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Health Education & Behavior

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DOI: 10.1177/109019819902600110

1999 26: 121Health Educ Behav Meredith MinklerPersonal Responsibility for Health? A Review of the Arguments and the Evidence at Century's End

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Health Education & Behavior (February 1999)Minkler / Personal Responsibility for Health

Personal Responsibility for Health?A Review of the Arguments

and the Evidence atCenturys End

Meredith Minkler, DrPH

Thisarticle examinesthe continuingcontroversiesregardingpersonal versus socialresponsibilityfor healthas they arebeingplayedout atthe turn of thecentury. Followinga briefexaminationof thecontested meaning of personal responsibility for health in recent historical context, attention is focused on the arguments for andagainst holding theindividual to be primarilyaccountable forhis or herhealthbehavior.The paper then makes

the case for morebalanced,ecologicalapproaches that stressindividual responsibility forhealth withinthe con-text of broader social responsibility. The article concludes by briefly summarizing the Canadian approach tohealth promotion as a useful example of what such a balanced, ecological approach might look like.

As we confront thedawn ofa new century, ideological andpoliticalcontroversiescon-tinue to surround the fundamental question of whether the individual or the broader soci-etyshouldbe held responsible forpersonalhealth behaviors. Forhealth educationprofes-sionals, however, a more usefulquestion involves how we can achieve a balance betweenindividualand social responsibility, so thatsimplistic either/orpositionsare replaced by agreater appreciation of the contributions of both personal behavior change and broaderenvironmental change in facilitating health improvement. 1-3 To better articulate the needfor a more balanced approach, it is necessary to understand and appreciate the evidence

and the strong arguments that existon each side of the personal-responsibility-for-healthquestion. This article will begin by summarizing these arguments and underscoring theutility ofmore balancedapproaches aswe enter a new decadeand a new century.

Meredith Minkler is professor and chair of Community Health Education and a member of the Division of Health and Medical Sciences in the School of Public Health at the University of California, Berkeley.

Address reprint requests to Meredith Minkler, Professor and Chair, Community Health Education, Schoolof Public Health, University of California, Berkeley, Berkeley, CA 94720-7360; phone: (510) 642-4397; fax:(510) 643-8236; e-mail: [email protected].

This article is based, in part, on a presentation given at the symposium on Health Promotion and DiseasePrevention: Ethical andSocialDilemmas, sponsoredby the Hastings Center andthe Stanford UniversityCen-ter forBiomedical Ethics. The author gratefullyacknowledges DanielCallahanandothercolleaguesat the sym-posiumfor their feedback andsupport,and particularly AnnRobertson forher helpful reviewof an earlierdraftof this article. My sincere thanks also to Beth Freedman for her help with referencing and final editing, and the

anonymous reviewers whose suggestions greatly strengthened this article. Finally, I wish to acknowledge myfriend and colleague, Dr. S. Leonard Syme, whose seminal contributions to our understanding of the personaland social determinants of health have helped countless students, scholars, and practi tioners better understandthis complex area.Forhis intellectual stimulationandhis continuingsupport,encouragement,and inspiration,Igratefully dedicate this article to Professor Syme.

Health Education & Behavior , Vol. 26 (1): 121-140 (February 1999) 1999 by SOPHE

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Ecological perspectives on health promotion developed by McLeroy, Bibeau, Steckler,and Glanz 2; Stokols 3; and others 4-5 that stress individual responsibility for health within acontext of broader social change then will be presented and examined. The article willclose by briefly summarizing the Canadian model of health promotion as a concreteexample, at the national level, of a broader ecological approach. Despite recent setbacksexperiencedas a resultof ideological shifts, budget cuts, anddifficulties in translating therhetoric of such an approach into practice, the Canadian model will be seen to remain animportant and accessible vision of what a balanced perspective on health promotion mightlook like.

THE CONTESTED MEANING OF PERSONALRESPONSIBILITY FOR HEALTH:

AN INTRODUCTORY NOTE

As medical ethicist Daniel Wikler6

has argued, the seemingly simple premise thatindividualsare responsible fortheirhealth means very differentthings to differentpeo-ple. The self-help or holistic health advocate who calls for taking control of ones healthback from the traditional medical establishment thus is likely to hold a very differentinterpretation from that of the individual forwhom personal control over health is funda-mentallya moralquestion of rightandwrong. To underscore andclarify thesediverseper-spectives, Wikler turns to Dworkins 7 typology of the several alternative meanings of responsibility in the debate over health promotion and personal responsibility for health.The latter schema differentiates between role responsibility (ones body belongs to one-self), causal responsibility (ones health status is in large part determined by personalbehavioral choices), and responsibility based on liability for costs and other undesirableconsequences of ones illness.

