Theresa Marteau and colleagues argue that behavioural and social causes of poor health must be tackled in parallel in order to reduce inequalities
CREDIT: This is an edited version of an article that originally appeared on The BMJ
Life expectancy in England is stalling, while at the same time health inequalities are widening. The 2020 Marmot Review of health inequalities in England showed that, between 2010 and 2018, the gap in life expectancy at birth between those living in the least and most deprived areas increased; for men, the gap increased from 9.1 to 9.5 years and, for women, from 6.8 to 7.7 years.
The COVID-19 pandemic is set to widen these inequalities yet further. For example, the age-standardised mortality rate associated with COVID-19 in the most deprived areas in July 2020 was 3.1 deaths/100 000 population – more than double the rate in the least deprived areas (1.4 deaths/100 000 population).
Both the 2010 and 2020 Marmot Reviews outline actions in five priority areas for health equity; giving every child the best start in life, good education and lifelong learning to maximise capabilities, fair employment and good working conditions, healthy standard of living for all and healthy and sustainable places and environments in which to live. Preventing ill health requires a focus on the behaviours that follow the social gradient and contribute most to chronic disease, including smoking and unhealthy diets.
Policies focusing on behavioural causes
In England the four leading behavioural causes of years of life lost are tobacco use, unhealthy diet, alcohol consumption and physical inactivity. Importantly, all of these behaviours are socioeconomically patterned; changing them, therefore, has the potential to increase not only life expectancy, but also healthy life expectancy, which has a 19-year gap between rich and poor – yet, despite England announcing some policies on these behaviours in England over the past decade, there has been little effective action.
Most of the relevant policies have centred on childhood obesity. At national level this includes the publication of the childhood obesity plan in 2016, which was followed by two further chapters in 2018 and 2019. These documents proposed important population level measures, including several that target commercial determinants of health such as advertising and marketing. A soft drinks industry levy was introduced in 2018, and is showing promising effects in both driving reformulation and reducing sales of sugary drinks. But the other major measures proposed have yet to move beyond the consultation stage. The outgoing chief medical officer for England stated, in 2019, that we are “nowhere near achieving” the government ambition to halve childhood obesity by 2030.”
What would effective policy comprise?
Two complementary types of interventions can change behaviour; those that target conscious processes and those that target non-conscious processes. Providing personalised risk profiles, for example, requires conscious effort to influence smoking and eating behaviours. By contrast, changing the context or choice architecture within which a behaviour occurs—for example, by increasing the proportion of healthier foods offered – requires less conscious effort by an individual to make healthier decisions.
Conscious processes generally make higher demands on people’s cognitive, social and material resources. These resources are not evenly distributed across society, so interventions which rely on them can widen health inequalities; such effects are known as ‘intervention-generated inequalities’. Unfortunately, interventions which rely on conscious processes have dominated policy responses to health inequalities in England since the 1970s.
Interventions with most promise for both improving population health and reducing the gap between the poorest and the richest are those aimed at whole populations using interventions that largely target non-conscious processes. These include fiscal and economic interventions, marketing approaches, and interventions which alter the availability of products that harm health.
Tackling behavioural and social causes in parallel
The behavioural causes of health inequalities—tobacco use, unhealthy diet, alcohol consumption and physical inactivity —share several drivers with the social causes. These include factors such as unequal distribution of income, goods and services, education, employment, power and, importantly, poverty – with its attentional, emotional and material consequences.
Intervening on the social determinants can, therefore, also have a positive effect on the behavioural determinants. For example, increasing household incomes in the poorest households can increase spending on fruit and vegetables and reduce spending on tobacco and alcohol – perhaps by reducing stress in these households.
One set of drivers that shapes much of the routine, habitual and impulsive behaviour contributing to health inequalities is the stimuli, or cues, that surround us in physical, economic, digital, social and commercial environments. Cues that encourage unhealthy behaviours – such as the presence of tobacco, alcohol and fast food outlets – are, generally, much more prevalent in areas of high deprivation.
The large and growing health inequalities in England described in the Marmot 2020 Review can be both stalled and reversed. Although greater policy focus has been given to behavioural causes than social causes of inequalities over the past decade, this focus has not been matched by effective action at the scale needed. Given that behavioural and social causes share some, but not all drivers, effectively tackling health inequalities requires that we address both behavioural and social causes, in parallel, and at a scale commensurate with this huge and growing problem.
Tackling health inequalities should now form the core of all policies to build resilient societies post COVID-19.
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