Socioeconomic inequalities and “bad behaviours” - Kylie Ball

13 May 2014

National Health & Medical Research Council Principal Research Fellow, Centre for Physical Activity, Deakin University, Melbourne, Australia
Convenor, ISBNPA SIG for Socioeconomic inequalities in diet, physical activity and obesity

Health inequalities by socioeconomic position have been documented consistently across populations, socioeconomic indicators, health outcomes and over time. Robust evidence also attests to the existence of widespread socioeconomic inequalities in health behaviours, including eating, physical activity and sedentary behaviours. Given the key role played by these behaviours in protecting or predisposing individuals to chronic disease risk, these behavioural factors likely comprise at least part of the pathway through which socioeconomic position impacts health.
A corollary of this is the notion that efforts to address health inequalities should focus on modifying the key behaviours that might be placing those of low socioeconomic position at increased risk. However, behaviour change approaches for addressing health inequalities have recently been criticised on a number of counts,(1) even being likened to “teaching people to swim to prevent Titanic-like disasters.”(2)
Does this suggest we should give up our efforts as behavioural researchers in attempting to address socioeconomic inequalities in nutrition, physical activity and sedentary behaviours?
I would argue not, but rather, suggest that approaches need to be multifaceted. Upstream and structural change to address the social determinants of health is necessary and critical, and a failure to address unequal distributions of material and social resources in societies will likely lead to a persistence of health inequalities. However, this should not be at the expense of initiatives also aimed at behaviour change. Modifying upstream factors alone will not resolve health inequalities, if individuals do not possess the cognitive and behavioural skills and resources that have been demonstrated countless times to influence participation in these key behaviours. Such upstream structural action is difficult, costly and time- consuming to bring about and is unlikely to occur within the near future given many identified challenges (3). While we can and should continue to advocate for upstream action on inequalities, the widespread nature and long-term persistence of inequalities in health and health-related behaviours requires action on all fronts – structural and behavioural.
Rather than discounting behavioural approaches to improving eating, physical activity and sedentary behaviours we need additional robust evidence on the most successful behaviour change approaches among low socioeconomic groups – evidence which is still sorely lacking. We also require evidence – for example, from creative intervention programs and well- evaluated policy change approaches - on the impact of different approaches on reducing or widening the magnitude of inequalities; and on the effectiveness and cost-effectiveness of promising behavioural approaches in tandem with upstream initiatives.

1. Katikireddi, S.V., Higgins, M., Smith, K.E., Williams, G. Health inequalities: the need to move beyond bad behaviours. J Epidemiol Community Health 2013;67:715-716 
2. Reimers,J, HealthWest Partnership. Further Response from HealthWest Partnership to the Senate Committees on Community Affairs: Australia’s domestic response to the World Health Organization’s Commission on Social Determinants of Health report – Closing the gap within a generation. 2012. 
3. Baum FE, Laris P, Fisher M, Newman L, Macdougall C. "Never mind the logic, give me the numbers": former Australian health ministers' perspectives on the social determinants of health. Soc Sci Med. 2013 Jun;87:138-46.