In a study published today in the Journal of Public Health, researchers from the University of Cambridge and RAND Europe find that theory and evidence on health inequalities drawn from history, sociology, philosophy, psychology, biology and neuroscience have been largely ignored in a series of government efforts to limit health inequalities and reduce non-communicable diseases over the last 45 years.
Since the mid-1970s, UK government attempts to reduce health inequalities by preventing non-communicable diseases have focused on changing individual behaviour. Successive public health programmes – which have had very limited success – have been based on the assumption that individual choices largely guide our behaviour, and that our behaviour, in turn, is a key determinant of our health. But rates of diseases related to over eating, consuming too much alcohol and lack of physical activity continue to rise, as do the associated problems of health inequalities.
The authors, Natasha Kriznik with Ann Louise Kinmonth and Mike Kelly from the Primary Care Unit at the University of Cambridge and Tom Ling at RAND Europe, show in this study that individual choice alone cannot explain the patterns of unhealthy behaviours that cause diseases and associated health inequalities. Changes over time – historical developments – and relationships in society beyond the individual are a critical part of the picture to be taken into account in actions to tackle health inequalities.
An historical understanding of the development of sickness and death over generations, of the relationship between biological and social factors and of the power relationships between governments, institutions, industries and civil society are necessary to understand the causes of non-communicable diseases and how to address them.”
– Professor Mike Kelly, Senior Visiting Fellow, Primary Care Unit
The success of tobacco control in the UK, for example, relied not only on long term action to influence individual choice but also on tactics to address the role of the markets and advertising as well as explicit steps to counteract the ‘dirty tricks’ of the tobacco industry.
Six important policy documents published by UK governments between 1976 and 2010 were analysed for this study to see how far evidence on interconnecting factors – beyond the individual – has informed public health policy. The results show that, even where existing public health strategies have failed, the wider evidence base did not influence actions taken. The researchers argue that the dominant focus on individual choice and responsibility is one reason for the lack of success of public health measures since the mid-1970s.
To help policymakers to address health inequalities and get off the hook of previously failed policy initiatives, the authors propose a checklist of questions.
Ten questions to consider when developing policy recommendations to address health inequality
Q1. Are proximal risk factors used as the primary justification for solutions to address health inequalities?
Q2. Is evidence included relating to the influence of the wider determinants of health?
Q3. Have the recommended approaches to addressing health inequalities appeared in policy documents in the last2, 5, 10 and 15 years?
Q4. Have these approaches shown cost-effectiveness in formal studies over sufficient time intervals?
Q5. Are there clear steps from identification of a cause of the problem to actionable interventions?
Q6. Are the mechanisms of action of the recommended intervention described?
Q7. Are the recommendations grounded in the social and economic contexts of everyday life?
Q8. How are the relationships between the state, industry, civil society and individuals taken account of in explanations for health inequality and proposals for action?
Q9. What evidence of historical social conditions have been used in the analysis?
Q10. Are there any considerations of the relationships between social and biological processes?
Further guidance and context is provided by the authors in the published paper.
“Moving beyond individual choice in policies to reduce health inequalities: the integration of dynamic with individual explanations.” Journal of Public Health, 13 March 2018
About the St John’s College Reading Group on Health Inequalities and forthcoming conference on 1 June 2018: “Comparative perspectives on social inequalities in life and death: An interdisciplinary conference”
Media: Lucy Lloyd
Image: Dr Jon Ferdinand for the Primary Care Unit