Inequalities in health behaviours during the COVID-19 pandemic – a commentary

INTRODUCTION

The COVID-19 pandemic that started in December 2019 in Wuhan province in China and gradually spread caused an estimate of almost 7 million deaths globally [1]. Importantly, inequalities in infection rates, morbidity, severity of infection and mortality from COVID-19 were documented across the globe. Poorer outcomes were found among those living with lower socio-economic status, belonging to ethnic minority groups (which was often associated with limited health care access or engagement, and increased infection exposure) as well as attributed to the syndemic – a magnification of impact of inter-connected health factors – between the COVID-19 infection and the exiting inequalities in chronic health burden [2-4]. Inequalities in COVID-19 health outcomes brought to the forefront the health inequalities that had been present and impacting on health outcomes already pre-pandemic [3]. For example, in the UK, higher COVID-19 mortality rates were found among those living in the most deprived 10% of local areas in England in comparison to those living in the least deprived areas. Pre-pandemic health inequalities in these regions could have contributed to that. Specifically, adults aged 50-69 living in the most deprived areas in England had twice the risk of living with two or more long-term health conditions [5].

HEALTH INEQUALITIES

Health inequalities refer to systematic differences in health outcomes and status between different groups of people, communities or populations and different socially defined categories. Rather than arising from biological or genetic factors, health inequalities arise from disparities in social and structural determinants of health, such as socioeconomic status, education, access to healthcare services, employment opportunities, the built environment, and living conditions. These inequalities arise from the unequitable distribution of resources, power, and opportunities and are therefore avoidable, unjust and unfair [6]. For example, health inequalities exist between different socioeconomic groups (e.g. prevalence of depression [7]), racial and ethnic populations (e.g. maternal mortality in the UK [8]), and genders (e.g. prognosis following myocardial infarction [9]). It is paramount that new health policies consistently address inequalities and prevent the existing disparities from widening. Epidemiological studies during the COVID-19 pandemic point to yet another factor that could exacerbate the existing health inequalities – the inequalities in health behaviour change in response to a pandemic.

HEALTH BEHAVIOURS

Health behaviours are actions that individuals take, which can directly or indirectly influence physical and mental health and well-being. Some of these actions can be health protective, such as taking part in recommended vaccination programme and practicing good hygiene, or health promoting, such as engaging in regular physi­cal activity. Importantly, already before the COVID-19 pandemic research showed important inequalities in health behaviours, with those in the population who have lower socio-economic status, income, education, or who live in deprived areas being less likely to engage in health promoting and protective behaviours, and more likely to engage in risky and unhealthy behaviours [10]. Furthermore, the unhealthy behaviours tend to cluster, such as daily cigarette smoking, physical inactivity, and excessive alcohol consumption, which are all contributing to poorer health outcomes among the deprived populations [11]. Indeed, both poor health status and unhealthy behaviours have been shown to be key explaining factors for the observed excess mortality among adults in the lower income groups in comparison to higher income groups [12]. As health behaviours are influenced by a number of individual, contextual and societal factors, making and maintaining changes in behaviours of the population often requires multifaceted interventions [10].

