Introduction

How best to promote health in schools? Due to the rapid spread of non-communicable diseases, such as asthma, diabetes and obesity, this question has gained importance. There is a consensus that schools – which everyone attends during the crucial period of growing up – ‘have a great impact on the health and emotional wellbeing of children and young people’ (Mannix-McNamara and Simovska, 2015, p. 3). Even more so since the number of extended schools, at least in Western countries, is increasing, and with it the amount of time per day students spend in schools. Thus, schools are challenged to become health-promoting environments that structurally enable rather than prevent healthy lifestyles. Moreover, being healthy in both a physical and a mental sense is seen as a key condition for educational success, which in turn facilitates students’ integration into society and working life.

This paper seeks out to compare and contrast two different approaches policymakers could hypothetically apply in school health promotion: the settings approach, originally outlined in the Ottawa Charter of the World Health Organization (1986), and nudge tactics, prominently promoted by Richard Thaler and Cass Sunstein (2008). While the former approach ‘is well known, widely utilized and top-rated’ (Torp et al, 2014, p. 3), ‘firing the imagination of professionals, politicians and citizens’ (Dooris, 2013, p. 39) for more than three decades, nudge did not gather momentum before 2008, the year Sunstein and Thaler published their worldwide bestseller. However, recently ‘behavioural methods are increasingly proposed as a panacea for health improvement’ (Crawshaw, 2013, p. 620). In consequence, the quite old debate in public health whether to either focus on the social determinants of health, i.e. the underlying structural and systemic factors that influence people’s health conditions (Marmot, 2005) or on people’s behaviour and lifestyles, i.e. eating habits, physical (in)activity or smoking, has been revitalized (Baum and Fisher, 2014). This paper innovates theorizing on health promotion by comparing the settings approach to nudge. In particular, both concepts’ strategic orientation and approaches to deal with people’s social identities, diversity and norms are contrasted. While nudge tactics in public health and elsewhere have mostly been discussed at a more fundamental level so far, this paper contributes to the critical literature on nudge by judging its implications in a specific area of health promotion: schools. Moreover, the question is addressed whether nudge and the settings approach can be blended or, as one of the paper’s referee put it, ‘are simply too far apart to be reconciled’.

The paper starts by re-examining the settings approach in health promotion derived from the Ottawa charter (WHO, 1986). For this reason, the underlying assumptions of settings approach concerning health will be revealed and its claim to be holistic, people-centred and social norms-based will be questioned (2). Against this backdrop, the guiding rationales of nudge in public health will be reflected, taking into account the state-of-the-art ethical and empirical critiques according to literature (3). By introducing two examples of nudge – smart lunchrooms and activity-friendly built school environments – their practical implications for the school setting are illustrated (4). The conclusion recapitulates nudge’s most significant limitations and points out why, despite its current shortcomings, the settings approach seems better suited to promote health in schools (5).

Recapitulating the Pre-nudge Area in Health Promotion: The Settings Approach

In health promotion, behavioural policy interventions are still the exception rather than the rule. However, since nudging as a policy instrument has already ‘penetrated popular culture’ (Carter, 2015, p. 375), serving as a blueprint for public policy reform in health promotion and elsewhere (Jones et al, 2013), current policies have to be reviewed in order to assess the meaning of impending change. This section reflects the underpinning values, driving goals and practical shortcomings of the settings approach in (school) health promotion.

