Integrating structural drivers of health inequalities into the prevention of non-communicable diseases

O’Donnell C, Hanlon P, Blane D, Macdonald S, Williamson A, Mair F. We should consider prevention burden in our approach to tackling NCDs. BMJ Opinion, Sep 20, 2020. (accessed Oct 28, 2021)

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This case study is an opinion piece rather than a report of original research. Although directed at health professional practice, it demonstrates the value of integrating a focus on wider structural determinants in the construction of questions, and the design of research evaluating behavioural or lifestyle public health interventions (in this case to prevent non-communicable diseases). The concept of the prevention burden is a useful way of considering how this could be done.   

The authors argue that public health messages and interventions that focus on health behaviours (e.g. relating to diet, exercise, alcohol and tobacco consumption) assume that these behaviours are the result of individual decisions shaped by a person’s sense of responsibility and their motivation to change risk-related behaviours. Making this assumption can place the influence of social practices, cultural norms, and upstream social determinants of health (such as poverty, discrimination, and stigma) into the background.

The authors propose that the focus of interventions to prevent NCDs should shift away from a concern with individuals changing health-related behaviours to reduce lifestyle-related risk factors. Instead, they authors advocate for an emphasis on assessing, firstly, the scale of the prevention burden placed on individuals by public health messages and interventions, and secondly, the capacity individuals have at their disposal to respond to the demands placed upon them.

The authors define prevention burden as “the workload associated with tackling multiple risk factors in the context of an individual’s capacity to undertake that work”. This capacity, they suggest, is determined by aspects of their immediate context and by intersecting societal and structural factors (e.g. poverty, homelessness, seeking asylum, racism, etc).

The concept of prevention burden, therefore, aims to makes visible and emphasises the unequal capacity of people to address NCD risk factors depending on their position on intersecting axes of disadvantage and inequality. The authors argue that attention to prevention burden has important implications for public health messaging and intervention design, and it could also support the integration of an equity lens in the design of evaluations.