Socioeconomic inequalities and “bad behaviours” – Kylie Ball

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

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.
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)

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
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.
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.