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The Dutch health & fitness industry can play an important role in tackling societal issues of public health and well-being, preventive health care and exercise- poverty. To become an influential and full partner in the public policy making process, the industry needs to change drastically.
Ambition of the health & fitness industry
For one part of the Dutch population, the current innovative power of the health & fitness industry offers sufficient services to maintain a healthy active lifestyle, such as with the growing offer of online training and the development of applications of robotics and domotics. For another part of the Dutch population however, a drastic change of the health & fitness industry is necessary because this part of the population is not being reached enough, assuming this industry aspires to become an influential and full partner in addressing the societal issues of preventive health and exercise poverty. And this ambition would be appropriate because this industry has a great deal of tacit knowledge, practical knowledge and experience, on the basis of which effective public policy can be developed, and because the industry plays an important role in the implementation of this public policy.
Health benefits for who need it the most
The greatest health benefitscan be achieved in the part of the population, that are not reached enough, people with a low socio-economic status. People for whom exercise and healthy living are not a matter of course. Not because of a lack of motivation, but because priorities lie elsewhere. Although sport is essential for health, it is not a basic necessity of life. Safe shelter, food and financial security are. When you have to worry every month whether you can feed your children and pay your rent, there is hardly any room for sport and healthy eating in a financial, social, physical and psychological sense.
In addition, the physical and social environment plays a role. Exercise and going outside are not a matter of course when you live in an unsafe neighborhood, with little green space and lots of traffic. (The importance of being outdoors) Or when unhealthy behavior such as sitting a lot, eating cheap and unhealthy food, and smoking are the social norms in your environment. As visible in the Dutch TV show Better! about health poverty in the suburban community.[1]
Wicked problem
The Netherlands is struggling with exercise poverty [2], a wicked problem. Wicked problems are social problems that are highly complex in nature and cannot be addressed from a social engineering or predictability perspective. The belief in the existence of one right approach to solving the problem from one central actor must be replaced by an approach from multiple perspectives [multi-perspectivity], perceptions, rationales and emotionalities [multiple rationality], from all parties involved in the problem.
Wicked problems require long-term and intensive cooperation in which all parties involved subordinate their own interests to the common interest and there is a shared need to address the problem.
Essential in addressin gwicked problems is that in generating and utilizing relevant knowledge and experience (Tacit knowledge) for the benefit of addressing the problem, no party is excluded, as often happens with the target group involved. It is also necessary to avoid selection in the knowledge utilized based on status, familiarity or size of a party, such as that of a government agency (the Dutch Tax Administration) versus a target group (parents who received child allowance). [3]
Effectiveness of public interventions
Tackling exercise poverty in the Netherlands is a responsibility of all of us. Public policy interventions that are expected to be effective, should take place on multiple levels, over a long period of time. To be expected effective means that interventions have a solid foundation [policy theory] on the basis of which success can be expected. Effective should thereby be formulated more broadly than solely in terms of financial effectiveness. For example, an intervention can also be effective when practice shows that implementers of an intervention or an intended target group of an intervention, perceive it as feasible and acceptable.
For example, practice shows that Lifestyle Coaching at the individual level is often perceived as effective by the client and intended health effects are achieved with this intervention. However, because Dutch government effectiveness measurements are only carried out on lifestyle coaching at the group level, there is a lack of 'hard' data on the effectiveness of individual lifestyle coaching (and thus of funding from health insurers). While this individual intervention can be effective.
Not particularly effective but often used are health interventions based on the assumption tha tproviding more information leads to behavior change and healthier choices. As in the Dutch National Prevention Agreement (Nationaal Preventieakkoord). An assumption, by the way, that underlies many public policies.
It is too simplistically stated that lack of information underlies health problems. Or, by analogy as is often stated in the health & fitness industry, that lack of motivation underlies inadequate exercise habits. Short-sighted and incorrect. Humans are not purely rational beings and therefore do not act purely rationally. Informing, punishing and rewarding or financially incentivizing to motivate are often not very effective interventions. Human behavior is extremely complex, and influencing it many times more so.
