British Academy – Written evidence (INQ0024)
The British Academy is pleased to respond to this inquiry. The key points we want to raise are that:
- The biggest barrier to the much needed paradigm shift towards healthy ageing is not scientific or technological but political – policymakers should focus on the lifelong ageing process.
- Upstream behavioural health interventions targeting communities or workplaces are more effective and less likely to exacerbate health inequalities than downstream interventions that target individuals.
- There is a lack of evidence on the long-term impact of behavioural interventions and on the interplay between and optimal combinations of these behavioural factors.
- Technology-based interventions could disproportionally benefit more advantaged areas of the population and so further exacerbate inequalities in healthy ageing.
- The British Academy is the UK’s national academy for the humanities and social sciences. It is an independent fellowship of world-leading scholars and researchers; a funding body for research, nationally and internationally; and a forum for debate and engagement.
- The humanities and social sciences and those who study them enrich and deepen our understanding of the world around us. Since its creation, the British Academy has celebrated these subjects and demonstrated their contribution to the understanding of humanity, economies and societies. We bring both the expertise of our fellowship and insights from these disciplines to bear on public policy issues.
- The humanities and social sciences are inescapable if we are to tackle the complex and interconnected challenges facing societies today. Through the connections between our disciplines and those in science and technology, including the life-sciences, we will be better able to understand and shape the great themes of our age – including the challenges and opportunities presented by demographic and technological change.
- This response represents the views of the British Academy, not one specific individual, however Professor Alan Walker, a Fellow of the British Academy and an expert on Social Policy and Social Gerontology, and Dan Holman, Research Associate, were extensively consulted in drawing together this response.
How firm is the scientific basis for public health advice about healthy lifestyles as a way to increase health span, including physical health and mental health?
- Research evidence is generally conclusive that diet, physical activity, alcohol consumption, smoking, sleep, sedentary behaviour, and social interaction influence physical and mental health. Moreover, evidence shows that multiple healthy behaviours result in the greatest health gains1,2.
- Healthy lifestyles across the life course influence the chances of a healthy life span, from childhood growth and development to maintaining function in older age3. It is never too late to intervene, with recent research showing that increased protein intake and physical activity in those aged 85+ may delay disability4.
- There is evidence that behavioural interventions are effective at increasing physical activity in older adults, at least in the short term5. Despite the majority of older adults being sedentary6, a recent systematic review found no interventions specifically targeting sedentary behaviour itself7. A systematic review of lifestyle interventions for mental health found that evidence is strongest for interventions targeting exercise and diet, especially in combination8.
- There is a distinct lack of evidence on whether the effects of behavioural interventions are sustained over the long-term. There is a risk of a continued waste of resources on downstream behavioural interventions (targeting individuals) which are consistently shown to be less effective and more likely to generate inequalities than upstream interventions9,10 (e.g. targeting whole workplaces, communities, or the whole population).
- What are the practical impediments for this advice being acted on?
A recent systematic review found that:
- ‘Barriers that recur across different health behaviours include lack of time (due to family, household and occupational responsibilities), access issues (to transport, facilities and resources), financial costs, entrenched attitudes and behaviours, restrictions in the physical environment, low socioeconomic status, and lack of knowledge. Facilitators include a focus on enjoyment, health benefits including healthy ageing, social support, clear messages, and integration of behaviours into lifestyle. Specific issues relating to population and culture were identified relating to health inequalities.’11
- To avoid blame and stigmatisation, which decrease the chances that individuals will feel motivated to engage in healthy lifestyles12, it is crucial that health behaviours are not seen as solely individual decisions but as being shaped by cultural and societal factors13. These include availability of and access to nutritious, non-processed food14, good quality jobs and work-life balance to allow for healthy sleep15, diverse and inclusive social networks to facilitate interaction16, green spaces17, and tobacco via taxation and other related discouragement or availability policies18.
- There has been a related shift among public health practitioners and researchers to think of health behaviours instead as ‘health practices’, to acknowledge that behaviours interact with each other (with implications for health outcomes) as part of our everyday lives in the contexts in which we live19. Recent National Institute for Health Research guidance has been drawn up on taking account of context in population health interventions, which should be utilised in considering how public health advice on healthy lifestyles can be acted upon20.
b. Are there examples of good practice in the UK/devolved nations, or elsewhere?
- Smoking and drinking alcohol are widely known among the public to be detrimental to health, yet often this knowledge is not sufficient to stop people engaging in them. With respect to smoking, far more effective in the UK has been a suite of policies including taxation, plain packaging, the public smoking ban, and the emergence of e-cigarettes18. With respect to alcohol, the public health benefits of increased prices are advocated by the World Health Organisation21, and recent modelling suggests minimum unit pricing will reduce harmful drinking the most by those on low incomes22. More recently there has been a surge of interest in taxing other unhealthy products such as high fat or sugary foods, and a recent systematic review found this approach is also effective23.
