4a. Defining Environment-Oriented Theories   

As your textbook notes, environment-oriented theories are premised on the assumption that individuals are embedded within, and influenced by, social networks, organizations, community, and society.¹ Accordingly, a supportive environment, which enables healthy choices by individuals, is critical for addressing the conditions that give rise to preventable diseases. Examples of environmental conditions addressed by these theories include social influences (e.g., social support and social capital), access to the social determinants of health (e.g., income, food, housing, education), and the broader organizational and political climates affecting access to these determinants.

Environment-oriented theories also address barriers to making healthy choices, such as lack of transportation, inconvenient hours for parenting classes, or living in a “food desert,” a geographic neighbourhood without grocery stores or farmer’s markets offering access to fresh, affordable, healthy food options including fruits and vegetables.

Environment-oriented theories encompass theories of community mobilization and policy change, which we’ll be returning to in subsequent modules.

Rob Rogers (2012, May 25). Food Desert [Editorial Cartoon]. Pittsburgh Post-Gazette. Retrieved from http://editorialcartoonists.com/cartoon/display.cfm/111382/

While the need to address the more “upstream” social, environmental, political, and economic conditions contributing to preventable disease is now accepted as a key tenet of population health practice, this was not always the case. The limitations of early population health initiatives, which focused mainly on encouraging individuals to change their health-related behaviours, led to an increased understanding of the need to consider socio-environmental influences in the planning and implementation of population health initiatives.

The Rise and Fall of the “Lifestyle” Approach: Towards a Broader Perspective

“You are responsible for your own health”: The Roots of the Lifestyle Approach

The two decades following the end of the Second World War were characterized by a marked improvement in the health status of western industrialized nations. Mandatory public health regulations including mass immunization, sewage disposal, water purification, and the pasteurization of milk had substantially reduced the incidence of communicable diseases. Concurrently, years of advocacy efforts by community activists, labour unions, and progressive social movements resulted in a series of social and economic reforms that went a long way towards eradicating the levels of poverty and unhealthy living conditions contributing to premature morbidity and mortality.^{2, 3}

America's Health Rankings (n.d.) How the United States Successfully Eradicated Polio. Retrieved from http://publichealthlegacy.americashealthrankings.org/eradication-of-polio/

Non-communicable or “chronic” diseases such as heart disease, cancer, and stroke were beginning to supplant communicable diseases as the leading causes of mortality in the western world. Beginning in the 1950s, epidemiological research revealed that the incidence of chronic diseases were linked to a variety of specific causative factors, including tobacco use, high-fat diets, lack of physical activity, and unsafe levels of alcohol consumption. Exposure to these risk factors was then considered to be a function of personal choice, as individuals could make decisions affecting their levels of physical activity and their consumption of alcohol, tobacco, and unhealthy food products.⁴

Accordingly, public health practice began to focus on efforts exhorting individuals to reduce or eliminate the major risk factors for chronic disease. This heralded the beginning of what was later deemed to be the individual or lifestyle approach to health promotion.^5,6 

The lifestyle modification approach to preventing chronic diseases received the explicit endorsement of the Canadian government with the 1974 publication of A New Perspective on the Health of Canadians, more commonly known as the Lalonde Report (in recognition of the Minister of Health who commissioned it).⁷ The Lalonde Report introduced the health field concept, which delineated the factors influencing health status as human biology, environment, health care organization, and lifestyle.

Personal responsibility over all aspects of health are emphasized throughout the Lalonde Report. Unhealthy practices are described as “self-imposed risks” (p. 16)⁷, while the section of the report dealing with health status notes that “individual blame must be accepted by many for the deleterious effect on health of their effective lifestyles” (p. 26)⁷. Although the influence of the environment (one of the four identified health fields) is acknowledged, the report contends that “the deterministic view must be put aside in favour of the power of free will, hobbled as this power may be at times by environment and addiction” (p. 36).⁷ These were the core beliefs and principles that guided the lifestyle modification approach to health promotion.

