Changing Behaviour: An Essential Component of Tackling Health Inequalities
In this analysis, Theresa Marteau and colleagues argue that behavioral and social causes of poor health must be tackled in parallel to reduce inequalities.
The 2020 Marmot review showed that health inequalities in England have widened since 2010. Both the 2010 and 2020 Marmot reviews outline actions in five priority areas for health equity. However, the 2010 Marmot review included a sixth area—strengthening prevention of ill health—that was omitted from the 2020 review on the basis that it had received more policy focus over the past decade than the other areas. This policy focus was, however, unmatched by effective action.
Policies focusing on behavioral causes
In England, the four leading behavioral causes of years of life lost are tobacco use, unhealthy diet, alcohol consumption, and physical inactivity. Most of the relevant policies have centred on childhood obesity. At national level this includes the publication of the childhood obesity plan in 2016 followed by two further chapters in 2018 and 2019. Major measures proposed have yet to move beyond the consultation stage.
Policy activity across the three other behavioral causes has been uneven, with some strong action on tobacco control but little on alcohol and physical activity.
English governments have introduced no new policies in the past decade on alcohol control. Minimum unit price, which early findings in Scotland suggest has potential to reduce the social gradient in alcohol harm, was eschewed in England in 2013. Since then government policies have served to increase rather than decrease the affordability of alcohol, with no notable cuts or freezes in alcohol duty, including in the most recent budget.
The four UK chief medical officers published an update in 2019 of their 2011 guidelines for physical activity, but no formal policies have been introduced at national level.
What would effective policy comprise?
Changing behaviours equitably requires multiple interventions in multiple systems. Policy makers need to work at local, national, and international levels, engaging with the communities they serve. Interventions should include approaches that target high risk individuals as well as those aimed at whole populations.
Two complementary types of interventions can change behaviour: those that target conscious processes and those that target non-conscious processes. 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. They include fiscal and economic interventions, marketing approaches, and interventions altering the availability of products that harm health.
Tackling behavioural and social causes in parallel
Behavioral causes of ill health and inequality—tobacco use, unhealthy diet, alcohol consumption, and physical inactivity—share only some drivers with the social causes. Intervening on the social determinants can therefore also have a positive effect on the behavioral determinants. But such effects, while welcome, are insufficient on their own to change behaviors at the scale needed to reduce the health inequalities. It is also necessary to tackle the drivers of the behavioral causes that are not shared with the social causes.
One set of drivers that shapes much of the routine, habitual, and impulsive behavior contributing to health inequalities is the stimuli or cues that surround us in physical, economic, digital, social, and commercial environments. Cues that encourage unhealthy behaviors such as the presence of tobacco, alcohol, and fast food outlets are generally much more prevalent in areas of high deprivation. Removing or reducing the environmental drivers of unhealthy behaviors and replacing them with drivers for healthier behaviors would have beneficial effects across populations, with the largest effects in the areas of highest deprivation.
Achieving effective policy action requires strong political and public support to overcome powerful lobbying from commercial organisations that profit at the expense of population health.
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 behavioral causes than social causes of inequalities over the past decade, this focus has not been matched by effective action at the scale needed. Given behavioral and social causes share some but not all drivers, effectively tackling health inequalities requires addressing both behavioral 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.