Non-communicable diseases (NCDs) and multimorbidity (the presence of two or more chronic conditions) are increasing globally.1 While newer lifestyle-related risk factors are emerging,2 the prevention of major NCDs often focuses on four modifiable risk factors: smoking, obesity, low physical activity and alcohol.3 These cluster within individuals and communities and, like multimorbidity, are concentrated among the most socioeconomically deprived where they exert greater levels of risk.2 Guidelines focus on lifestyle-related risk factor reduction, encouraging healthcare professionals to promote behaviour change.4 We believe this fails to recognise the burden placed on the people asked to make changes, especially those with multiple risk factors and/or multimorbidity, and downplays the influence of wider contextual factors. This has become even more pressing during the covid-19 pandemic, with higher risks associated with socioeconomic deprivation, ethnicity and obesity,5 and attempts to suggest that “healthier lifestyles” may offer some protection against covid-19.
There are two important considerations. Firstly, individualised approaches to behaviour change rarely address the wider social determinants of people’s health such as poverty, unemployment, stigma and discrimination. Secondly, there is an over-simplified distinction between “upstream” social determinants of health and “downstream” individual characteristics and behaviours.6 Upstream social, cultural, environmental and political factors shape the behaviours and practices of individuals, placing individuals and healthcare professionals in positions of tension between upstream contextual and downstream individual pathways to (ill) health.
Acknowledging these tensions, we should consider our approach to tackling risk factors for NCDs. One approach would be to look at prevention burden. Prevention burden stems from an understanding of treatment burden: the workload and demands experienced by patients, families and carers, when managing NCDs and the role that individual capacity plays in tackling these demands.7,8
Public health messages, campaigns and interventions aimed at modifying health-related behaviour to prevent NCDs, impose burdens on individuals, who will vary in their capacity to respond. Health promotion, and associated behaviour change, is often framed as an individual responsibility.9 Where approaches do consider wider upstream determinants, these are often seen as simply limiting or determining behaviour, rather than seeking to understand how an individual’s contextual situation shapes their capacity to address behaviour change.10 The long term burden of sustaining behaviour change in the face of difficult life circumstances is also insufficiently acknowledged.
Addressing prevention burden means acknowledging and dealing with issues at multiple levels.
Firstly, we need to consider individual factors. We suggest that prevention burden arises when there are multiple potential targets for change, for example, reducing alcohol intake alongside increasing physical activity, interacting with an individual’s personal and social circumstances. For those with limited capacity, having multiple health-related targets may be overwhelming and a barrier to addressing any risk factors.
Secondly, we need to consider social practices and cultural norms. Health behaviours are not simply individual decisions, but a complex interplay between individual agency and the context of people’s lives.11,12 Changing behaviour requires changing established practices and habits, often with social and cultural implications. This exerts an additional burden on individuals, which may be overlooked by a more simplistic focus on individual behaviour.
Finally, societal and structural factors have an impact. Clustering of risk factors and multimorbidity in areas of socioeconomic deprivation means people are also more likely to experience financial and practical barriers to addressing health behaviour change.13 This may be most marked for people experiencing multiple disadvantages, for example, homelessness people or asylum seekers.
In response to the challenge of prevention burden, we suggest that healthcare professionals should establish individual priorities with patients. Discussion of behaviour change should incorporate the principles of shared decision-making while understanding patient capacity, with recommendations tailored to an individual’s circumstances and priorities.
We should consider practices rather than individual behaviours. Healthcare professionals and systems should see risk factors as part of complex social practices. Instigating and maintaining change therefore goes beyond personal motivation to encompass social practices and networks.
Socio-cultural factors should be seen as aspects of the wider context in which any intervention takes place. Socioeconomic, cultural, environmental and political factors impact on an individual’s capacity to enact change. Understanding and supporting individual capacity is vital if change is to be sustained.
Finally we need to confront structural barriers. Systems and structures, including fiscal and environmental factors, can act as barriers to effective engagement in preventive strategies and addressing risk factors. Social or cultural groups at the margins of society may be particularly vulnerable to structural barriers, such as policies to reduce benefits provision or access to healthcare. It is incumbent upon all those involved in healthcare to recognise and challenge these barriers.
Healthcare systems and professionals should consider prevention burden if we aim to support behaviour change and address risk factor reduction without further widening inequalities in health. Acknowledging that risk factor reduction must take account of individual capacity and requires tangible work by individuals is the first step. To make a difference it is essential that policies and service provision acknowledge prevention burden, ensure health promotion activities are better tailored to meet the needs of diverse populations and are targeted proportionately at those in areas of greatest need. In this new world, where we learn to live with NCDs, multimorbidity and covid-19, such an approach is needed now more than ever.
Catherine O’Donnell is Professor of Primary Care R&D and a primary care scientist, University of Glasgow, UK. @odo_kate
Peter Hanlon is an MRC Clinical Research Training Fellow and General Practitioner, University of Glasgow, UK. @PHanlon17
David Blane is a Clinical Research Fellow and General Practitioner, University of Glasgow, UK. @dnblane
Sara Macdonald is a Senior Lecturer in Primary Care and a sociologist, University of Glasgow, UK. @SaraMacdonald13
Andrea Williamson is a Senior Clinical University Lecturer, University of Glasgow, UK. @aewilliamsonl
Frances Mair is the Norie Miller Professor of General Practice, University of Glasgow, UK. @FrancesMair
All authors have long-standing interests in the care of patients living in marginalised situations and the impact of social determinants of health on health and wellbeing and the organisation of health care.
- The Academy of Medical Sciences. Multimorbidity: A priority for global health research. London, 2018.
- Foster HME, Celis-Morales CA, Nicholl BI, et al. The effect of socioeconomic deprivation on the association between an extended lifestyle score and health outcomes in the UK Biobank cohort. The Lancet Public Health 2018;3:e756-e85.
- World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. Geneva: WHO, 2013.
- Piepoli MF, Hoes A, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). European Heart Journal 2016;37(29):2315-81. doi: 10.1093/eurheartj/ehw106
- Public Health England. COVID-19: review of disparities in risks and outcomes. London: Public Health England, 2020.
- Rutter H, Bes-Rastrollo M, de Henauw S, et al. Balancing upstream and downstream measures to tackle the obesity epidemic: A position statement from the European Association for the Study of Obesity. Obesity Facts 2017;10(1):61-63. doi: 10.1159/000455960
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- Mair FS, May CR. Thinking about the burden of treatment. BMJ 2014;349:g6680. doi: 10.1136/bmj.g6680
- Kwasnicka D, Dombrowski SU, White M, et al. Theoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories. Health Psychology Review 2016;10(3):277-96. doi: 10.1080/17437199.2016.1151372
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- Blue S, Shove E, Carmona C, et al. Theories of practice and public health: understanding (un)healthy practices. Critical Public Health 2016;26(1):36-50. doi: 10.1080/09581596.2014.980396
- Maller CJ. Understanding health through social practices: performance and materiality in everyday life. Sociology of Health & Illness 2015;37(1):52-66. doi: doi:10.1111/1467-9566.12178
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