How to encourage healthy choices: Public policy or personal behavior?


Veronica Combs (BF’16, FL’16), director of community engagement, Institute for Healthy Air Water and Soil

“You have an ugly shirt on.”

Dr. Laquandra Nesbitt stood at the front of the room and looked out across the 2016 Bingham Fellows class. It was our first full day.

“Who am I talking to?” she asked, sweeping her glance to every table. Some people smiled, waiting for the punch line. A few of us looked down for a quick reminder of what we had pulled out of the closet earlier that morning.

“No one wants to be the one to hear that message,” Dr. Nesbitt said. “That message is only for you when you hear it from someone who has your best interests in mind.”

Fashion choices are subjective but diagnoses of obesity and diabetes are not. No one really wants to accept the message that he is overweight. It’s also easy to dismiss the risk of diabetes, even if blood sugar readings tell a different story. A quick glance at health data from the last 10 years shows that Americans find it very easy to ignore warnings about heart disease, a couch-potato lifestyle and the risk of high blood pressure.

Even as she illustrated the complexity of health communications, Dr. Nesbitt pointed out a larger challenge. Physicians influence only a small part of an individual’s overall health.

This population health pie chart shows that physicians influence only 20% of a person’s overall health. As the chart below shows, health behaviors – smoking, diet, exercise, genetic heritage – take up only 30% of the pie.


The other factors that influence health include:

  • A person’s home address
  • A person’s education level
  • A person’s race

To influence all those factors – the non-healthcare factors that determine how healthy or sick a person, you have to look at population health, instead of the health of an individual. Population health is a relatively new term. It’s the idea that you have to consider the wellbeing of a group of people and address the 50% of the pie that doesn’t involve the doctor’s office or an individual’s personal choices.

Dr. Thomas Frieden is the director of the Centers for Disease Control. He created this population health pyramid to illustrate all the factors that influence health.




Here are a few examples of what each level of the pyramid looks like in a practical sense, moving from the top down:

  • Drug rehabilitation and regular exercise
  • Prescriptions and surgery
  • Immunizations and fluoridated water
  • Smoke-free workplaces and healthy school lunches
  • Access to safe housing and affordable college education

The Bingham Fellows’ focus this year is empowering citizens to lead healthier lives. As we learn more about the health challenges in our community, we’ll have to pick a level on the pyramid. Will we focus on influencing individual behavior or work on policy change that could affect the health of the entire community? Interventions focusing on lower levels can reach more people and require less individual effort, as Dr. Nesbitt explained. She recommended that the class pick two or more layers.

“How will you allocate your resources across the pyramid?” she asked.

That is one of many questions that the Bingham Fellows class of 2016 will have to answer between now and graduation in October.

Learn more about the Bingham Fellows program.