Multi-level collaboration
Influencing health behavior, to have any effect, will at least have to do justice to the complexity of behavior and of behavior change, and will have to take place at multiple levels. At the level of the individual; of his immediate environment; and of the physical, social, political and economic environment at the macrolevel. This will require, in addition to a social science policy theory, the involvement and responsibility of all parties involved in the problem, together, with a common interest and a shared need.
Social responsibility
If the Dutch health & fitness industry aspires to be an influential and full-fledged partner in addressing societal issues of preventive health and exercise poverty, purely commercial objectives should not be leading. With wanting to play a full partnership also comes a social responsibility. This social responsibility can take various forms and be expressed in various ways. We discuss two examples here:
1. Cooperation with (primary) care
NL Actief Prevention Centers are health & fitness centers accredited by the Dutch health & fitness association NL Actief, to offer specialized guidance to people with (an increased risk of) a chronic condition. These centers, some 120 in the Netherlands, work together with health care providers such as the general practitioner and physiotherapist.[4]
Awareness of Prevention Centers among health care providers in the Netherlands is not a given, and these centers are not yet full players in the Dutch health care system. This leaves many opportunities for collaboration and added value untapped, such as for general practitioners, more than half of whom report experiencing an excessively high workload.[5] Referral to a Prevention Center may be an appropriate treatment method for a proportion of patients. Surgery in a fitter patient is more likely to be successful, preventing complications and healthcare costs later.[6]
Investment in strengthening the position of NL Active Prevention Centers is essential if the health & fitness industry wants to be an influential and full partner in addressing the societal issues of preventive health and exercise poverty. Financing by health insurance companies of treatment by Prevention Centers, which is currently lacking, is a prerequisite for this.
2. Nudging in the neighborhood
Nudging is a behavioral science approach that assumes that understanding behavior provides an opportunity to change or redirect that behavior some what.
People do not necessarily make choices that are good for them. More over, making choices becomes increasingly difficult when problems become more complex, or when the effect of a choice is not immediately apparent. As with losing weight when following a diet. Choices that are rare, unknown, or on which people do not get feedback are also difficult.
Automatic system
According to nudging, it is important to understand where people go wrong in their choices because they rely too much on their automatic system. The operation of this automatic systemon choice behavior proceeds through three tracks:
1. Anchoring
This refers to assessing an unknown phenomenon based on one's anchor. If someone who hires a Personal Trainer as ‘a stick’ is asked why most people do not exercise, that person will most likely answer that people are not motivated to exercise independently. So the answer depends on soneone’s own experience, their anchor. However, that assessment often proves incorrect.
2. Availability
This refers to the fact that the probability of a risk is often estimated to be higher when examples can be made up of that risk, when someone has just experienced that risk, or when one can empathize with that risk. For example, a person will rate higher the risk of a heart attack after years of unhealthy eating when it has occurred in their immediate environment.
3. Representativeness
This is about stereotypes. People often see patterns that are not necessarily there [cognitive bias]. For example, when people have heard that someone started playing sports and was later diagnosed with a hernia, it is quickly concluded that there is a causal relationship between sports and hernias (Low back pain and CrossFit and injuries). While this is not necessarily true.
Group pressure
In addition to the automatic system, the influence of peer pressure should not be underestimated. This can cause people to make choices they don't really want to make. People tend to conform to the group if they know that their answer will be made known to that group and because they often mistakenly believe that the group is watching them.
It also appears that when an influential person or someone confidently speaks in the group, this can influence the group's choice. It is striking that group judgments are internalized and that after years that judgment is still alive, even though the composition of the group has totally changed.
Pluralistic ignorance
Sometimes we perpetuate a tradition or idea when we ourselves no longer know why, but because we think everyone else thinks it's right (pluralistic ignorance). For example, the social norm in a neighborhood may be that exercising is a waste of your time, or only for yuppies.[7]
The role of health & fitness companies
A health & fitness company located in a neighborhood can nudge residents' behavior in several ways. Obviously by selling memberships, but also by encouraging exercise among residents who cannot or even do not necessarily want to become members (the inactive residents).