While role responsibility in this schema may imply nothing more than ones role as a

biologicalorganism, causal responsibility implicatesthe individuals choices and actionswith regard to diet, exercise, and so forth in helping to determine his or her health status.In the words of the late Rockefeller Foundation president, John Knowles, 8 the primarycritical choice facing the individual is thus whether to change his [ sic ] personal badhabits or quit complaining. He can either remain the problem or become the solution toit. Finally, responsibility based on liability would suggest that the unhelmeted cyclistwho sustains a head injury, or the smoker who develops lung cancer, bear responsibilityfor the medical care costs and other undesirable consequences of his or her foolishbehaviors.

Depending upon which interpretation of personal responsibility forhealth is adopted,Wikler notes, onemayinvoke ethical or even judicialnotions of paternalism,general util-ity, communitarianism, or fairness and compensation to, in turn, inform policy choicesregarding health and health promotion and disease prevention. 6

Although it is beyond the scope of this article to discuss the impact of each of theseconceptual orientations, they are introduced here to underscore that even among strongadvocates of personal responsibility for health, profound, albeit often unspoken, dis-agreements mayexist in thefoundational assumptions concerningthe meaning of

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responsibility in relation to individual health and health-related behaviors.

PERSONAL RESPONSIBILITY FOR HEALTH INRECENT HISTORICAL PERSPECTIVE

Notions of personal responsibility forhealthhave surfaced and resurfaced throughouthuman history. The effects of lifestyle on health were emphasized in ancient Greece andRome, and the notion that individuals had at least some control over their health contin-ued, to varying degrees, through the Middle Ages and the Renaissance (see Reiser 9 for agood historical overview).

In theUnited States, as in othernations, several shiftsin theassignmentof responsibil-ity for health have been witnessed, with an emphasis on personal control and self-sufficiency emerging in the early 1800s and again toward the end of the 19th century.Despite such shifts, however, a dominant cultural preference for notions of personalresponsibility has been noted throughout our history, which is consonant with Jeffer-

sonian democracys emphasis on voluntarism, decentralization, and only limited obliga-tion to the common good. 9

The dominant view of health promotion in the United States today emerged in the1970s in response to a growing disillusionment with the limits of medicine, pressures tocontain health care costs, and a social and political climate emphasizing self-help andindividualcontrolover health. 9-12 It isa visionthatsees individual behavioras in largepartresponsible for the health problems we face as a society. In the words of J. K. Iglehart, 13

editor of the journal Health Affairs , this vision suggests that most illnesses and prema-ture death are caused by human habits of living that people choose for themselves (emphasis added).

Ironically, this traditional approach to heath promotion has tended to be disease ori-ented, rather than health oriented. As Wallack and Montgomery 14 have pointed out, itdefines health primarily as the absence of disease and sees disease as being associated

largely with known andcontrollable risk factors such as cigarettesmoking, poor diet, andheavy drinking. The individual is seen as the appropriate focus for intervention to controlrisk factors, with those interventions typically consisting of providing knowledge andskills for changing unhealthy behaviors.

This visionof healthpromotionwasgiven institutional expression in Canada, with thepublication of theLalonde report 15 in 1974, andin theUnited States, in thesurgeon gener-als report, Healthy People , published in 1979. 16 Both of these documents, it should benoted, discussed the role of broader environmental factors in influencing health and didnot limit themselves to a discussion of individual lifestyle or personal behavior issues.The surgeon generals report, for example, argued persuasively that we are killing our-selves, not only by our own careless habits but also by polluting the environment andpermitting harmful social conditions to exist. 16 Despite their efforts to address some of these broader issues, however, the major contributions of both the Lalonde and the sur-geon generals reports lay in calling attention to the often substantial role individuals canplay in modifying their personal behaviors and in other ways improving their healthstatus. 17-19

In the United States, the surgeon generals reportwas followed by the development of clearly articulated and measurable Objectives for the Nation. 20 The listing of activities

