title: Understanding the interplay of lifestyle and deprivation to support policy and intervention development: a mixed methods study
Creators: name: Foster, Hamish Michael Elliot
Publisher: name: University of Glasgow
Year: 2024

description: Introduction

Unhealthy lifestyle factors (e.g., smoking, high alcohol intake, poor diet) are among the leading risk factors for adverse health outcomes (e.g., mortality). Socioeconomic deprivation is also a risk factor for the same adverse health outcomes. Unhealthy lifestyle factors tend to cluster within individuals and more deprived populations tend to have higher prevalence of multiple unhealthy lifestyle factors.

Much prior research on lifestyle and deprivation has focussed on explaining health inequalities via the prevalence and severity of a few unhealthy lifestyle factors finding that lifestyle can explain a moderate or large amount of inequity, but not all. There has been far less research into whether there is an interaction in the association between combinations of unhealthy lifestyle factors and deprivation. For example, deprivation might influence the association so that deprived populations experience disproportionate rates of adverse health outcomes from combinations of unhealthy lifestyle factors. Further, no prior studies have examined the influence of deprivation on lifestyle associations with adverse health while measuring lifestyle using a wide combination of unhealthy lifestyle factors that includes a measure of social connection (e.g., infrequent social contacts), an example of a ‘new’ or ‘emerging’ lifestyle factor, alongside more traditional factors.

Examining how deprivation influences the association between wide combinations of lifestyle factors (including ‘newer’ lifestyle factors) and adverse health outcomes could reveal higher risk groups that could guide policy and interventions.

Aims:

1) To improve understanding of the association between combinations of unhealthy lifestyle factors, socioeconomic deprivation, and adverse health outcomes.

2) To explore which measures of social connection could be included in a broad measurement of lifestyle i.e., a lifestyle score.

3) To develop a lifestyle score that encapsulates the risks associated with a wide combination of lifestyle factors (including measures of social connection) and socioeconomic deprivation.

4) To understand how combinations of unhealthy lifestyle factors are perceived in the context of socioeconomic deprivation.

Methods

This was a mixed methods study harnessing quantitative and qualitative methodology. There were three main parts or work packages (WP) for this thesis:

WP1 - a systematic review of prospective cohort studies that report on the effect of socioeconomic status (SES) on the association between a combination of lifestyle factors and adverse health outcomes.

WP2 - statistical analyses of UK Biobank, a large prospective cohort of around half a million adults, to a) estimate the associations between measures of social connection and all-cause and cardiovascular (CVD) mortality and b) create a weighted lifestyle score and examine the effects of deprivation, sex, and ethnicity on the association between the lifestyle score and adverse health outcomes.

WP3 - qualitative analysis of key stakeholder perspectives from four focus groups with 25 members of the public and 18 interviews with community, health, and policy professionals.

Results

Systematic review

Six prospective studies were identified that examine the interaction between a combination of lifestyle factors and deprivation for adverse health outcomes. The studies were widely heterogenous in their definitions of unhealthy lifestyle factors, their markers of socioeconomic position, their methodology to assess interactions, and their results. However, there remained a clear suggestion that mortality risks associated with a combination of unhealthy lifestyle factors are seen in more deprived groups, which suggests lifestyle support and policy interventions targeting these populations might usefully be evaluated.

Social connection

Structural (objective) components of social connection, such as the frequency of friends and family visits or living alone had stronger associations with all-cause and CVD mortality than functional (subjective) components, such as feelings of loneliness. However, combinations of both functional and structural components of social connection had the strongest associations highlighting potential benefits that could follow from measuring and supporting both types of social connection. For example, compared with participants with higher levels of both components of social connection (e.g., not living alone and not often lonely) those with lower levels of both components had higher CVD mortality hazard ratios (HRs [95% CI] 1.63 [1.51, 1.76]) than each component alone (functional isolation - 1.17 [1.06, 1.29], structural isolation - 1.27 [1.18, 1.36]).

Weighted lifestyle score and socioeconomic effects

A weighted lifestyle score comprising 11 lifestyle factors (including frequency of friends and family visits and weekly group activity as a measure of social participation) was created using the relative all-cause mortality effects sizes for each individual factor. Smoking had the highest score weighting while social participation contributed a similar weighting to that of more traditional lifestyle factors such as low physical activity and low intake of fruit and vegetables. The association between the weighted lifestyle score and all-cause and CVD mortality was stronger both among more deprived groups and among men. For example, within each quartile of deprivation and compared with those with the healthiest scores, all-cause mortality HRs (95% CI) for those with the unhealthiest scores were 2.55 (2.35, 2.77), 2.92 (2.70, 3.16), 3.27 (3.02, 3.54), and 3.54 (3.27, 3.82) in the least to most deprived quartiles, respectively.

Stakeholder perspectives

There was wide and detailed appreciation of the socioeconomic barriers to healthy living and perceptions captured here de-emphasised the importance of individual-level responsibility for healthy choices. However, it was felt there was always some level of individual agency or choice and, among professionals, there was a perceived duty to support and encourage healthy change in even the most arduous of socioeconomic circumstances. This appeared to create a tension between perceptions of agency and structure whereby clinical and public health practitioners felt, on one side, a duty to support agency of those with unhealthy lifestyle factors and, on the other side, a deep understanding of the structural forces of the social determinants of health behaviours. Innovative policy and legislation are needed to tackle upstream determinants of numerous unhealthy lifestyle factors simultaneously and across populations.

Conclusion

Deprived populations may experience disproportionate adverse health outcomes from a wide combination of lifestyle factors, including emerging factors such as social participation. Tackling the disproportionate harm associated with combinations of unhealthy lifestyle factors in deprived populations will require numerous levels of innovative intervention and policy. Alongside wider structural and policy change that make healthy lifestyle choices more equitable, lifestyle interventions that incorporate our understanding of the social determinants of lifestyle and that tackle numerous lifestyle factors simultaneously could support individuals and communities affected by deprivation to avoid multiple unhealthy lifestyle factors.