Originally posted 11/10/2010
The answer is yes…and well, not really. This answer is often framed yes or no: either we have free-will, “just say no” responsibility for our behaviors, or we have no responsibility because of the life situations we find ourselves in. Of course the truth is somewhere in between – but what is the balance between them? The answer has important policy implications, particularly with regard to informing investment priorities.
I’ve often noted (as in last week’s Child Health post) that currently available evidence is insufficient to effectively guide public and private policy makers’ investment decisions with regard to population health improvement. That said, we must recognize the cutting edge research being done in this area. For several decades, Paula Lantz and Jim House and colleagues at the University of Michigan have used a longitudinal database called the Americans’ Changing Lives Survey (ACLS) to explore answers to important questions using the most sophisticated social science methods available. The ACLS has tracked 3600 adults from 1986 to 2005, querying them 4 times over that period.
In their most recent paper (published in the May 2010 issue of Social Science and Medicine) they developed models to explore relationships among various factors (such as age, gender, ethnicity, education, income, smoking status, physical activity level, and many others) and risk of death. They were particularly interested in connections between income and behavior and wanted to determine if poor people have worse health because they have poor health behaviors – or if something else is going on.
Not surprisingly, the findings showed that people with lower incomes tended to have more unhealthy behaviors and people with higher incomes tended to have healthier behaviors. Regardless of income, smoking and low levels of physical activity were both associated with an increased risk of death. But more importantly for this blog, the findings revealed that unhealthy behaviors are far from the only reason low income populations are at increased risk of death. Independent of health-related behaviors and other control factors, the risk of death among those in the lowest income category was 76% greater than those in the highest income category (which was similar to the risk differential between smokers and nonsmokers). In addition, the independent effect of the lowest level of physical activity was nearly triple that of income and smoking.
The authors conclude with a call for health policy and clinical incentives to enhance income security, promote smoking cessation/prevention, and support physical activity. While these results do not tell us exactly what our population health investment strategy should be across behavioral and non-behavioral factors, they make clear that a balance is required. To improve population health, policy and programmatic resources are needed to help make the healthy choice the easy choice – not only with respect to health behaviors but for healthcare, employment, and education as well.
The concept of behavioral “choice” is often interpreted to mean individual choices independent of external (and often constraining) factors. Careful studies like this one provide evidence that keeps us from operating from such a simplistic perspective. To improve population health, we all need to make better health choices – but we also need to understand and remedy the economic and educational upstream factors which determine the extent to which this is possible.