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for achievingeachobjective was extremely thorough and includedstrategieson the levelsof institutional change, legislation, and policy, and not merely in the realm of personalbehavior change. In reality, however, implementing this broad vision of health promo-tion, particularly in an era of fiscal conservatism, proved difficult indeed. Moreover, asformer Office of Health Promotion Director Lawrence Green 21 noted, the sharp distinc-tion drawn in United States policy between health promotion (focused mainly on behav-iorand lifestyle issues) and health protection (concerned morewith the physical environ-ment) led to a narrower interpretation of health promotion in the United States than inmany European nations, which argued that both physical and social environmental fac-tors lay within the purview of health promotion. In Greens 21 words:

We Americansallowed our health promotion terrain to be restricted to lifestyledeterminantsof health, butwe also allowed lifestyleto be interpreted toonarrowly as pertaining primarilyif not exclusively to the behavior of those whose health is in question.

As a consequence, most of the programs that grew out of the renewed push for health

promotion and disease prevention in the United States beginning in the late 1970s tendedto focus primarily on the level of personal behavior change. 22 The programmatic empha-sis on individual responsibility for health, in short, frequently was not accompanied byattention to individual and community response-ability ,23 or the capacity of individualsand communities to build on their strengths and respond to their personal needs and thechallenges posed by the environment. 24 Following an examination of the case for andagainst a predominantly personal responsibility focus in healthpromotion, I will returntothe notion of a more balanced approach that stresses both individual responsibility andbroader society action to enhance response-ability.

THE CASE FOR PERSONALRESPONSIBILITY FOR HEALTH

The pastthree and a halfdecades haveseenthe amassing ofan impressivebodyof evi-dence supporting the importance of individual responsibility for health. 15,16,25-30 Indeed,bioethicist Daniel Callahan 29 has argued that nothing is more evident in the statistics of public health than the role played by individual health behavior in contributing to acci-dents,illness anddisease. In a now classic seriesof studies, forexample, Breslow andhisassociates 26 revealedthatmen who followedseven personalhealth habitseating break-fast, drinking only in moderation, not smoking, and so forthhad lower morbidity andmortality rates than those who followed six; those who followed sixof thehabitshad bet-ter health and mortality outcomes than those who followed five; and so forth. Similarly,Kayman, Bruvold, and Stern 25 demonstrated that individuals who develop their own dietand exercise plans are more successful at achieving and maintaining weight loss thanthose who play a more passive role. Finally, when McGinnis and Foege 27 calculated theleading causes of death forAmericans under 75, notby disease, such as cancer, coronaryheart disease and stroke, but rather by putative or actual cause, tobacco, diet, and exer-ciseall factorsdirectly related to individualbehaviorwere foundto constitutethe great-estcausesof prematuredeath.The twomost rapidly increasing causesof mortalitysexualbehaviorandillicitdrug usealsowere amongthosewith strongbehavioralcomponents.

The case for a strong emphasis on personal responsibility for health frequently also isbuilton thefactthat there ismuch room forimprovement in thehealth habitsof




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are bombarded with advertisements for high-fat, high-calorie foods but consistently areprovided large servings of such foods when they eat at most restaurants and fast-foodestablishments.At thesame time,as Robison 61 pointsout, When ourculture continuestosay to us, why walk when you can ride? when it admonishes us to get every new labor-saving device, and to not even leave our chair to change a TV channel or our computer tosend a fax, is it any wonder that the notion of building in 40 minutes three or four times aweek for exercise goes against the grain? Without discounting the significant role of genetics in influencing obesity and body size at the individual level, leading geneticistshave pointed out that [t]he current increase in obesity has nothing to do with genes andeverything to do with how we live, 62 including these broad cultural realities. When suchenvironmental factors are taken into account, thelimitationsof an approach to healthpro-motion based on personal responsibility for health are cast in stark relief.

Another important dimension of the victim-blaming potential of an overemphasis onpersonal responsibilityforhealth involves the fact, notedby Becker, 63 that when beingillis redefined as being guilty (p. 19), we may inadvertently stigmatize the disabled, theelders, peoplewho are overweight, and other already devalued groups in oursociety. The

renewed emphasis on individual responsibility for health thus has been accompanied bythe reemergence of a Victorian era notion that healthy old age is a just reward for a life of self-control and right living. 64,65 In Levins 66 words, good health has become a new rit-ual of patriotism, a marketplace for the public display of secular faith in the power of thewill. Within such a vision, where is there a place forthe 85-year-oldman with a disablingrespiratory ailment or the obese and severely arthritic elderly woman in a wheelchair?