Conceived as a truly holistic concept, the settings approach promises to address all factors influencing people’s health in a certain lifeworld, i.e. places where people ‘learn, work, play, and love’ (WHO, 1986). Drawing from ‘a range of novel theoretical resources’ (Whitelaw et al, 2001, p. 339), which emanate from disciplines such as sociology, psychology, management and geography, the settings approach shifts the focus of health promotion from the individual and risk factors to the complex social ecology of the lifeworlds in which people pursue to unfold their social identities (Mittelmark, 2014). Behavioural dimensions of health (e.g. people’s lifestyles and habits) are not neglected in the settings approach but perceived to be strongly dependent on social norms and the context in which the social determinants of health such as educational attainment, employment and income status are produced and maintained (Marmot, 2005). As Dooris (2013, p. 40) puts it, health is accordingly defined broadly as ‘a multi-layered and multi-component concept involving inter-related physical, mental, ‘spiritual’ and social dimensions’. Using Antonovsky’s model of salutogenese (1996) as a key reference point, the settings approach aims to shape social environments in a holistic manner by empowering people to become health-seeking owners of their local lifeworlds. Rather than reducing (or banning) pathogenetic causes (e.g. trans-fats or artificial sweeteners in food), the settings approach embraces the rationale of joint-up working on the causes of the causes of health risks such as economic, spatial and political structures of the respective setting (e.g. neighbourhood, workplace or school). Thus, from a governance perspective setting-based health promotion relies on networks as a mode of governance (Héritier and Lehmkuhl, 2008) and rests on the idea of involving citizens through deliberative tools and procedures. Following the interdependence of structure and agency (Giddens, 1991), it is assumed that enabling people to develop a ‘sense of coherence’ (Antonovsky, 1987) within healthy settings leads to sustainable public health results. According to this conviction, people – engaged citizens, caring family members and co-producing community activists – contribute to a flourishing environment that in turn promotes and maintains public health. Moreover, it is conceived that in these settings social norms related to health and health-related behaviours (e.g. the social acceptance of taking the bicycle or eating more vegetables) may be altered. This, however, can only be achieved by policymakers’ whole-system thinking that takes ‘account of contextual norms, values and interrelationships’ (Dooris, 2009, p. 30). Thus, changing setting-specific social norms requires deep investigations into the social and cultural texture of a certain context, i.e. profound knowledge on what constitutes people’s social identities, peer-groups and lifestyles. Consequently, any health-related intervention needs to be ‘multi-modal, multi-level and socially valid’ (Mittelmark, 2014, p. 19) and systematically integrated with the setting’s core business. With respect to schools, activities hence should positively support schools’ educational missions instead of being isolated add-ons (Rosas, 2015). In this sense, setting-based health promotion in schools is ‘seen to have been particularly successful’ (Dooris, 2013, p. 46) as it is demonstrated by the European network of Health Promoting Schools (HPS) (Barnekow Rasmussen, 2005). Likewise, the Whole School, Whole Community, Whole Child (WSCC) approach, recently developed by US experts on education and health, claims to be an integrated and cross-sectorial model bundling all resources locally available (Lewallen et al, 2015).

However, a healthy dose of scepticism towards the bewitching rhetoric of holism, inclusive networks and joined-up approaches seems appropriate since the local practice of settings-based health promotion often falls behind their far-reaching goals. This is caused by shortcomings in the conception and/or implementation of the settings approach. First, on the ground, the noble intention to create ‘supportive health environments and community action’ (Macnab et al, 2014, p. 172), i.e. preferring structural instead of behavioural prevention, may turn out to be a flowery phrase for doing business as usual. In this case, settings are just understood as spaces for targeting individual health behaviour rather than as social environments that may be collectively reshaped to become health promoting by its own nature (Whitelaw et al, 2001). Such a light version of the settings approach occurs if schools, despite rhetorically embracing principles such as equity and cross-sectorial cooperation, de facto merely conduct well-meant hands-on projects on behavioural issues such as healthy eating and physical activity. Second, key values of the settings approach such as empowerment and local ownership may corrode if health promotion activities borne out to be ‘part of a larger agenda with pre-set priorities and assumptions about what is “good work”’ (Mittelmark, 2014, p. 20). Third, forcing, for example, schools to apply a predefined settings-based approach that considers the local particularities and pre-existing social norms insufficiently, e.g. the students’ social and cultural heterogeneity, may lead to ‘unintended effects’ such as the stigmatization and/or exclusion of vulnerable groups (ibid.). Thus, unfolding the settings approach’s potentials is an ambitious and complex endeavour facing several real-world constraints. Moreover, health promoters, be it in schools or other local settings, often fail to ‘enable, mediate and advocate for policy and political change’ (de Leeuw and Clavier, 2011, p. ii243).

Thus, the difficulty of implementing the settings approach evokes calls to rely increasingly on behavioural insights in health promotion. Indeed, at first glance, ‘steering citizens down paths that are more beneficial to them and society at large’ (John et al, 2009, p. 366) seems to be, as we will see in the next section, a promising alternative for policymakers to promote health. How does nudge differ from setting-based health promotion?