The Trials of Community Trials: Uncovering the Limitations of the Lifestyle Approach

The North Karelia Project

Michael Turek (2015, April 7). Mauno Lempinen, a woodcutter in his 90s, serving lunch with his wife Helka. Retrieved from https://www.theatlantic.com/health/archive/2015/04/finlands-radical-heart-health-transformation/389766/

In 1970, residents of North Karelia, a rural county in Eastern Finland, suffered from one of the highest rates of heart disease in the world. When citizens of the county petitioned the government to take immediate action to address this health issue, the North Karelia project, a community-based heart health program, was initiated. The ultimate goal of the project was to reduce the incidence of heart disease in the county through bringing about reductions in related risk factors, such as smoking and a high-fat diet. To achieve its goal, the North Karelia project relied on a mix of interventions including social marketing campaigns, educational programs, and policy initiatives such as placing restrictions on smoking and the availability of high-fat food products. ⁸

Unlike the plethora of similar projects it inspired, the North Karelia project was largely successful in achieving its goals. By 1995, the annual mortality rate of coronary heart disease in the middle-aged (below 65 years) male population in North Karelia had decreased 73% from the pre-program years (1967–71).⁹

The following graph shows the significantly higher (85%) decrease in the mortality rate (per 100 000) in North Karelia compared to the rest of Finland, a trend which continued after the North Karelia project was extended nationwide in 1977.

 

Puska, P., Vartiainen, E., Laatikainen, T., Jousilahti, P., & Paavola, M. (Eds.). (2009). The North Karelia Project: From North Karelia to national action. Helsinki: Terveyden ja hyvinvoinnin laitos.

 

The success of the North Karelia project sparked a large number of similar heart health initiatives, including the Pennsylvania County Health Improvement Project¹⁰, the Multiple Risk Factor Intervention Trial (MRFIT)¹¹, and the U.S. National Heart Lung and Blood Institute-sponsored projects in California, Minnesota, and Rhode Island.^12–14 Both the Minnesota and Rhode Island projects were designed using several of the behaviour change theories described in Module 2.^{13, 14}

All of these programs were evaluated using quasi-experimental designs known as community trials.¹⁵ “Control” communities with demographic characteristics similar to the intervention sites were selected for comparisons with the intervention communities for the prevalence of targeted risk factors (e.g., smoking, physical activity levels).

Like the North Karelia project, these initiatives relied on a mix of health communication campaigns and community-based educational events (e.g., contests, health fairs) encouraging the adoption of healthy lifestyles. Unlike the North Karelia project, the results of these heart health trials were, at best, modest, or, at worst, negligible in relation to the general positive direction of broader societal trends.^{16, 17}

Analysis

So why did the imitator projects fail while the North Karelia project succeeded? Analyses have revealed a number of reasons, many of which are related to methodological limitations inherent in the evaluation of community trials.^{15, 16} However, there are two important reasons — both of which are embedded in environmental-oriented theories of population health — to keep in mind.

1. Level of community engagement

The first reason concerns the level of community engagement in identifying heart health as a priority issue and developing effective countermeasures. As was noted previously, the impetus for the North Karelia program came directly from concerned community residents, and community representatives were actively engaged in decision making from the outset of the project.⁸ By contrast, the ensuing community heart health trials were launched as “top down” initiatives in response to the pre-conceived agendas of public health professionals rather than grassroots agitation from community members.¹⁵

2. Regulations and policies addressing social and environmental causes

The second reason is related to the scope of the respective projects. The North Karelia project included regulatory and policy measures to curb smoking and access to high-fat foods, while policies addressing the social and environmental causes of heart disease were not a focus of the subsequent community heart health trials.^{15, 17} Simply exhorting people to eat a healthy diet through mass media or community education programs is not sufficient; we also need to address the socio-environmental barriers to healthy eating at the organizational, community, and societal levels.