Wang 67 similarly has demonstrated how health promotion approaches to injury pre-vention that stress personal responsibility and carry the implicit or explicit message,Dont let this happen to you! often inadvertently stigmatize people with disabilities,suggesting that they are inherently flawed and undesirable. She poignantly quotes aparaplegic who, on viewing a series of ads depicting people in wheelchairs with scare-provoking captions said, It feels like I should be preventing myself! In cases like these,an overemphasis on individual responsibility for the state of ones body or health may

inadvertentlycontribute to messages that reinforceageism, prejudiceagainst people withdisabilities, and other stigmatizing attitudes.

Another widely heldcriticism of the heavy emphasisplaced on personal responsibilityfor health involves the argument that such a perspective lets government off the hook byassigningblame forpremature morbidityand mortalityand thelike to theindividual.Fre-quently underlying this criticism is the fact that conservative governments have used therhetoric of personal responsibility for health to justify cutbacks in needed health andsocial programs. 12,19,46,47 The 1996 Welfare Reform Act, for example, which repealedAmericas 60-year-old commitment to welfare entitlement for the poor, containednumerous sanctions against undesired individual behaviors (such as becoming a teenagemother) and was, in fact, named the Personal Responsibility and Work Opportunity Rec-onciliation Act. 68 Although the long-term effects of this measure will be very difficult togauge, inpart as a resultof itscoincidencewith a booming economy, initial estimatessug-gest that it could throw more than 1 million additional children into poverty. 69 The politi-cal use of the language of individual responsibility to support programs and policies likethis one may be significant in their human costs and consequences. 70,71

Critics of an overemphasison personal responsibility forhealth alsofrequently invokean epidemiological argument, pointing out that encouraging individual behavior changecan have only limited impacton thedistribution of disease in communities. 48 Two factorscontribute to thisreality. First, as health educationprofessionalsarepainfullyaware,




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getting people to maintain behavioral changes over time, like cutting back their intake of high-fat, high-caloriefoodsor sustaining an exerciseregimen, is difficult. Half of allindi-viduals who beginan exercise regimen quit within6 months. 61 Thisdiscouraging statisticmay reflect in large part ineffective prescriptionsbasedon faulty theory and/or unrealistichopes forbodily composition changes that cannotbe guaranteed by even themost faithfuladherence to an exercise regimen. Regardless of the specific reasons, however, the highrates of nonmaintenance of exercise regimenslike the high recidivism rates for smok-ing cessation and weight lossunderscore the complexity of the behaviors that must bealtered ifpeopleare to achievedesired healthoutcomes. As oneresearcherputit, personalresponsibility approaches that liken giving up smoking and other unhealthy behaviors tojust saying no to a scone at a tea party trivialize the difficulty of such sustainedactions. 72

In addition to the difficulty of behavior change maintenance, epidemiologists pointout that the sheer prevalence of diseases such as lung cancer, heart disease, and strokemean that solutions focused on individual responsibility for change are unlikely to havemuch effect. Each year, for example, several million people are newly diagnosed with

coronary heart disease in theUnitedStates;73

each day, 6,000 teens smoke their firstciga-rette and another 3,000 enter the ranks of regular smokersthose who smoke at leastone cigarette daily. 74 Given such realities, a personal responsibility approach does littleto alter the distribution of disease in the population because new people develop diseaseeven as sick peopleare cured andbecause new peopleenter theatriskpopulation as oth-ers leave it (pp. 496-497). 73

Critics of the personal responsibility approach to health promotion also point to thelimited effectiveness of many of the large well-funded programs that have focused onindividual behavior change. In the Multiple Risk Factor Intervention Trial (MRFIT), asSyme 52 pointsout, menwho were highlymotivated andwere in the top10%risk categoryfor coronary heart disease, and who had access to an intensive intervention in a 6-yearperiod, were able to make only modest changes in their eating and smoking behavior.Similarly, the widely touted Community Intervention Trial for Smoking Cessation