The company can use its knowledge and network to approach neighborhood ambassadors: Individuals with whom inactive residents can identify as "one of us." These ambassadors have knowledge of what is going on among inactive residents. They can offer insight into underlying beliefs, ideas, norms and values that lead to people not being active. In addition, ambassadors can be role models in the process of moving towards a more active lifestyle (Representativeness) and increasing awareness about opportunities to exercise more (Creating a new anchor).
Through the ambassadors, the company can connect with inactive residents and engage with them in a conversation about the question, "How can we help you get more active within the opportunities you currently have?"
It is not a given that someone can come up with the answer to that question on their own. If a certain behavior, such as taking your children to school on foot, does not fit within the existing behavioral repertoire or does not fit within the social norm, that behavior is not a given and should not be taken for granted that someone comes up with it on their own.
And even if it would, then it should not beassumed that taking your children to school on foot is also seen as a viable option. Often, when we need to perform different behaviors, we quickly think in terms of limitations, why something is difficult or not going to work. For example, because you assume that it will take too much time to walk and then you will be late for work, or because you think your children won't like it.
A health & fitness company can use its knowledge, experience and network to enter into The Other Conversation* with inactive residents about how to make a more active lifestyle sustainably possible. Sustainable means in a way that suits the individual and their life,because only then is there a chance for lasting change. "How can it be done; what do you need to make it happen; are the assumed barriers real; what qualities can you use to make it possible?" Perhaps there are more people with children in the neighborhood, and a joint walk could be organized. Maybe a referral to a physical therapist will help when it turns out that someone has knee pain without knowing about treatment options. Perhaps a busy road in the neighborhood interferes with opportunities to be outdoors, and the health & fitness company can contact the municipality to address this.
The company can play a facilitating and stimulating role in providing insight into the possibilities for a more active lifestyle in a way that suits the individual and their life, without directly serving their own commercial interests. Social responsibility instead of pure commerce.
*The other conversation is a Positive Health conversation technique in which the focus is not exclusively on the health problem, but on the qualities, resilience and possibilities that someone has and that can be used to learn to take control over health and quality of life.
Concluding
The health & fitness industry has enormous potential to have a substantial impact on issues of preventive health and exercise poverty. For example, by cooperating intensively with other involved parties; by investing in strengthening the position of NL Actief Prevention Centers; by demonstrating the added value of exercise as a treatment method; by nudging in the neighborhood; and so on.
Wanting to contribute to tackling social issues also requires bearing social responsibility. Commercial objectives will sometimes have to be subordinated to this. The fact remains,however, that the health & fitness industry is not a philanthropic sector. For example, it cannot be the intention that a fitness center invests a lot of time (and money) in nudging in the neighborhood, with the result that residents become members of other exercise providers in the neighborhood. Unless those other exercise providers also participate in nudging in the neighborhood, and parties such as the municipality or health insurance companies play a (financial) role, thus better balancing social responsibility and commercial viability. Social issues thus require a broadly supported approach with appropriate preconditions that actually enable their concrete implementation. The ball is in all parties' court!
Create your own health!©
References
[1]https://pers.avrotros.nl/nieuw-programma-antoinette-hertsenberg-beter-over-gezondheid-en-leefstijl-in-volkswijk-voorstad/
[2]https://www.nederlandse-sportraad.nl/actueel/nieuws/2021/12/21/column-erik-scherder---twee-pandemieen-en-de-overheid-doet-niets.-hoe-kan-dat
[3] Houppermans (2011). Twee kanten van de medaille. Een onderzoek naar de kwaliteit van de beleidsvoorbereiding.
[4]https://www.nlactief.nl/actueel/nl-actief-preventiecentra-verstand-van-zaken-gevoel-voor-mensen/
[5]https://www.parool.nl/amsterdam/overbelaste-huisartsenzorg-dreigt-in-negatieve-spiraal-te-belanden~b7d00e13/#:~:text=Volgens%20de%20Landelijke%20Huisartsen%20Vereniging,moeite%20om%20vervanging%20te%20vinden.
[6] https://www.fit4surgery.nl/
[7] Houppermans (2011). Twee kanten van de medaille. Een onderzoek naar de kwaliteit van de beleidsvoorbereiding.
