The examples above show systematic differences across various measures of health for different population groups in England. This section explores differences in the likelihood of engaging in healthy or unhealthy behaviours and differences in the wider determinants of health, which are important causes of health inequalities arising and persisting over time. Both involve differences in the health risks that people are exposed to and in the opportunities that they have to lead healthy lives.
Inequalities in behavioural risk factors
People’s behaviour is a major determinant of how healthy they are. Public Health England’s 2020–25 strategy identifies smoking, poor diet, physical inactivity and high alcohol consumption as the four principal behavioural risks to people’s health in England today. Behavioural risks to health are more common in some parts of the population than in others. The distribution is patterned by measures of deprivation, income, gender and ethnicity, and risks are concentrated in the most disadvantaged groups. For example, smoking prevalence in the most deprived fifth of the population is 28 per cent, compared to 10 per cent in the least deprived fifth.
Risky health behaviours also tend to cluster together in certain population groups, with individuals in disadvantaged groups more likely to engage in more than one risky behaviour. The prevalence of multiple risky behaviours varies significantly by deprivation. In 2017, the proportion of adults with three or more behavioural risk factors was 27 per cent in the most deprived fifth, compared with 14 per cent in the least deprived fifth.
Health-related behaviours are shaped by cultural, social and material circumstances. For example, recent estimates suggest that households in the bottom fifth of income distribution may need to spend 42 per cent of their income, after housing costs, on food in order to follow Public Health England’s recommended diet.
Furthermore, evidence suggests that some people’s circumstances make it harder for them to move away from unhealthy behaviours, particularly if they are worse off in terms of a range of wider socio-economic factors such as debt, housing or poverty. This is compounded by differences in the environments in which people live, with deprived areas much more likely to have fast food outlets than less deprived areas (Blackpool, for example, has more than five times as many fast food outlets per head than Sevenoaks).
Interventions and services aimed at helping to change behaviours need to be able to adapt to the reality of people’s lives, address the wider circumstances in which behaviours take place, and recognise the difficulty of achieving and maintaining behavioural change under conditions of stress.
The wider determinants of health
- The wider determinants of health are the social, economic and environmental conditions in which people live that have an impact on health. They include income, education, access to green space and healthy food, the work people do and the homes they live in.
It is widely recognised that, taken together, these factors are the principal drivers of how healthy people are, and that inequalities in these factors are a fundamental cause of health inequalities. Addressing these wider socio-economic inequalities is therefore a crucial part of reducing health inequalities.
Table 1 provides some examples of health impacts relating to a range of wider determinants. The examples focus on individual determinants, but these determinants are often experienced together and cumulatively over time. Particular groups can be disadvantaged across a number of factors, and these disadvantages can be mutually reinforcing. Deprived areas have, for example, on average nine times less access to green space, higher concentrations of fast food outlets and more limited availability of affordable healthy food.
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