Because We are Imperfect and Error-Prone: Nudge Tactics in Public Health

This section introduces nudge tactics as a health promotion tool and recapitulates its (ethical and empirical) critiques. Nudges are subtle interventions, defaults and a way of presenting choices that ‘alter people’s behaviour in a predictable way, without forbidding any options or significantly changing their economic incentives’ (Thaler and Sunstein, 2008, p. 6). They are applicable in various policy fields such as consumer protection, energy or environment (Bogliacino et al, 2016). Nudging people towards socially desired directions ‘seems to be a reflection both of an overarching political ideology and a drive towards minimally disruptive, market-preserving regulatory strategies’ (Quigley, 2013, p. 596). As Pykett et al (2011, 2013) have shown, the concept fits well with a creeping consumerism in public policy putting a strong emphasis on individual choices while paying less attention to collective voice and deliberation. Nudge is also compatible with a neoliberal transformation process towards smart, technology-based and service-centred societies seeking to optimize the use of human capital and productivity (Leggett, 2014).

However, it seems that in no other field there is as much discussion about the appropriateness and ethical issues of nudge than in the realm of health which is proven by the growing volume of academic literature on the topic (see a.o. Cohen et al, 2016; Roberto and Kawachi, 2016). The current attention being paid to the new wave of behavioural health policies is surprising since ‘it could seem as if nudge is a reinvention of the wheel’ (Vallgårda, 2012, p. 201). Health promoters have always embraced the dictum making healthier choices easier in their attempts to design public policy (de Leeuw and Clavier, 2011). What changed is the vehemence, accompanied with ‘decreasing emphasis upon structural or environmental changes’ (Crawshaw, 2013, p. 620), with which behavioural insights are used as blueprints to revise public health policies. Even critics have to admit that nudging people is inevitable since there ‘is no neutral design in any scenario’ (Leggett, 2014, p. 6) of structuring choices in public life. Nudging – relying on the wisdom of ‘the always benevolent nudger’ as Rebonato (2012, p. 221) somewhat ironically noted – is, thus, based on underlying assumptions about which public choices are best. With respect to health promotion, making vegetables and salad the default side order in canteens and making stairs more attractive than lifts in public buildings are prominent interventions in the choice architecture. As it is assumed, eating healthier and doing more physical exercise are behaviours people ‘would have chosen under circumstances where more reflection was possible’ (Selinger and Whyte, 2011, p. 927). Since most of us ‘choose options that demand the least (physical and intellectual) effort’ (Mols et al, 2015, p. 84), well-intentioned health nudges may help people ‘overcome their cognitive imperfections’ (White, 2016, p. 72). Since ‘impulsive actions’ (Jones et al, 2013, p. 111) endanger a reasonable health behaviour, nudgers seek to ‘“exploit” and “manipulate”’ (Rebonato, 2014, p. 379) people’s ‘fast’, i.e. unreflective or automatic thinking (Kahneman, 2011) in order to improve public health. Mols et al (2015, p. 84) who criticize nudge from a social identity perspective have appropriately coined this strategy as ‘governance by stealth’ due to policymakers’ reliance on secrecy, trickery and cleverness while designing nudges. Against this backdrop, it is not surprising that critics (see sources cited below) embark on a fair number of ethical dilemmas associated with nudge in general and particularly in public health. With respect to health promotion, ethical issues such as how to deal with people’s interests and learning capabilities but also nudge’s implications for social norms and democratic rights should be briefly considered.

First, by influencing behaviour in ‘a systematic, covert, and predictable way’ (Blumenthal-Barby and Burroughs, 2012, p. 9), nudgers judge other people’s interest by their own convictions. Health, it is assumed, represents everyone’s greatest interest to which all other preferences and interests are subordinated; consequently, nudging people straightforwardly towards healthier lifestyles seems justified. Assumptions according to which health is not ‘a simplistic, monolithic interest’ (White, 2016, p. 73) and that nudge ‘may interfere with interests representing other aspects of the good life’ (ibid., p. 76) are rejected by nudge advocates from the outset.

Second, critics argue that nudge inevitably results in a fragmentation of people’s identity set (Bovens, 2009). If nudgees are exclusively conceived as duped consumers to be protected from their own mistakes, they are ‘not challenged to learn to make good choices’ (Selinger and Whyte, 2011, p. 929). Thus, nudgers do not address other health-related identity facets such as the one of responsible citizen or competent co-producer (Ewert, 2016).