COVID-19 PANDEMIC AND INEQUALITIES IN HEALTH

Pandemics such as the one caused by COVID-19 create major physical (e.g. mortality and morbidity) and mental (e.g. stress, anxiety, sleep disturbances) health impact on the communities affected by them. These consequences can be magnified further by the impact of public health measures that are taken by the governments to tackle the pandemic, such as physical and social isolation and home or facility confinement (including so called national or regional ‘lockdowns’ [13]), as well as economic insecurities, job and income losses, and opportunities losses (e.g. limited access to services, education and other support on which people relied on pre-pandemic. During the COVID-19 pandemic we saw an unprecedented restrictions in individual movement and travel leading to rapid changes to lifestyles and daily functioning that were a result of different degrees of lockdowns that different countries imposed.
Importantly, the impact of the social distancing and other protective measures on lifestyle and health behaviours was not uniform across the populations studied. Hundreds of studies have been conducted and published researching this topic – far too many to adequately summarise in the present article, but below examples were selected to illustrate some of the complexity of the literature in this field. Specifically, systematic reviews of epidemiological studies have reported population changes across a range of health-related behaviours during and as a result of the COVID-19 pandemic, with many being detrimental to health [14]. The findings included changes to physical activity levels, which could be expected given the movement restriction guidelines, with many studies reporting declines in activity overall and increases in seden­tary behaviours [15]. However, some studies reported increases in activity among some popu­lations [14, 16]. Similarly, studies from different countries reported different changes to dietary and nutritional patterns, including some improvements, e.g. in greater adherence to Mediterranean diet across many European countries [17], but many reported unfavourable changes such as increased in the calory intake, meal frequency, and snacking [17, 18]. There have also been mixed findings concerning alcohol consumption. For example in Europe this varied by studies and regions although there was a general trend suggesting increased alcohol consumption [19]. The increased calory consumption from unhealthy meals and alcohol could in turn be contributing to unfavourable changes to weight and BMI during the pandemic [20].
Studying population-level and aggregate data on health behaviours during the COVID-19 pandemic can sometimes mask relevant public health information. For example, one UK study showed that when analysing po­pulation data cross-sectionally, the findings pointed to no changes to the levels of physical activity before and since the start of the first nation-wide UK lockdown in Spring 2019. However, the same study, when analysing the same data longitudinally, showed stark changes to individual patterns of physical activity, with a third of UK adults maintaining the same physical activity levels as before the pandemic, but another third of adults considerably decreasing (even halving) their physical activity levels, and another third considerably increasing (even doubling) their physical activity. Furthermore, there have been inequalities in the physical activity outcomes as reported elsewhere [21], specifically, the increases in activity were found among the White ethnic groups, educated and financially better-off groups, as well as those who were already active prior to the pandemic [22]. Other studies also found that the largest declines in physical activity were found among ethnic minorities, those who were unemployed, those from more deprived backgrounds, and those who were the youngest and oldest age groups or had a medical condition [21, 23].
Inequalities were found also across other health behaviours. Studies on diet found that men, members of ethnic minorities (who tend to have socio-economic disadvantage), as well as those with lower education and financial difficulties were at higher risk of consuming lower amounts of fruit and vegetables [21]. Research on alcohol consumption in the UK found that about a third of adults increased and 20% decreased their alcohol consumptions, with increased consumptions associated with different factors among men and women, and including deteriorating financial circumstances and pre-pandemic alcohol consumption levels [24]. Increased or solidified high alcohol consumption was found among those who were heavy alcohol drinkers before the pandemic, while other groups showed decrease in alcohol consumption [19]. In Canada, those who were facing financial hardships due to COVID-19 tended to increase engagement in unhealthy behaviours: tobacco and cannabis use, alcohol and junk food consumption, and TV and internet screen time. The same study found that younger and Canadian- born adults were also more likely to engage in these unhealthy behaviours, in comparison to older and immigrant adults [25].

DISCUSSION

COVID-19 pandemic and the introduction of lockdowns and different social distancing measures have created circumstances that led to health behaviour changes. These changes were non-uniform, however, and studies reported different findings across geographical locations but also between individuals with different socio-demographic and other characteristics within the same countries. Some individuals showed a favourable increase in healthy behaviours (e.g. increased physical activity), some maintenance of their pre-pandemic behaviours, and some showing a decrease in healthy behaviours (e.g. fruit or vegetable consumption) or an increase in unhealthy behaviours (e.g. increase in alcohol consumption). Where additional information on factors associated with the behaviour change was available, research pointed to inequalities in how individual behaved, with those better off before the pandemic often being able to maintain their healthy behaviours or even improve them. Therefore, while many behaviour changes during the pandemic were detrimental to health, this was not inevitable - positive behaviour change was possible.
Except for the imposed lockdowns and social isolation and movement constraints acting like natural experiments, there have been little systematic effort from governments and national bodies aimed at supporting healthy behaviour change or maintenance implemented during the pandemic [26]. This is not surprising as the clinical, scientific, operational, policy and financial efforts focused on limiting the impact of COVID-19 virus spread and mortality. Nevertheless, what is also means is that the observed inequalities in changes in health behaviours during the pandemic were likely arising from the pre-pandemic inequalities in capability, motivation and opportunity to engage in these behaviours as well as from the pre-pandemic engagement in these behaviours, which are all socio-economically patterned [10]. Some individuals were better positioned to cope with the pandemic in more adaptive and healthy ways than the others. These epidemiological findings suggest that the changes in health behaviours observed during the COVID-19 pandemic are therefore likely to further contribute to deepening of the existing health inequalities in health outcomes and well-being.

