Choice Architecture in Public Health: A Social Ecological Perspective

Public health research and practice today often focus on “choice architecture” to influence individual health-related behavior, particularly in the areas of health promotion and risks related to life-style choices. There are two insights underlying this approach. One is that human decisionmaking is not always reflective; it is also reflexive or automatic. That is why setting choice defaults is so powerful in producing patterns of behavior. The second insight is that decisions, both reflective and reflexive ones, are influenced by the natural or social environment within which they take place. Choices are designed, either explicitly or implicitly, virtually all the time, by material options or by cultural meanings and social institutions, norms, and sanctions. The question is not whether to engage in choice architecture, but how and to what ends.

The program of choice architecture shows contextual or ecological recognition, but when focused on individual behavior and choice, it is not sufficient to guide the policy and practice of an ecological public health. This paper argues that what is needed is a health architecture for whole communities, and it explores the normative dimensions of this notion. When seen from the perspective of social ecology, health architecture will not focus solely on designing arrangements that nudge reflexive behaviors that are beneficial; it also designs social and institutional arrangements that empower reflective actions that are normatively structured by values of equal dignity and solidarity. This is civic ecology for public health and a health architecture that is effective, equitable, and sustainable.