Third, nudge’s utilization of social norms is considered ethically problematic. Given the fact that ‘we are strongly influenced by what others do and by who communicates information’ (Blumenthal-Barby and Burroughs, 2012, p. 5), using social norms as nudges is a morally questionable instrument to promote public health. Disseminating social norms strategically (e.g. by messenger like 70 per cent of the students do sports every day) whose accuracy is often difficult to verify may affect people’s autonomy and ‘lead to stigmatization’ (McFerran, 2016, p. 154).

Fourth, there is a genuine conflict between nudge and democratic rights and principles (John et al, 2009). A non-transparent implementation of health-promoting choice architectures may ‘undermine democratic control’ (Gingerich, 2016, p. 97) for people seeking ‘for voice not choice’ (Room, 2016, p. 126). As it is criticized, choice architects unilaterally answer crucial questions such as ‘Who decides? Which nudges are applied? Over which forms of behaviour? Based on which required level of evidence?’ (Brown, 2012, p. 313) and, therewith, deny features of active citizenship such as individual agency, deliberation and shared decision-making (Pykett et al, 2013).

As it should have become apparent by now, the settings approach and nudge seem to be worlds apart with regard to the conception of subjects to be addressed, the definition of health and objectives of health promotion. Table 1 summarizes key differences of the settings approach and nudge in health promotion.

Table 1 Comparison of the settings approach versus nudge in health promotion (own presentation)
Full size table

Most importantly, by nudging people into certain behaviours, their capacity to reflect their own interests and deliberate collectively over health issues is not valued. Furthermore, besides the shortcomings of the settings approach nudge may ‘eclipse attention paid to the public and structural determinants of the capability for good health’ (Owens and Cribb, 2013, p. 269). The question if a combination of setting- and nudge-based health promotion is conceivable will be addressed in the following. First, however, two examples of nudge in school health promotion shall be assessed critically.

Nudge in School Health Promotion

Schools are crucial environments where healthy lifestyles can be internalized and civic virtues actively practised (Jones et al, 2013, pp. 122–133). Due to the increase of extended schools, regularly visited by students till the late afternoon, health challenges that were previously to a large extent beyond schools’ spheres of influence such as obesity, physical inactivity and mental stress become important. While the settings approach has a long tradition in school health promotion, nudge is a relatively new concept for tackling health problems in schools. In the following, two examples – smart lunchrooms and an activity-friendly built environment – exemplifying how nudge promotes healthy eating behaviour and more physical exercise in schools are introduced and critically commented on. Both examples rest on the assumption that the ‘context in which options are presented can shape the decision-making processes that impact health’ (Stulberg, 2014, p. 1). As it is argued, in schools the design of lunchrooms and schoolyards may be perceived as hidden educators impacting students’ health behaviour.

One may assume that nudge’s gist all comes down to the design of cafeterias and lunchrooms. According to Sunstein (2015), behavioural science in cafeterias represents a huge success story since empiric results concerning the nudging of people towards healthier food choices in cafeterias look promising (see a.o. Hanks et al, 2013). Indeed, cafeterias and lunchrooms are ideal environments for applying behavioural tools in order to change ‘the convenience, attractiveness, normative nature of healthy foods’ (ibid., p. 867). For instance, non-profits such as the so-called smart lunchroom movement1 offer in-person trainings in schools, public lectures and various web-based resources (Smart Lunchroom Movement, 2016). For schools, facing the challenge to provide healthier school meals, nudge is attractive as a health promotion approach due to ‘its practical character’ (Burgess, 2012, p. 5): By simply offering salad first while placing chips out of sight or making vegetables the default side order of every dish students’ selection of food is influenced without prohibiting unhealthier choices. Moreover, lunchrooms should become ‘less institutionalized and more like cafes’ (Jones et al, 2013, p. 125). Tapping into the insights of social marketing (Crawshaw, 2013; Pykett et al, 2013), school canteens, formerly often sterile and impersonal spaces for having quick meals during breaks, are redesigned into consumer-friendly oases of wellbeing. Ideally, students hang out in smart lunchrooms as they would do with peers in their favourite fast-food restaurant. To nudge students’ behavioural change, school caterers virtually take on the roles of ‘health promoters’ (Jones et al, 2013, p. 128) who reshape lunchroom interiors. For instance, salad bars are placed prominently in the middle (instead of the corner) of lunchrooms, so that visitors pass them automatically. Additionally, healthy food is presented in much flashier and stylish ways than presumed unhealthy foods and drinks. Other nudges in the lunchroom concern the size and the design of kitchenware: Smaller plates and/or those including designate sections for fruits and vegetables influence how much and what kind of food lunchroom visitors consume. For schools, the concept of smart lunchrooms is promising since it partly relieves them of efforts to enhance students’ education in terms of nutrition and healthy eating. Pointedly formulated, smart lunchrooms do not require smart and health-conscious students since their overall design and the presentation of food are ‘consistent with automatic good choices’ (Bailes and Hoy, 2014, p. 494).