NEXT STEPS: TACKLING UNHEALTHY BEHAVIOURS DURING THE PANDEMICS

Given that pandemics affect health behaivours and these in turn can have both acute and long-term impact on morbidity and mortality in general, health promotion interventions should continue to be implemented during pandemics alongside other health protective interventions such as vaccination programmes, social distancing measures, and infection prevention. Given the identified individual differences as well as health inequalities in engaging health-related behaviours, such interventions may need to be targeting in the first instance the most vulnerable and worse off members in the population, as well as those who engage in unhealthy behaviours already.
Physical activity is a clear target for such interventions during any future periods of social isolation and lockdowns [27]. Relevant interventions should focus on supporting appropriate to individual’s needs and circumcentres ways for adhering to the recommended weekly levels of physical activity (i.e. 2 days of strength training and at least 150 minutes of at least moderate to vigorous intensity physical activity each week [28]). Such interventions should capitalise on the existing online and digital resources and tools [29], but also consider additional practical support, e.g. providing discounted offers for home sports equipment. Another candidate behaviour is healthy diet, such as promoting healthy options for snacking as well as restrictions in calory intake during periods of limited physical activity caused by a lockdown.

NEXT STEPS: RESEARCH AND SURVEILLANCE OF HEALTH BEHAVIOURS DURING FUTURE PANDEMICS

Ongoing monitoring of health behaviours in the aftermath of the pandemic will be important for planning of the future public health interventions. Furthermore, given the importance for health outcomes and wellbeing of health behaviours and changes to health behaviours during a pandemic such as the one caused by the COVID-19, we should take time to reflect on the successes and challenges of different research programmes and devise plans for rapidly designing, deploying and conducting population-based research into health behaviours during potential future global public health emergencies that disrupt lifestyle. As our capability for collecting and analysing big data in relation to health and behaviours increases [30], we should look into ways of harnessing the power of technology to help us more readily and effectively gather insights and develop data-informed health promotion strategies.
It is also important to note that despite there being hundreds of published papers on the impact of COVID-19 pandemic on health behaviours, there have been many challenges to studying health behaviour change during the pandemic. Some of the practical challenges to conducting such research include, but are not limited to: the difficulties in recruiting at fast pace sufficiently large and as close to representative samples from a given population as possible; very narrow windows of time to collect the necessary data (e.g. data collection should coincide with the relevant periods of the pandemic, such as lockdowns or periods of relaxation of the distancing rules); use of different measures to assess individual health behaviours that lead to challenges to data synthesis; collection of insufficiently detailed data on the behaviours themselves or the factors associated with them (including those relevant to health inequalities, like socio-economic status, ethnicity). Collecting detailed data on individual health behaviours and factors associated with them also requires using very long surveys which in turn can lead to low engagement, response fatigue, attrition from studies and missing data. Furthermore, there have been considerable differences in social distancing measures introduced during different COVID-19 pandemic waves and between countries, making direct comparisons and data pooling very challenging [13]. Finally, access to relevant and detailed baseline (i.e. pre-event) data for health behaviours of interest may be limited in many countries and for communities, which provides additional challenges when trying to assess the impact of the pandemic or other disasters. This in turn points to the great value for both national and local surveillance systems to be developed and maintained.

CONCLUSIONS

COVID-19 pandemic and the resulting from it national and regional lockdowns as well as other restrictions brought several large-scale natural experiments that had notable impact on health behaviours. The recorded changes in health behaviours tended to have socioeconomic gradient, with more favourable changes observed in those who were better off before and during the pandemic. Poorer, riskier and more detrimental to health behaviours were noted among those in the society who were already poorer. Although more longitudinal research will be needed to determine the long-term impact of the observed behavioural changes, we can nevertheless expect that COVID-19 pandemic has contributed to the maintaining and likely has further exacerbated health inequalities by through deepening the disparities in health-related behaviours. Managing pandemics and their impact should not only be limited to curative medicine and infection prevention and control, but should also consider the behavioural determinants of health and include health promotion and health behaviour change interventions as integral to pandemic response.

DISCLOSURE

The author reports no conflict of interest.

References