase” project in Stockholm, Sweden, movement sensors placed on the subway staircase trigger the sound of musical notes when someone takes the stairs. This turns an activity people tend to avoid into a pleasant musical experience.1212 Ariely D, Loewenstein G, Prelec D. Tom Sawyer and the construction of value. J Econ Behav Organ 2006;60:1–10.
In behavioural health economics, the challenge lies not just in instilling the message that the healthy choice is the right choice, but also in facilitating the healthy choice.

The recognition that health promotion and disease prevention play a crucial role in the control of chronic diseases and their re-engineering into the health system have been major breakthroughs in health and health care. If the HiAP approach is to preserve these hard-fought gains and have a palpable impact, policies will need to rely on strategic plans and creative programmes that enable the individual, family and community to make the healthy choice. A concerted effort towards this end will take us from “health in all policies” to health in everyday practice.


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