(COMMIT) project, which represented the most ambitious and sophisticated antismok-ing program ever attempted, achieved only modest results. 75 It is important to note thatmany of thekey architects of theseambitiousefforts, which focused heavily on individualbehavior change, are now among the most articulate spokespersons on the need for abroader environmental or societal responsibility focus. Stanford Heart Disease Projectfounder Jack Farquhar 42 thus strongly advocates increased excise taxes on cigarettes,which, he argues, could reducesmoking rates farmore effectively than individual changeapproaches. Similarly, a lead researcher in the MRFIT program now advocatesapproaches that stress community empowerment and increased social responsibility. 52

Increasing evidence suggests that macro-level or environmental interventions,grounded in notions of social responsibility for health, can exert a powerful effect inchanging behaviors on a broad scale. A 10% increase in the price of cigarettes, for exam-ple, has been shown to decrease teen smoking by 14%, and it is projected that a $2 perpack taxwoulddecreaseadolescent tobacco useby almost46%. 42 Similarly, reductionsinthe speed limit to 55 have had a dramatic effect on auto safety, and mandatory seat beltlaws cut automobile fatalities by more than 75,000 from 1992 to1995 alone. 76 Such factsand figures are compelling, and they bring us back to the epidemiological argument thatonly by focusing on broader environmental forces, rather than on individual behaviorchange, can we hope to have much impact on the distribution of disease in society.




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A finaldimension of thecaseagainst toostrong an emphasison personal responsibilityfor health involves the argument that through such an emphasis we risk establishing atyranny of health, in which personal health goals are substituted for more important,humane, societal goals. 63 It is beyond the scope of this article to examine in detail thedangers inherent in healthism, which placeshealth itselfat the centerof a new moralityand elevates it to the level of a primary virtue. 77,78 But the cautions that have been raisedagainst health becoming the paramountvalue of our society 63 should be seen as consti-tuting another important rationale for broadening the focus of our health promotionapproaches in ways that more fully acknowledge and attend to the larger environmentalforces that must be addressed if we are to attain healthier societies.

OVEREMPHASIZING SOCIAL RESPONSIBILITYFOR HEALTH: SOME FINAL CAUTIONS

In casting this article in terms of the arguments and the evidence for and against pri-

mary attention to personal responsibility for health, I have necessarily focused on theindividual side of thepersonalversus socialresponsibilityequation. It shouldbe stressed,however, that legitimate concerns also have been raised concerning health promotionapproachesand mind-setsthatfocus tooexclusivelyon the socialdeterminantsof health.

First and foremost, for example, such approaches often ignore the fact that many indi-viduals, despite often highly adverse environmental circumstances and constraints, domanageto quit smoking, dramaticallychange theirdiet andexercise patterns,and in otherways act effectively to improve their health. Too exclusive an emphasis on social respon-sibility forhealth ignores human agencyand may, as a consequence,downplaythe impor-tantroleof individuals, health educators,and other practitionerswho mayassist individu-als in making these important lifestyle changes.

Second, as Stokols 79 has noted, Environmental analyses of health promotion give lit-tle or no attention to the varying behavioral patterns and sociodemographic characteris-

tics of the people occupying particular places and settings (p. 285). By failing toacknowledge individual and group differences in how people respond to their environ-ments, such approaches may miss the fact that environmental interventions, such as poli-cies promoting smoke-free workplaces, may vary substantially in their health impactswith the behaviors and life circumstances of individuals and groups. The health benefitsof a policy creating smoke-free workplaces, for example, may be far less for employeeswhose behaviorincludessmoking athome orduringbreaks andsimilarly maybe reducedfor those groups of employees who face greater stressors due to low income and educa-tional levels. 79

A third criticism of health promotion approaches stressing too exclusively the socialresponsibility side of theequationinvolves the lack ofprecisionwith which social deter-minants of health often are defined, which, in turn, poses great difficulties in measuringand evaluating the effectiveness of macro-level interventions. 4 In the case of substanceabuse prevention, for example, when one moves beyond such environmental factors asalcohol availability and advertising and into the realm of variables like social inequalityand racism, operationalizing terms and measuring impacts becomes far more challeng-ing. 80 While the importance of focusing on these underlying factors cannot be denied,healthpromotion efforts to address socialdeterminants of health that do notclearly iden-tify which social factors are being targeted and how they are being defined and measured




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may do a disservice in making it impossible to determine whether such interventions do,in fact, have an impact.

