Behavioural science has become an increasingly popular discipline to address public health issues and gaps. The use of behavioural science for public health stems from the perspective that behaviours are crucial in shaping health outcomes. The World Health Organization’s (WHO) website on behavioural science for health mentions right at the beginning, “Human behaviour affects health outcomes.” When behavioural science is used in examining public health issues, these often entail understanding which factors drive a certain behaviour. This is so that health interventions modify the relationship between the factor and behaviour to promote positive change and subsequently achieve intended health outcomes. However, behavioural science research intended to be applied on the ground to address public health issues is impacted by the ideology governing the public health sector, that is neoliberalism. Hence, the behavioural science field does little, if anything at all, to challenge the political economy encompassing health behaviours, and instead focuses more on the individual and working within the parameters of neoliberal thinking.
A Brief Overview of Behavioural Science Theories
Theories and models of behavioural science often consist of individual, interpersonal, and environmental factors which are theorised to influence behaviour. For example, Ajzen’s Theory of Planned Behaviour (1991) suggests that intention to enact a behaviour is a precursor to enacting the behaviour, and what influence this intention are 1) how one evaluates the behaviour, their attitude towards the behaviour; 2) subjective norms such as social expectations and pressure; and 3) perceived behavioural control, that is, their belief in being able to enact the behaviour. More recently, the Capability, Opportunity, and Motivation (COM-B) model by Michie et al. (2014) describes behaviour as being affected by capabilities (the physical and mental ability to enact the behaviour), opportunity (external factors which either inhibit or facilitate the possibility of enacting the behaviour) and motivation (cognitive processes which influence decision making).
These are just two of many behavioural science theories and models which hypothesise on how to change behaviour across a range of areas such as health behaviours, consumer behaviour and marketing, technology and so on. The two models described here have been used to understand how to promote change in health behaviours (i.e. TPB: chronic diseases, blood pressure self-care, smoking cessation, physical activity; COM-B: adoption of diets, physical activity, vaccination). I describe these two models to illustrate that there is consideration of both individual/interpersonal factors and structural ones as well (i.e. ‘Opportunity’) in behaviour change theories. However, even with considerations to structural factors, Davis et al. highlight that public health interventions “tend to emphasise individual capabilities and motivation, with limited reference to context and social factors,” despite behaviours being embedded within these factors which make up contemporary social life (Fox and Klein, 2020).
COM-B, a Case Study
The COM-B model uses the term ‘Opportunity’ to describe the presence of enablers/inhibitions to enacting a behaviour, and so behaviour is framed as being possible if the opportunity is presented. However, the opportunity to enact a behaviour is in and of itself a much more complex web of systemic factors that cannot be succinctly addressed under the single term, ‘Opportunity.’ For example, low income can be categorised under ‘Opportunity’ as a factor inhibiting eating healthily. But such categorisation does not warrant further examination of how and why they are low income, and how this low income generates and compounds inequities in healthy eating. It is, instead, remedied by short-term solutions such as providing incentives. Additionally, having ‘Opportunity’ (which can constitute this complex web of systemic factors) alongside the individual-level factors, ‘Motivation’ and ‘Capability’ potentially equalises the factors rather than demonstrating how ‘Motivation’ and ‘Capability’ are often determined by systemic factors, that is, ‘Opportunity.’
Recognising these problems with the COM-B model, Nguyen-Trung et al. (2023) developed a socioecological adaptation, referred to as Se-COMB, where “Motivation” and “Capability” were placed at the individual level which were nested within four socioecological levels expanding the “Opportunity” category. The four levels were interpersonal, community, institutional and structural levels. While this adaptation seems promising, the model’s application in two papers following the original, used the socioecological levels as a framework to examine communication strategies for air pollution and actors/targets within these different levels. The application of socioecological levels could have provided an opportunity to examine, instead, how the levels intersect to produce differential effects of air pollution on different segments of the population. Coupled with the fact that air pollution exposure is a result of and maintained by the players benefiting from the capitalist economic system such as the automobile industry, industrial activities, and power plants (State of Global Air, n.d.). Business is assumed to go on as usual here, with strategies focusing, instead, on reducing individuals’ activities which contribute to pollution.
These applications do not challenge the socioecological levels that are structured as such and how their arrangement and power distribution feeds into health behaviours. Alas, Nguyen-Trung et al. (2023) mention that with their Se-COM-B, “socioecological analysis [gives a systematic perspective but] implies no link to behaviour change interventions.” Compare these analyses to Engels’ (1845) work, The Condition of the Working Class in England, which examined how the social and working conditions that were produced through industrial capitalism impacted the health of workers and their families. In his research, he draws the link between industrial development and the capitalist political economy in: 1) worsening health outcomes among the working class who are forced into working in these conditions to sustain within the capitalist economic system and; 2) the lack of economic mobility among the working class in that they remain earning low wages as this is what the capitalist economic system requires for maximising profits for the bourgeoisie. This illustration of how the political economy is tied to health outcomes and inequities in 1800s England is not that far from what we see now.
