Why do health policies designed to reduce inequalities increase them instead?

A new article, Lifestyle drift and the phenomenon of ‘citizen shift’ in contemporary UK health policy, published in the Sociology of Health and Illness sheds light on why health policies designed to reduce health inequalities rarely achieve this goal, and often end up increasing them instead.

It starts by retelling the ‘public health parable’, comparing doctors and hospital workers to a person who has to save people from drowning in a river. Again and again they jump into the water to drag people out and bring them back to life. Eventually the rescuer shouts in frustration: “I’m so busy saving these people from drowning that I don’t have time to go upstream to stop them falling in!”

The river metaphor is often used when we talk about public health. ‘Downstream’ interventions focus on things like individual behaviour change and treatments for illness. ‘Upstream’ interventions focus on the social factors that contribute to health and prevent illness such as housing, employment, education.

Upstream intervention is like building a bridge to healthier lives, whereas downstream intervention is throwing a life ring to someone who is already drowning. Upstream intervention addresses social inequalities because factors like unemployment, low-income, poor housing, low education attainment, all have detrimental impacts on health. These factors also make it harder for people to change their lifestyles because they restrict the ‘choices’ people have available to them and their capacity to change the patterns of their lives.

One reason health policies designed to reduce health inequalities fail to do so is because of ‘lifestyle drift’. Lifestyle drift describes a common trend: policies start with a commitment to upstream intervention but, over time, drift downstream to focus on lifestyle modification. Lifestyle interventions tend to deepen health inequalities because richer people take advantage of them while poorer people are less able to.

In this article, Oli Williams and Simone Fullagar present findings from a study in one of the most deprived neighbourhoods in England to demonstrate how lifestyle drift happens. They show how limited funding leads to ‘precarious partnerships’ between health providers. These partnerships can initially help to tackle the social causes of ill-health but as funding runs out the partners stop working together and in some cases even start competing against each other to get funding. This sees them drift away from the previous priority of reducing health inequalities.

The authors also show how lifestyle drift can progress into what they term ‘citizen shift’. This describes when lifestyle interventions initially help people overcome social factors that inhibit behaviour change, but over time provide less and less support.

As support is taken away the responsibility for lifestyle modification – and overcoming the barriers to behaviour change created by social inequalities – is shifted to individuals. For instance, a weight-loss group in a deprived area may initially let local people attend for free. Then after a while local people are expected to pay although their social situation hasn’t changed. The authors explain this as shifting responsibility away from governments, who design health policies, to some of the most vulnerable people in society.

The paper concludes that downstream lifestyle interventions are inappropriate and ineffective in reducing health inequalities. However, if lifestyle interventions are included in a programme of upstream intervention designed to reduce social inequality, then they have potential to support a narrowing of the health gap between richer and poorer people.

Open access link to the pre-print version of the paper

Oli Williams held the NIHR CLAHRC West Dan Hill Fellowship in Health Equity while he wrote this paper.