Finally, as Green, Richard, and Potvin 4 have noted, complexity breeds despair, andtoo exclusive an emphasis on the multilevel environmental determinants of health canlead health promotion practitioners to the fatalisticand spuriousconclusion thatnothing they can do will be of any consequence. The continued strong need forprogramsthat help individuals take control over, and change, unhealthy personal behaviors makesuch fatalism an attitude we can ill afford.

In sum, a single-minded preoccupation with social responsibility for health tends tocarry its own set of problematic consequences. What is needed, instead, and what mosthealth educatorsadvocate, is a more balanced approach.It is to thelatter that we now turn,with special attention to the ecological models for health promotion that provide usefulconceptual frameworks for research and practice in this area.

BALANCING INDIVIDUAL AND SOCIAL RESPONSIBILITY

FOR HEALTH: ECOLOGICAL MODELS FORHEALTH PROMOTION

Epidemiologist S. Leonard Syme, 81 one of the worlds leading experts on the risk fac-tors associated with coronary heart disease, once wrote the following:

No one would [question] that, as individuals, we are responsible for our health. In the finalanalysis, we are the only ones who can change our behavior. We are the only ones who liftfork tomouth, who inhalesmoke,who plant feeton sidewalk. And weare the onlyoneswhocan decide to do these things. . . . [But] we dont live in a vacuum. Whether we like it or not,our thoughts, ideas, wishes and behaviors are influenced and conditioned by the peoplearound us, by the environments in which we find ourselves, and by the customs, traditions,fads and fashions to which we are continuously exposed. . . . Effective behavior changetherefore requires that we do our best as individuals,but also that we work together with oneanother to create more healthful and supportive social environments. (p. 56)

The notion of doing our best as individuals while attending to the broader environ-mental determinants of health is nicely captured in the ecological perspectives on healthpromotion that have gained increasing currency in recent years. 2-5,79 Individual behavioris the outcome of interest in most of these ecological models, and as will be noted later,they include an emphasis on intrapersonal change as well as on transformations on theinterpersonal and broader community, institutional, and policy levels. A key attribute of such approaches, moreover, involves their appreciation of the human agency perspectivethat changes at the individual level can, in turn, influence the broader systems of whichindividuals are a part. As Wallerstein and Bernstein 82 have noted, for example, the veryprocess of planning and carrying out a health promotion program can shape individual

consciousness about responsibility and causal factors in health. Such perceptions in turnmay play a critical, empowering role as individuals and their communities are enabled tobetter address health-related problems.Although ecologicalmodels forhealth promotiondo tend to place their greatest emphasis on those causal factors influencing health andhealth behavior that are environmental rather than individual in nature, the focus of thesemodels on reciprocal relationships between people and their environments should beunderscored.




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The application of social ecological thinking to health and health behavior dates back several decades (see, e.g., May 83 and Catalano 84,85) and is well-grounded in early healtheducationapproaches. Greenet al.s 86 PROCEDE/PROCEED model, for example, whichwas developed as a planning and evaluation tool more than 30 years ago and has beenapplied in several hundred published accounts, has a distinct ecological flavor. By help-inghealth educatorsworksystematically backward from a desired outcome, such as qual-ity of life, through various epidemiological, behavioral, educational, organizational,administrative, and policy determinants, the model aids in planning multilevel interven-tions consistent with ecological thinking. 86,87 Similarly, Banduras 88 social cognitive the-ory, although widely identified as the leading personal agency perspective, has, in fact,evolved into an ecological model. In his recent book, Self Efficacy: The Exercise of Con-trol , Bandura thus soughta balance between individual efficacy and broader politicalandothercollectiveforms ofactionfor socialchange, concluding with a call forsocial initia-tives that buildpeoples sense of collective efficacy to influence theconditions that shapetheir lives and those of future generations (p. 525).

A more explicit ecological model for health promotion was developed by McLeroy,

Bibeau, Steckler, and Glanz,2

who, in turn, built on the work of Brofenbrenner89

and oth-ers. 90 McLeroy, Bibeau, Steckler, and Glanzs model emphasized five nested levels of influence: intra - and interpersonal factors , community and organizational factors , and public policies each were seen as intimately interdependent levels ofanalysis that must beconsidered if we are to better understand both health-related behaviors and interventionsthat may be appropriate at each level. Individuals developmental histories and theirsocial support systems; the organizational structures and processes that can positively ornegatively affect health behavior; community-mediating structures such as schools,neighborhoods, and churches; community networks and power structures; and both thecontent of our public policies and the role of participation, advocacy, and otherprocesses in their formation thus all were described as key components of a broad eco-logical perspective.

