How to explain why fixing health goes beyond the health service
Poverty kills. If we want a health society we need the right building blocks in place, including good quality jobs, housing and education.
Without these, our lives will be shorter and we’ll spend longer in poorer health. This has a big economic impact, as workers are forced to leave the labour market due to ill-health.
This is all well-established and the evidence for it is overwhelming. The very latest study from the Health Foundation shows that a 60-year-old woman in the poorest areas of England has a level of ‘diagnosed illness’ equivalent to that of a 76-year-old woman in the wealthiest areas.
This study is confined to England, but is especially important because of how it has been put together. Whilst previous studies into the extent of health inequalities have largely relied on people’s self-reported health, it linked hospital and primary care data to examine socioeconomic, regional and ethnic variations in the prevalence of long-term illnesses. These include mental health conditions as well as physical ailments.
As the cost of living crisis starts to squeeze family budgets, it will become harder and harder for households to afford the building blocks for good health – keeping warm, keeping up rent or mortgage payments and keeping nutritious food on the table.
That’s just one of the reasons why it is vital that both politician, their policy-makers and the general public all understand the link between poverty and ill-health.
At the moment there is no such understanding and the mismatch between public perceptions and the evidence has consequences because public opinion shapes political decision making.
If we want people to live longer and in better health we will need buy-in for policies that go well beyond the NHS. That is not going to happen until we learn how to communicate more effectively with the public.
This is of supreme importance at a time when life expectancy is stalling and faltering as poverty bites.
Several think tanks on health have been worried about this issue for some time and trying to understand what the public thinks, why, and what the barriers are to getting the message across.
Now the Health Foundation has published How to talk about the building blocks of health , a brilliant guide as to how to communicate about health inequalities, prepared by Frameworks. It should be essential reading for the Department of Health, all health professionals and politicians.
It builds from research which was carried out during the pandemic.
Researchers had brought together a cross-section of the public from across the four UK countries to take part in virtual workshops in early 2021.
Most were unaware of the extent of inequality in health outcomes, particularly the unequal COVID-19 mortality among different groups.
Some accepted the information but went on to explain it through their own confirmation biases.
For example some explained the differences in mortality rates between men and women by saying men visited the doctor less, were less hygiene conscious and less compliant with the rules.
Time and again participants stressed the importance individual behaviour in COVID-19 outcomes for example the measures people took to control exposure to the virus, such as hand washing, or in emphasising existing behaviours, such as people who took more exercise being fitter and less likely to have a worse outcome from the virus.
And whilst those people who were socioeconomically disadvantaged showed a good understanding of the links between hardship and ill health, they were reluctant to acknowledge these inequalities in health outcomes. The researchers suggested this could be understood “as an attempt to resist the stigma and shame of poverty and poor health and to assert (or reassert) individual agency and control.”
This has been a consistent theme since this kind of research was first carried out in 2018. Up to 97% believe that either a great deal or fair amount of responsibility for staying healthy lies with the individual.
During the pandemic in 2020, there was a substantially higher emphasis on the role that the NHS, local authorities and the government had to play. This has declined but the public’s perception of the role of national and local government in maintaining health remains higher than before the pandemic.
This may well mean we are entering a period where people are more receptive to wider government action on health beyond the NHS.
At the same time there has been not only a concern about health inequalities but an appetite to address them. A February 2021, a survey found that 81% of people said it would be a very big or fairly big problem if inequalities in life expectancy worsened between more and less deprived areas of the country.
And two-thirds of the public (69%) want government to reduce inequalities between different groups.
But when the connection between health and broader inequalities is not made explicit support for action diminishes so when asked to choose three or four areas of inequality considered to be most serious from a list, only 28% of the public cited ‘health inequalities and life expectancy’ as one of the most serious challenges to Britain. Other types of inequalities generated much more concern, with inequalities between ‘deprived and well-off areas’ (61%), and ‘income and wealth’ (60%) being considered the most serious.
Furthermore even when people do understand the connections the problems whether they be of class or race or where people live can seem impossible to solve. People can feel powerless. The key to this is to provide simple, single factor answers to break problems down. For example one explanation for differences in levels of Covid deaths between different ethnic groups was information on hygiene and mask wearing not being communicated in someone’s first language. The easy, actionable answer is to translate leaflets. By turning to easy actionable answers, where that is possible, that sense of powerlessness can be avoided.
The climate crisis offers useful lessons in shifting the public towards evidence-based understanding while not overwhelming them. Initially many people felt the climate agenda was intractable, created by systems and processes that are bigger than them as individuals. Through repeated, public explanation of the overall consequences of climate change, with actions that individuals can take alongside what the state needs to do, it is possible for individuals to feel they have a level of personal control, while gaining interest in the wider systemic problem.
The toolkit is free to use and available to all. It is based on four years of research, so it is not a style guide based on personal taste but a clear, evidence-based pathway to getting the message across, something that the health community has failed to achieve to date.
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