- These success stories raise the question of whether population-level approaches to discourage harmful behaviours can also be used to encourage healthy ones, for example in relation to physical activity and nutritious foods. Apart from taxation, the evidence suggests other effective approaches are likely to centre on upstream social, economic, cultural and political interventions rather than downstream individualised behaviour change approaches.
- One community-level intervention that was designed with a focus on enjoyment as an incentive was the Scotland-based Football Fans in Training (FFiT)24. This involved training sessions at professional football clubs to tackle male obesity. Outcomes were positive and the intervention was further tested in England and other European countries (EuroFIT) again with generally positive outcomes25. Other local, regional or even national physical activity programmes in the UK could benefit from this focus on enjoyment and social interaction.
How complete is the understanding of behavioural determinants and social determinants of health in old age, and of demographic differences?
- It is well established that the health behaviours noted, continuing into the latest years of life, are important predictors of healthy ageing26–28. Similarly, the social determinants of health framework has identified a comprehensive range of social factors at multiple levels that influence health. What is missing is more understanding of the dynamic interplay between biological, psychological and social factors over the life course29. For example, little is known about optimal combinations of behaviours, how to act on these, and whether to increase healthy or decrease unhealthy behaviours30.
- Gender, ethnicity, socioeconomic and area-related inequalities in healthy ageing are very well-documented, but much less is known about how these demographic factors overlap and interact with each other to drive healthy ageing outcomes, though research on this is underway31.
- Technologies have much to offer older people, including enabling them to live independently for longer, but they do raise issues that go beyond the questions posed by the Committee in its call for evidence. For example, it is possible that technologies which monitor or restrict a person’s freedom of movement would be held to be in breach of article 5 of the European Convention on Human Rights (EHRC) unless combined with the necessary safeguards, such as the Liberty Protection Safeguards introduced by the Mental Capacity (Amendment) Act 2019.
- Further, article 8 protects the right to private and family life and it is possible that monitoring technologies could engage those rights. It is worth noting that article 8 is a qualified right and interference could be justified if, for example, necessary for the protection of health.
- What these examples illustrate is the need for consideration of how technology can be developed and deployed in ways that take account of the human rights of older people. Thinking this through from the earliest stages of development should help to mitigate the risk of potential human rights violations and encourage older people to engage with a wider range of new technologies. It should also provide a greater degree of confidence to private and public sector care providers that they can maximise the use of technology, whilst meeting their obligations under the ECHR.
- Arguably the biggest barrier to the much-needed paradigm shift towards a healthy lifespan is not scientific or technological but political. Even though ageing is labelled as a ‘grand challenge’ it is often old age, rather than the ageing process, that is the focus and concern here is often driven by negative perceptions of increased longevity. Policy makers should foreground the ageing process itself, which is life long38 – ‘active ageing’ is such an approach39. Its focus is the life course and aims to prevent both chronic conditions and their grossly unequal distribution. This requires interventions throughout the life course including to promote knowledge about the ageing process and measures that can be taken to ensure healthy life expectancy, such as introducing young children to the 100 year long life40.
- So long as reducing inequalities is at the heart of any healthy ageing policy and the focus is on the whole life course, the best evidence suggests we could have a society where a greater proportion of people can enjoy disability-free life for longer, which would be of great mutual individual, societal and economic benefit37.
To what extent are inequalities in healthy ageing, as well as differences in acceptance of technologies, a barrier to achieving the aims of the Government’s Ageing Society Grand Challenge?
- To what extent could achieving the Government’s aim of five more years of healthy and independent life exacerbate, or reduce, these inequalities?
- The main ways that inequalities in healthy ageing can be reduced are by redistribution measures, which face complex political factors, or by directly tackling the personal, psychosocial and cultural determinants of health inequalities32. Yet there is a lack of effective interventions for the latter, with a recent overview of 30 systematic reviews finding little evidence on what works to reduce health inequalities, excepting some effective interventions in housing and the work environment33. Yet this elusive goal remains critical because as well as the clear moral case, health inequalities cost the economy around £56-70 million per year34.
- Improving overall population health carries the risk of exacerbating health inequalities35 as many policies and interventions benefit those who are most advantaged, which may be a particular risk for technological interventions36. An overview of systematic reviews suggests this is much more likely with downstream interventions that target individuals than with upstream interventions targeting communities or workplaces10.
18 September 2019
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