Subsequent work by Stokols; 3,79 Green, Richard, and Potvin; 4 Sallis and Owen; 5 and

others 87 has further developed and refined thesocial ecological framework forhealth edu-cation and health promotion research and practice. It has underscored, for example, theneed to (1)examine the joint or cumulative effects of personal and environmental factorsin designing health promotion programs;(2) take into account the linkages between vari-ous settings and levels, and how change at one level affects others; (3) use a multidisci-plinary perspective, integrating knowledge and methods from a variety of fields; and (4)look for and address the unanticipated consequences of intervention strategies. 4-5,79,87

Green, Richard, and Potvin 4 further have stressed the need to carefully differentiatebetween health promotion settings and health promotion targets and have elucidated themanydifficulties inherent in evaluating ecologicalhealth promotion programs, which bydefinition do not lend themselves to either experimental or quasi-experimental design.Finally, and in response to the latter concern, Richard et al. 87 have devised and tested aframework for assessing the integration of the ecological approach in health promotionprograms, leading thewayfor more careful analysis of theeffectivenessof such efforts inthe future.

Numerous examples of approaches to health promotion that implicitly or explicitlyapply an ecological approach can be found in the health education literature in suchdiverseareasas substanceabuse prevention, 81,91 nutrition, 92 worksitehealth promotion, 93-95 physical activity, 96 HIV/AIDS prevention, 97,98 school health, 99 tobacco control, 100 andhomelessness. 101




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Efforts also have been made to end the tobacco company sponsorship of cultural andsporting events. 108

In several Canadian provinces, Premiers Councils on Health have been established,through which government leaders in the different sectors provide advice on health pro-motion and work together in jointly setting goals for helping to address the social deter-minants of health. 108 Throughout Canada, hundreds of cities have designated themselveshealthy communities, stressing intersectoral planning, high-level community partici-pation, and reciprocity between the individual and the broader society. Finally, in theNorthwestTerritories, land claims, and the developmentof First Nations Peoples rightshave been discussed as part of a broadly defined health agenda. 109

Despite these encouraging examples, however, substantial difficulties in translatingthe Canadian rhetoric into reality also have been noted. A recent analysis of close to fourdozen health promotion programs funded by the Ministry of Health, for example,revealed thatalthough manyincluded activity at the interpersonal and organizational lev-els, communities and politicalsystems werenot frequently targeted. 87 The authors indeedconcluded that it remains relatively rare to encounter multi-target, multi-setting pro-

gramsthat fully integratean ecologicalapproach toward health promotion interventions(p.326). Although theuse of a conveniencesample in this study precludesthe generaliza-tion of its findings, the results underscore the need for more systematic research into theextent to which ecological models are, in fact, being attempted and with what success.

Critical analysis also is warranted as one moves to the broader level of federal policy.In this regard, Berkowitzs 110 recent examination of fitness policy in Canada is notewor-thy. Taking a softer approach toward involving Canadians in physical activity (e.g., bystressing the health benefits of gardening and walking rather than a proscriptive exerciseapproach), the government-promoted Active Livingprograms literature is replete withthe new health promotion language of empowerment, community development, andparticipation. Yet, as Berkowitz notes, the programs accenton doing more with less isbeing used to justify cutbacks in formalexerciseprograms and services, as well as fitnessresearch and development, 110 and the ecological approach espoused in documents like

Achieving Health for All 104 is not much in evidence.Even for programs that do more actively embrace an ecological model, hard outcome

data that would indicate whether this approach has resulted in actual declines in morbid-ity and mortality tend not to be available. In part, as Robertson 111 suggests, this mayreflect the real difficulties many practitioners have faced in moving from the ecologicalhealth promotionrhetoric to concrete guidelinesfor programimplementationand evalua-tion. In addition, as Rootman 112 and Green 113 predicted, cutbacks in social spending havegreatly constricted the implementationof health promotion, which, in turn, has hamperedevaluative efforts. Finally, as Robertson 114 and others 115 have pointed out, the shift fromhealth promotion to population health as a guiding discourse forpublic health policy andpractice in Canada, particularly given the latters emphasis on an epidemiological andevidence-based notion of health, has mitigated against broader ecological programmingefforts. Although population health, like health promotion, stresses the social determi-nants of health, the language of population health has been used by conservative policymakers to provide powerful justification for major cutbacks in health care and in morebroadly defined health promotion efforts. 114