If the interior design of lunchrooms influences the eating behaviour of students, it is the shape of the school environment that impacts students’ physical exercise. Following this logic, nudge advocates aim to outwit students’ inclination towards physical idleness and human inertia by ‘regulating the built environment to promote healthier lifestyles’ (Khan, 2011, p. 386). In practice, the school environment, i.e. school grounds but also adjacent areas, has to be equipped with numerous inbuilt nudges to move while replacing obstacles that facilitate physical inactivity. Nudges that promote ‘walkability and other kinds of physical activity through design’ (Carter, 2015, p. 379) in the school setting are, for example, wide sidewalks and safe bicycle lines leading to schools, playground-like schoolyards (including uneven grounds, little hills, obstacle courses, suspension bridges and rope ladders) but also centrally located staircases and slow-moving elevators in school buildings. Inside classrooms, standing or height-adjustable desks are nudges which enable students to become physical active. All these ‘subtle environmental cues’ are deemed to ‘de-convenience’ students’ (ibid.) everyday school life that is otherwise dominated by an unhealthy sedentary lifestyle. Activity-friendly built school environments are also compatible with emerging markets for health education apps (Kratzke and Cox, 2012). These may be programmed to send text messages, figures or graphics to students nudging them towards more exercise or informing them about their calorie consumption while walking on school grounds. Such options of interconnecting the school environment with students’ smartphones via health promotion apps are various but still largely unexplored (ibid.).

Against the background of a looming ‘public health crisis at the hands of chronic lifestyle-driven diseases’ (Stulberg, 2014, p. 5), the merits of nudge-based health promotion in schools seem evident. There are in fact good reasons to assume that smart lunchrooms may actually nudge students towards a more ‘mindful eating’ and protect them from impulsive ‘hot state decisions’ (Smart Lunchroom Movement, 2012, p. 1, 5) while choosing food. Likewise, activity-friendly built environments may promote students’ physical exercise inside and outside schools. Contrasted to the settings approach, however, the employment of health nudges in schools is – despite its potentials – accompanied by at least three problems and pitfalls that need to be addressed.

The first problem concerns the strategic orientation of nudge-based school health promotion. Focussing on individual choices, nudge may promote behavioural change but is based on a rather ‘thin conception of the agent’s social context’ (Leggett, 2014, p. 14). Measures of structural prevention such as joint action for extracurricular sport or cross-sectorial coalitions to improve the quality of life in segregated neighbourhoods next to schools cannot be achieved by nudge. In sharp contrast to the settings approach’s ambition, behavioural policy tools do not address the roots of environmental health inequities such as deprived neighbourhoods or missing parks and sports facilities. Instead, they merely manage undesired consequences of health inequity by redesigning choice architectures in a particular setting while leaving the setting as a whole (i.e. its political, economical and socio-cultural structure) untouched. In this respect, school meals are a telling example: Fundamental and sustainable solutions such as the expansion of public subsidies for school meals or a stricter regulation of quality standards are not induced by behavioural policymakers. Instead, they are already satisfied if certification numbers for (often structurally underfunded) school meal programmes increase due to default options which nudge parents to automatically enrol their children into these programmes (Sunstein, 2015). As a policy tool, nudge hence seems to thwart innovative solutions to complex challenges like the provision of school meals, as White (2013, p. 98) critically remarked: ‘If the only tool you have is a nudge, every choice looks like a bad one – and every cafeteria looks like “choice architecture”’.

