Redistributing power, not nudging behaviour, is the way to improve health

Focusing on individual behaviour can make health inequalities worse

A series of seismic political shocks has started to wake up many in positions of power to the detrimental impacts of inequalities that have accrued over the past few decades. Nowhere are these inequalities more apparent than in the nation’s health.

Both the length of your life, and the amount of time you can expect to live in good health, depend on where you live. Men in Blackpool, the most deprived local authority in England, die 7.4 years earlier than men in Wokingham – the least deprived – and will have 16.5 years less of healthy life.

Even starker are health inequalities within an area. Stockton-on-Tees has the widest health gap in England with a male life expectancy gap of 17.3 years between its least and most deprived wards. This is about the same as the average life expectancy gap between the UK and Senegal.

And it’s getting worse. Health inequalities have been rising since 2012 and average life expectancy has stalled. There are also worrying statistics surfacing about growing levels of mortality amongst poorer infants.

Something needs to be done.

The state of the health debate

Health is a prominent feature of political debate in the UK. A key battleground during the 2017 general election was funding for the health system. This debate, however, is far too narrow in scope.

Our free at the point of use health service is the foundation of our welfare state, and is rated higher than any other comparable healthcare system in the world. Clearly, ensuring that the NHS is properly funded is of vital importance.

Yet only around 10% of the differences in health outcomes are due to access to health and social care services. If we are to tackle the UK’s unacceptable level of health inequalities, we need to widen the debate beyond healthcare to include the reasons why people become ill or stay well. We need to think about tackling the causes of inequalities in health outcomes, not just the symptoms.

Individual behaviour change

One common approach to thinking about why people become ill is to focus on behaviour. Health inequalities, according to the behavioural perspective, are the result of individual choices. The argument goes that poorer people tend to have more unhealthy behaviours, so we need to change the behaviour of poor individuals to encourage better lifestyles.

This argument has traditionally focused on providing information about the health impacts of smoking, drinking too much alcohol, eating too much fast food and not doing enough exercise. Increasingly, some are also adopting lessons from the behavioural sciences and attempting to nudge’ individuals into healthier lifestyle choices by appealing to our unconscious behavioural cues.

However, behavioural approaches have a number of pitfalls when it comes to tackling health inequalities. First, they fail to explain why poorer people tend to adopt more unhealthy behaviours in the first place; and second, they fail to explain why poor people with healthy lifestyles still tend to have worse health outcomes.

Evidence has even shown that these approaches may make inequalities worse, since those who take up behavioural changes are those most able to – those higher up the socio-economic ladder who already have better health.

Redistributing power and the conditions that create health

There has been decades of research demonstrating that health is not an individual matter determined by personal choices, but is rather the result of wider inequalities in society and your position within it.

The poorer you are, and the poorer the area in which you live, the less likely you are to have a stable job and control at work, a decent home, or an income to afford a healthy diet. All of these are evidenced to affect your health, either by restricting the healthy choices available to you, by leaving you in poor material circumstances (damp or cold housing affecting your respiratory health, for instance) or by affecting your psychosocial state (such as insecurity in work or a low position in the social hierarchy affecting your mental health).

The powerlessness experienced by many disadvantaged groups can led to greater exposure to health-damaging living environments, since those without power are less able to change the situation in which they find themselves. Moreover, a sense of powerlessness can lead to high levels of stress, causing mental health problems amongst disadvantaged groups.

Social inequalities, driven by the distribution of power, income and wealth, shape the health gap in our society. If we are to tackle the injustice of inequalities in health, then we need to take action on these wider societal inequalities.

Such action will be wide ranging. Michael Marmot, in his independent review into strategies for reducing health inequalities in England, makes a range of policy recommendations from the provision of high-quality childcare to measures to improve the quality of jobs. This will require action beyond the remit of healthcare and health departments in isolation, from across government and beyond.

Attempts to tackle inequalities must be done in collaboration and equal partnership with those affected. When action is taken with those affected – rather than done to them as with behaviour change – it is more likely to be effective. Those on the receiving end are best placed to say what is affecting their health and what will improve it. Moreover, by working with those affected, disadvantaged communities can build their power to make and influence the change that they want to see in their lives and neighbourhoods, and tackle a health-damaging sense of powerlessness.

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