To be sure, the new public health discourse continues to have strong support in manyquarters. Canadas community health centers, for example, continue to hire communitydevelopers (the rough equivalent of communityorganizers in theUnitedStates), andeco-logical approaches to health promotion remain popular in provinces such as Quebec,




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Ontario, Saskatuan. 116 The Canadian Public Health Associations 117 recent Action State-ment forHealth Promotion in Canada alsoreaffirmed the importanceof continuingto usethe Ottawa Charter as the framework that defines health promotion in Canada and laidout as well an explicit value base, in keeping with the Charter. Respect for individualchoice but priority to the common good in cases of conflict, popular participation in pol-icy making to determinewhat constitutes thecommongood, and thepursuit of socialjus-tice to prevent systemic discrimination andreduce health inequities were among theprin-ciples identified. Yet, the Action Statement , too, lamented the current climate of increasing poverty and cutbacks in the very health and social service programs that, itargued, historically have defined Canadians as a caring people. 117 Within such a cli-mate, the importance of translating the rhetoric of an ecological framework for healthpromotion programs into concrete and measurable policy and program objectives cannotbe overstated. For despite its current difficulties and unresolved problems, the Canadianframework for health promotion, and the values and principles underlying it, remain animportant example of a vision that offers a balanced concern for personal behaviorchange within the context of broader social change.

CONCLUSION

As the 20th century draws to a close, the health promotion landscape in the UnitedStates is filled with images, policies, and proscriptions that exemplify thecontinuing ten-sions between health promotion approaches stressing personal responsibility and thosecalling for a much heavier emphasis on broader social responsibility. As this article hasattempted to suggest, strong arguments can be made on both sides of the question aboutpersonal responsibility for health, which is itself more a battle of ideologues and politi-cians than of serious health education scholars and practitioners. For the latter groups, amore prudent and realistic course of action has been to work for a more balancedapproachone that ensures the creation of healthy public policies and health-promoting

environments, within which individuals are better able to make choices conducive tohealth.

Ecological approaches to healtheducation andhealthpromotion were seen in this arti-cleas providinga helpful conceptual frameworkforaction as we attempt to more system-atically integratethisbalanced perspective. Finally, the Canadian modelof health promo-tion wasputforthas an example of how an ecological framework ideally canguide healthpromotion thinking and action at the national level. Problems confronting the Canadianmodel, and in particular thedifficulties inherent in transforming therhetoric into measur-able criteria andoutcomes, were seen as substantial, as were thebudget cuts that have hadthe effect of severely constricting program efforts.

Furthermore, even if one ignores temporarily the implementation problems that havesometimes confronted health promotion efforts in Canada, it should be recognized thatsuch an approach maynot be entirely feasible withinthe constraints andideologicalreali-ties of the United States. As Canadian healthpromotion expert Ronald Labonte 118 is fondofpointing out, thenationalcredoof theUnited States, with itsindividuallyoriented life,liberty and the pursuit of happiness, bespeaks a very different worldview than that of Canada with itsparallel call forpeace, order and good government! As a consequence,when the notion of public or community good is invoked in the United States in argu-ments, for example, for mandatory motorcycle helmet use, common good often isoperationalizedin terms of theeconomicrights of law-abiding citizens.Public or




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common good, in short, is defined as my right not to pay for your foolish or risky behav-ior. 11,12 Broadening our concept of the common good to embrace a sense of our intimateinterdependencea notion that we are indeed all in this togetheris just one of theways in which the worldview of Americans would need to change if the full meaning of the Canadian approach to health promotion were to be captured in U.S. policy andpractice.

Yet, while acknowledging that such changes are unlikely, and keeping in mind as wellthe limitations of the Canadian approach, this framework, and the broad WHO vision of healthpromotion which it reflects,stillcan provide usefulvisions ofeffortsat thenationaland international levels to balance the need for personal responsibility with an equalemphasis on social responsibility. It is perhaps only by appreciating the validity of thearguments and the evidence on both sides of the question about personal versus socialresponsibility for health, and crafting an ecological approach to health promotion thattruly integrates both, that we can hope to achieve our health promotion goals at the dawnof a new century.

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