Practicality Versus Complexity
Perhaps one reason why there has not been much behavioural science research questioning the systems which create health gaps is because individual-centered behaviour change theories may be preferred for intervention designers to use on the ground when they are translatable to actionable strategies (actionable often meaning getting it done within the budget and timeframe). Thus, theories which focus on the individual makes it easier to design intervention strategies within “practical” settings as it is a much smaller scale task than, say, changing our entire economic system.
This is exemplified by the widespread use of the Transtheoretical model (or Stages of Change model) for behaviour change in health education and promotion in real-world settings (Taylor et al., 2007). Importantly, the model does not mention the role of external factors such as social, economic and environmental. It focuses, instead, on individual processes conceptualised as stages which lead to change, potentially explaining its popularity among practitioners. Even when alternative theories are used that may not be straightforward, they are not used in their entirety, with practitioners often being selective to make it tailored to the context they are in (Head & Noar, 2013). Their application is also compromised by considerations of funding, timelines, and getting results that prove there is a return in investment (Rothman, 2004; Premachandra & Lewis, 2022), all of which are characteristic of a neoliberalised public health sector as explained below. It is encouraged to keep practicality in mind at the beginning of the research process (Premachandra & Lewis), demonstrating how the behavioural science field now also functions and evolves within the parameters of a neoliberal public health sector.
How a Neoliberal-ised Public Health Sector Influences the Behavioural Science Field
To understand why practicality is favoured over considering the political economy surrounding health outcomes, we can examine how a neoliberal public health sector feeds into this preference. In following Bell and Green’s (2016) advice on specifying how neoliberal is defined here, the later sections will unpack the mechanisms by which public health sectors become neoliberal/are neoliberal.
Public health programmes have been managed and run via the framework of new public management (NPM). Dutta et al. (2023) defined as, emerging from the restructuring of the public sector to improve efficiency and governance and cut costs; “[using] market forces to serve public needs” as put by Simonet (2011, p.817) which demonstrates the neoliberal ideology behind this approach. Neoliberalism more broadly refers to the restructuring of the public sector beginning from the 1970s, moving from welfare states to “[celebrating] unhindered markets as the most effective means of achieving economic growth and public welfare,” as described by Maskovsky and Kingfisher (cited in Bell and Green, 2016, p.239). At the core of it, Bell and Green describe neoliberalism as embodying a “market-centric logic” to policymaking and governance.
Neoliberal ideas, namely public choice theory, shape the NPM approach (Dutta et al., 2023). Public choice theory’s “basic idea was that public servants are not all that dissimilar to market actors in that they pursue their own selfish interests” (Dutta et al., p. 97). By allowing the public to choose, it requires the public sector to be more efficient to the public’s needs and so should lead to better services. Such transformation also required convincing people to assume their role as ‘consumer’ now in accessing these services and comparing services to get the best one. Here, I also want to link the delivery and maintenance of an NPM approach to the public health sector, with the techniques of neoliberal rationality by Brown (2015), guided by Joy’s (2020) case study of a Canadian age friendly cities programme. These four techniques are benchmarking, governance, devolution, and responsibilisation. They shape neoliberal rationality and serve to reverse the social contract between citizens and the public health sector, where citizens are now expected to “regulate themselves to limit their risk to the state and the market” (Joy, 2020, p.2). I identify these four techniques within brackets in bold below.
I am currently based in Singapore, where public health programmes are run by organisations which receive funding from government agencies, but these are sporadic. Many of these programmes are expected to source their own funding from private donors, competing with others for these funding sources. When programmes are subject to such competition, they are now actors within a market competing to deliver a public service, becoming neoliberalised. Programmers need to show ‘data’ to their donors that prove their work is valuable, both monetarily and to the target population, adopting business-like practices in running these public health programmes (benchmarking). Recall the dilemma in intervention theory and implementation, where theories are favoured if they are practical because of these considerations such as funding and the monetary returns of delivering these programmes. Hence, we can see how through benchmarking, it influences the behavioural science research field as well.
Additionally, adopting governance approaches from the private sector, such as technical management and administration, into the public health field, attempts to neutralise the politics embedded within public health. Programmes are reduced to admin work and how to manage them (governance). Political debates about structural factors within the political economy of health are deemed inefficient. In tandem, power is devolved (devolution) from a central state to local agencies and governments. With local agencies and governments operating as businesses as highlighted earlier, they function apolitically (or rather, in service of neoliberal ideology) and so political power and decisionmaking becomes neutralised through this pipeline as well.