The second argument against a rather unreflective application of nudge in school health promotion deals with the underlying ethical and social implications of nudge. If school, as noted by John Dewey (1899, p. 12), represents an ‘embryonic society’, it reflects social problems and challenges of the respective time. Current key tasks of Western societies, e.g. coping with diversity, integrating migrants and, thereby, safeguarding a minimum of social coherence, have to be managed in schools at a smaller scale. Problematically, choice architects are likely to enforce cultural homogeneity when defining what health and healthy lifestyles mean in school contexts (Vallgårda, 2012). As it is criticized, nudge advocates show less interest in disentangling ‘the extent to which existing choice architectures (or norms) are profoundly rooted in social structures of class, gender and ethnicity’ (Brown, 2012, p. 314). Largely motivated to significantly reduce sheer numbers of obese children or those suffering from diabetes, nudge tends to embrace rather narrow and biomedical definitions of health by focusing ‘on specific areas of health such as sugar intake and exercise frequency’ (White, 2016, p. 76). Leaving the ‘complex interplay between social, cultural, and emotional factors that give rise to behaviour’ (Gill and Gill, 2012, p. 935) in a specific school setting aside, health nudges are not for the sake of everybody (White, 2016). From a nudge perspective, other preferences such as eating cake for breakfast or giving religious practice priority to physical exercise appear as irrational or unhealthy habits. Rather than being seen as a resource for a vibrant and multi-faceted school life, nudgers perceive students’ diversity and cultural differences as mere ballast in their attempts to shape health-promoting choices. An additional ethical issue concerns the exploitation of shame by nudge-based school health promotion (Eyal, 2014). Even if smaller plates or intentionally hidden sweets in the cafeteria do not prevent students to ask for a second helping or brownies for desert, these socially not desired options are marked with a ‘subtle stigma’ (ibid., p. 54) since they are beyond the norm of what choice architects conceive as healthy behaviour. While a ‘shame-based nudge’ (ibid.) may be the right tool to slightly reduce the consumption of alcohol during a company party, it seems highly inappropriate in a pedagogical setting that otherwise values free development and expression of students’ personalities.

This leads us to the third objection against nudge tactics in schools: Nudge addresses students not as learning and self-responsible subjects but as ‘[m]orally lazy, fragmented selves’ (Selinger and Whyte, 2011, p. 929). By conceiving nudgees as rather duped consumers, nudgers pay less attention to other social identities (see for an in-depth analysis: Mols et al, 2015) such as their roles as citizen, co-producer or community member. Hence, school health promotion which prefers ‘“nudging” to “teaching how to think”’ (Rebonato, 2014, p. 384) is not understood as a deliberative, participatory and open-ended process. While in the settings approach, for example, designing contexts such as lunchrooms or school yards ‘should be something that people pay attention to and engage in themselves, as political subjects capable to collective action’ (MacGregor, 2016, p. 618), nudge considers context design as something that is done to people as ‘objects of manipulation by experts’ (ibid.). However, schools are social settings in which students develop and explore their social identities, which means that any form of context manipulation, even those that are not harmful and for the students’ sake, is problematic. For instance, the implicit message of smart lunchrooms towards students is that they are neither willing nor able to make healthy food choices and thus tricking them is indispensable. Moreover, through nudge ‘public action is reduced to the exercise of individual choice on matters of behaviour’ (Pykett et al, 2011, p. 308) which reinforces an alienation process between students and the school as a public sphere. At risk of being lost is a sense for the collectivity and historicity, i.e. the political, administrative, economical and socio-cultural and spatial layers that shaped the school over time as a ‘thick social context’ (Leggett, 2014, p. 16), and its effects for the local understanding of health and (un)healthy behaviour. While such a view is, in theory, encompassed by the settings approach, nudge is decontextualized from local particularities ‘due to its overly narrow conception of time, materiality and “the social”’ (Brown, 2012, p. 307). In principal, the smart lunchrooms’ behaviour change logic is hence independent from the setting it is deployed in – be it schools in affluent or rather poor areas.

