At last, some media attention for the social determinants of health: but what next?

Yesterday, there was something of a breakthrough when it comes to reporting of health issues. Mark Metherell, who reports on health policy for the Sydney Morning Herald, achieved a prominent page-lead placement for a story about a report on the social determinants of health.

This is so unusual that it’s newsworthy in itself. (This is not a dig at the SMH in particular – the media in general has shown very little interest in the huge body of evidence that’s emerged in recent years about the importance of the social determinants of health, preferring to focus instead on hospitals, waiting lists and emergency departments. So hats off to Metherell).

The report was also covered by the Australian Financial Review, West Australian, The Advertiser, Courier Mail, Canberra Times, The Australian, Radio National breakfast, AM, 2GB and 3AW, and SBS TV news. Croakey and Crikey also gave it a run.

But as public health policy researcher Margo Saunders reminds us, the importance of the social determinants of health is not really news.

We’ve known about this for some time. What would be real news is if we had a breakthrough in understanding how to address them effectively, and how to create a fairer distribution of good health. Maybe we can learn from some current developments overseas in this respect.

Margo Saunders writes:

Findings which reveal the close links between health inequalities and the social determinants of health, such as income, housing status, and education level, will hardly have come as earth-shattering news to public health professionals.

The report, Health Lies in Wealth, produced by the University of Canberra’s National Centre for Social and Economic Modelling for Catholic Health Australia, has shown what many have long maintained: that socioeconomic status is the single biggest indicator of life expectancy and health status.

The findings are also consistent with other research on social determinants and health inequalities, including prominent reports from the UK: the Black Report (1980), the Whitehead Report (1987), the Acheson Report (1998) and the Marmot Review (2010).

As Martin Laverty, Chief Executive of Catholic Health Australia points out, there have also been reports from the USA and WHO. However, merely recognising that these inequalities exist does not tell us what we need to do about actually addressing them. And this is where an interesting discussion is occurring about health and behavioural change, as highlighted by a range of initiatives in Britain, if not Australia.

To coordinate and support social marketing initiatives, Britain established a National Social Marketing Centre (NSMC) in 2006. The NSMC works with organisations across government and non-government sectors on developing ‘behavioural interventions for a social good’. The emphasis is on social marketing for health, and the social determinants of health are among the issues the NSMC has addressed, using a wide range of social marketing techniques.

Even more significant is the recent establishment of a high-level unit (the Behavioural Insight Team) within the British Cabinet Office to focus on ‘how to use behavioural economics and market signals to persuade citizens to behave in a more socially integrated way’. The unit’s initial work is said to focus on public health issues such as obesity and alcohol consumption.  Deputy Prime Minister Nick Clegg has worded the challenge as one of finding ‘ways to encourage people to act in their own and in society’s long-term interest, while respecting individual freedom’.

The British House of Lords Science and Technology Select Committee has announced an inquiry into the use of behavior change interventions to achieve policy goals.  The overall question is similar to that being addressed by the Cabinet Office: how can behaviour change be influenced by different types of policy interventions that rely on measures other than prohibition or the elimination of choice?  The inquiry will focus on two case studies, one of which will be the use of behaviour change policy interventions to tackle obesity.  The deadline for evidence is 8 October 2010.

The Committee’s Call for Evidence, which is structured around sixteen key questions, seeks to build on other work on behaviour change issued by the Cabinet Office and the Government’s Social Research Unit since 2003.  (It is worth noting that a number of UK charities and research institutes, such as The Kings Fund, have been active contributors to research and discussions about public health, the role of government, and behaviour change.)

The Committee’s initiative reflects the attention being given to a reconstituted version of what used to be called ‘social engineering’.

Now called ‘nudge theory’, ‘asymmetric paternalism’ or ‘libertarian paternalism,’ the approach highlights the psychological factors that underpin decision-making and the power of default options – in other words, how the context in which decisions are made, or ‘choice architecture,’ can be used to influence behaviour in ways that will promote health and benefit individuals’ longer-term interests.

While public health advocates have fought a long ideological battle (and, to a large extent, continue to fight it in Australia) to convince politicians and the public that ‘free choice’ is being ‘socially engineered’ in unhealthy ways by commercial influences, it has taken the work of researchers such as Brian Wansink, author of Mindless Eating (2006), to bring to wider attention how human behaviour is subtly manipulated in ways which are contrary to our health and even to our rational preferences.

More attention is finally being given to default options, to the idea that the healthy choices should be the easy choices and to the idea of altering the social environment to encourage certain choices.  As a Caribbean leader noted at a regional health summit in 2007, ‘Individual responsibility, while important, only has full effect where people have equal access to healthy choices,’ and therefore ‘governments had a crucial role to play by altering the social environment to help make the healthy choice the easy choice’.

The concept of ‘nudging’ people into better choices gained prominence following the publication of Thaler and Sunstein’s 2008 book Nudge: Improving Decisions about Health, Wealth and Happiness.  The basic concept was explained, in terms of health issues, in an earlier article in the Journal of the American Medical Association: ‘…the guiding principle…is that institutions and incentives should be structured and aligned in such a way to maximize the likelihood that individuals will engage in behaviors that are beneficial, making those who would otherwise engage in unhealthy behaviors better off without adverse consequences to others’ (Asymmetric Paternalism to Improve Health Behaviors, G Loewenstein; T Brennan; KG Volpp, JAMA. 2007; 298(20):2415-2417 (doi:10.1001/jama.298.20.2415)

Drawing on what has been termed the ‘new’ field of behavioural economics – which is not new at all to the private sector or to commercial marketing – the ‘nudge’ approach acknowledges that a wide range of decision biases contribute to unhealthy behaviors.

Thaler (who is advising the British Cabinet Office) and Sunstein argue strongly for ‘self-conscious efforts, by institutions and the private sector and also by government, to steer people’s choices in directions that will improve their lives.’

Their two specific provisos (designed to head off objections, but the necessity for which some would argue) are that ‘freedom of choice’ must not be restricted, and that choices must be influenced in a way that will make the choosers better off as judged by themselves.  While the first proviso would serve to support the availability of unhealthy choices (how available? how unhealthy?), the second must accept that some individuals would, all things considered, choose to take the risk of a shorter life of immediate gratification, indulgence and consequent ill health over a longer, healthier life with perceived deprivations.

There are complex and intriguing questions about the potentials and the parameters for making it easier for individuals to attain a higher standard of health by ‘nudging’ them towards healthier choices.

The answers — which will cut across the disciplines of health psychology, social psychology, behavioural economics, marketing, neuroscience, sociology and gender studies – are likely to play an important role in meeting the challenges of health inequities and inequalities.”

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Meanwhile, it’s been reported that a majority of the Citizen’s Council of the National Institute for Health and Clinical Excellence in the UK believes that incentive systems could be an effective way of encouraging people to change their unhealthy lifestyles providing that certain conditions are met.  The Council is an advisory group made up of members of the public. The report isn’t yet up on the NICE website, at least not that I could find.

More on this in The Guardian.