And, as discussed above, the citizen is now regarded as a “consumer” who has to choose between what options work best for them (responsibilisation). This form of responsibilisation places the onus of managing their health solely onto the individual/consumer and their ability to ‘purchase’ a service (this ability being affected by their income, race, geography, and so on) as well as reliance on informal networks of care which are often unpaid labour. The reliance on unpaid labour is needed to keep the public health sector and its systems “unburdened” and cost-efficient (read: profitable).
Responsibilisation then also means that those who do not engage in consuming public services are blamed rather than the systems interacting that play a role in defining their capacities to access these services. For example, in Singapore, wealth inequality has worsened over the last two decades (Tjin, 2024), with low income households struggling with rising costs of living (Numbeo, n.d.). Thum Ping Tjin references Teo You Yenn’s (2018) work, ‘This is What Inequality Looks Like’, which provides a deeper examination of how neoliberal rationality exercised within public health has an effect on the adoption of healthy behaviours. Yenn details the socioeconomic quality in Singapore and the ruling party’s overemphasis on self-management and reliance on informal networks of care to be able to live in Singapore (responsibilisation).
As Yenn puts it (quoted in Tjin’s article), “Therefore, if someone is poor, it is their fault for not working hard enough, rather than being born into poverty or structural conditions that prevent social mobility.” By this logic, when income is tied to access to public goods, those who are poor are then blamed for not working hard enough to live a healthy life. These perspectives to explain why healthy behaviours are not practiced among low income households demonstrate the personal responsibility attributed to not being healthy (responsibilisation). This is a conclusion that is only legitimate under neoliberal thinking, which believes in the markets to run public goods subscribing to the capitalist economic system. Such a conclusion is also made logical because of the processes that have neoliberalised the public health system in the country (i.e. benchmarking, governance, devolution), leading to very reductive conclusions about why some perform a behaviour and others do not. Rather than understanding how the low income structurally shapes behaviours, and subsequently, health outcomes, low income is seen as a personal responsibility and a result of behaviours; that you should aim to work harder to live a healthier life, rather than healthy living being a right for all. This again is enshrined within the neoliberal rationality governing public goods in the country. Additionally, as highlighted above, neoliberalisation requires convincing the citizen they are now a consumer.
These methods of establishing and legitimising neoliberal rationality within public health and in understanding health behaviours provides a lens in explaining why behaviour science researchers and practitioners may choose practicality over complexity. It is more convenient to attribute behavioural gaps to individual/interpersonal factors rather than questioning the systems in place that shape these factors. It becomes easier to, say, incentivise healthy behaviours. For example, the Singaporean government often provides financial assistance and incentives (i.e. Healthy 365 points) to those participating in healthy activities such as buying healthy food, and these points can be redeemed for prizes and vouchers. Incentives are an increasingly common behaviour change strategy (Vlaev et al., 2019). Such strategies signify that there is an awareness of the challenges of earning lower incomes within the neoliberal capitalist system among researchers and practitioners, but the behavioural science field does not question this and instead, accepts this distribution of power (Fox & Klein, 2020; Nord, 1971). Such a strategy then merely feeds into the status quo, of wealth and health inequities within the economy, “and to the production and reproduction of class, gender and race” (Fox & Klein, 2020). They keep the neoliberal infrastructure intact and strengthen it by overstating the behaviour change reported and its impact on health outcomes, reinforcing the neoliberal, unchallenging perspective.
Where do we go from here?
The argument here is not that we have zero agency over what we choose to do, but a sole focus on individual choice is quite inaccurate of how we negotiate our agency with the political economy that also encompasses us. The field of behaviour change has given important insights in understanding how health outcomes manifest, but its lack of analysis on structural factors makes its own research and understanding of behaviours lacking as well. This gap is the consequence of how convenient it is to not question the systems at play here. Instead, behavioural science research and implementation is governed by, and contributes to the gambit of a neoliberalised public health sector. Behavioural science research which is catered towards needs on the ground now is bound to be attached to the parameters of neoliberal rationality in public health, which are enforced through the four techniques discussed.
As behavioural science researchers, we need to be more critical of and challenge the systems in place and the danger they pose on health for those who do not, ultimately, benefit from a capitalist economic system. This may mean more complex theorisation and models, interventions and policies that target structures, and action as simple as shifting the way we discuss behavior and health in our everyday work. It may seem that there is no solution when the public health sector feels immovable from its neoliberal approach, but research has played a pivotal role in advocacy. Take Engels’ work in 1845 which informed Marx’s thinking and was also echoed in the Black Report (Harvey, 2021), for example. At a time where health inequalities widen, we cannot keep defaulting to neoliberal thinking in how we analyse the roots of health behaviours.
Authored by Shameeta M.
Shameeta M. works in public health research and is currently based in Singapore. Her interests include analyzing neoliberal-ised public healthcare systems, community-based care, and being outside the margins.