Taken together, the objections against nudge in school health promotion strengthen doubts concerning the approach’s appropriateness in the school setting. What remains is the question whether any sort of a shrewd combination of the settings approach and nudge is hypothetically possible. Current public health policies are ‘characterised by a chasm between two central views’ (Baum and Fisher, 2014, p. 214) how to promote health as the following anecdote underpins: Being asked by the author whether he is interested to cooperate in a research project on behavioural policy-making in health promotion, a colleague recently responded promptly and unambiguously: I am a harsh critique of behavioural approaches, must decline. This value-loaded statement demonstrates the division among separate academic camps in health promotion that sharply oppose each other’s views. Nonetheless, on the ground, there seems, as Jones et al (2013, p. 131) have argued, to be some ‘potential for a more deliberative, ethical and empowering form of behaviour change’ in school health promotion and beyond. Originally, theoretical thinking on the settings approach considers ‘social marketing’ as one method to reach healthy lifeworlds besides others such as environmental modification and peer education (Dooris, 2009, p. 31). Following this idea, students for instance may in practice co-produce nudges concerning food choices or the built environment. Moreover, deliberatively defined choice architectures in school settings, engaging students ‘not as cognitive laggards, but as social beings’ (Mols et al, 2015, p. 95), are more likely to reflect local values, social norms and cultural diversity. Such an ‘enlightened version of behaviour change’ (Jones et al, 2013, p. 133) may increase the legitimacy of nudge, if the tool is used selectively and is carefully integrated in a more holistic approach of promoting public health (Van Den Broucke, 2014). Hence, in theory building bridges between setting- and nudge-based health promotion seems possible. However, this would require substantial concessions on both sides that seem (currently) rather unlikely: Health policymakers would have to agree to design nudges deliberatively (John et al, 2009), which would weaken nudge’s paternalistic element and its stealth operation. Likewise, advocates of the settings approach pursuing the Herculean effort to change structural and systemic factors of public health may have concerns about rather small-scale solutions emanating from behavioural tools.

Conclusion

Nudge advocates’ main argument is that choice architectures are an indispensable feature of social and public life (Thaler and Sunstein, 2008, p. 3). Therefore, setting up smart default choices in public policies appears justified in order to support people in mastering the ‘sheer complexity of modern life’ (ibid., p. 284). However, when applied to school health promotion, two fundamental limits of nudge strategies become clear – in addition to the social and ethical issues discussed above.

Concerning the first limitation, nudge’s restricted scope, the example of school meals is very illuminating: If we assume choice architects succeed in designing lunchrooms in a way that students automatically choose healthier snacks and dishes, the question remains whether these students will really be better off. In terms of scope, nudge tactics in school health promotion are restricted to school grounds. Health-affecting context factors, such as fast-food chains and supermarkets promoting ‘unhealthy choices for their own commercial ends’ (Quigley, 2013, p. 612), beyond the school gate are out of sight to nudgers. Nonetheless, the phenomenon of ‘food deserts’ (Shaw, 2014), adjacent to schools, may have a much bigger impact on students’ health than school meals. To put it bluntly: Smart lunchrooms remain relatively ineffectual if students are inclined to impulsively buy and consume unhealthy snacks on their way to school or back home. Contrary to nudge, the settings approach seeks to find solutions across social environments through deliberation and collective decision-making by, for example, negotiating with local groceries and takeaways about their food offers or mapping out health promotion strategies for schools and local neighbourhoods.

This leads to the second limitation of nudge in (school) health promotion: its degree of inclusiveness. Rather than being a feature of overall school development, designing health nudges in school contexts is an exclusive and elitist task carried out by health experts and policymakers. In this respect, Thaler and Sunstein’s (2008, p. 2) imagined criteria how to organize the selection of meals in school cafeterias are unmasking. One of the most obvious options, i.e. asking students what they prefer to eat and enable them to participate in the organization of the cafeteria and/or the provision of meals, is not even mentioned by the authors of Nudge. Students are neither perceived as owners of their cafeteria nor are they empowered as autonomous learners. Thus, the crucial question ‘who the [choice] architect is and to what ends they are trying to exert influence’ (Quigley, 2013, p. 605) has already been decided from the outset. This determinism is hard to accept because what is promoting health and what is not, especially in such sensitive settings like schools, is far from self-evident. Without seeking to downplay the challenges of current lifestyle diseases to school health, it is open for debate what is more worrying: The social implications of infantilized and gently patronized youngsters used to being nudged towards healthy decisions or self-responsible and engaged students who might in some cases be too heavy and slightly plodding. Finally, good health, understood as being in tune with oneself and the environment or as a ‘sense of coherence’ as Antonovsky (1987) puts it, does not require nudges but beliefs that life is comprehensive, manageable and meaningful. Where else should be the right place to develop such a healthy attitude if not school?

Note

  1. 1

    The movement is driven by the Cornell Center for Behavioural Economics in Child Nutrition Programs and funded by the Economic Research Service of the US Department of Agriculture.