A guest blog in which Gillian Pepper states the obvious…..
Some time ago now, I was chatting with Daniel over lunch. I told him that Richard Brown and I were continuing to find evidence in support of a theoretical model that Daniel published over a decade ago. Daniel surprised me with his response. He declared that the conclusions of his model (which I will explain in moment) were so obvious that it would be surprising if they weren’t true. He had a point. And yet, we continue to act as if the obvious weren’t obvious. Perhaps, Daniel and I agreed, our conclusions would need to be repeated numerous times and to many audiences before they can perforate collective consciousness. As a starting point, Daniel invited me to write this guest blog.
The model of the “obvious”
Though Daniel’s original model contains various details and assumptions, the key points are as follows:
- We are all exposed to health risks which, no matter what we do, will reduce our life expectancies. That is, there are risks beyond our behavioural control. For example, without refusing to ever leave our homes, we could never entirely eliminate our risk of death due to transport accidents. Daniel originally referred to this as extrinsic mortality risk, borrowing a construct from evolutionary biological models of senescence. We now call it uncontrollable mortality risk.
- Some people are exposed to greater overall risk than others, and some are less able to mitigate the risks they face. That is, there are inequalities in exposure to risk. Depending upon where in the world you happen to live, and what resources you have available to improve your safety, there are myriad uncontrollable risks that might affect you. If you’re unlucky, war, violence, natural disasters, or extremes of weather might be hazards you face on a regular basis. Or perhaps the risks you face might be less obvious issues, such as mould and damp in your home, a polluted neighbourhood, or flammable cladding on your building. Whilst these issues may seem controllable to a relatively affluent person, they can still be classified as uncontrollable for those who can’t afford to move to a better neighbourhood, or to make the necessary repairs to their housing.
- Uncontrollable risks reduce the future benefits of healthy behaviour. If there’s a non-zero chance that we will be struck down by an uncontrollable force before reaching an age at which the consequences of our lifestyle choices will be felt, then the temptation to indulge in short-term rewarding but long-term damaging behaviours, such as alcohol consumption will be greater. Especially when there is some benefit of that indulgence in the present (e.g. improved social bonding).
- There is also a trade-off: time, money, and effort spent on health cannot be spent on other things that matter to us. Daniel’s model examines varying strengths of trade-off but, in general, the idea is that efforts spent on taking care of our health conflict to some extent with other things that might be important to us. Anyone who has experienced sleep deprivation due to caring responsibilities or eaten unhealthy convenience food due to time pressures at work will readily understand such trade-offs.
- Consequently, exposure to uncontrollable risk should reduce our motivation towards healthy behaviour because it would mean investing efforts in health, instead of other priorities when, regardless of our efforts we might not live to see the long-term payoffs of taking better care of ourselves. This, I believe, is an unconscious driving force behind health motivation. One of a number of reasons (there will, of course, be other drivers too) that it can feel so difficult to do those things which we know would in some sense be better for our health.
- Finally, the model suggests there will be a compound effect of extrinsic risk and health behaviour. An important implication of this is that people who, by no fault of their own, can do little to control the risks they face, will be less motivated to take care of their health (mitigate the risks they can control) than those of us who are lucky enough to feel safe and in control of our lives. And this will make the gulf in their achieved life expectancy even wider than it would have been for structural reasons. Social disparities in health behaviour can thus be seen as a downstream consequence of structural inequalities, rather than whim or ignorance, as some might assume.
To summarise the general idea: if you believed that, despite best efforts, you might die young due to war or natural disaster, would you worry much about whether you were eating enough fruits and vegetables? Probably not. And that was Daniel’s point. It would be rather surprising if people living in environments laden with threat were keen to quit smoking and forgo junk food. Nonetheless, we’ve dedicated a fair bit of time to testing this model.
We first tested the model by devising a measure of perceived uncontrollable mortality risk and assessing its relationship with self-reported health behaviour. When that study uncovered surprisingly large associations between perceived uncontrollable risk and health behaviour, we sought evidence of a causal relationship. We ran experiments designed to alter people’s levels of perceived control and measure their subsequent food choices. These found that people who were primed to feel that their personal risk levels were largely controllable were more likely to choose fruit than chocolate as a reward for taking part in the study. Richard Brown and I collected data during the COVID-19 pandemic to assess whether perceptions of uncontrollable risk had increased, and whether this was related to health behaviours in the UK (relatedly, we worked with Calvin Isch and colleagues to look at perceptions of uncontrollable risk in the USA). We found that perceived uncontrollable mortality risk had increased due to the pandemic and that it was associated with greater odds of smoking and lower odds of meeting Government guidelines on diet and exercise. More recently, Richard and I have published a replication and mini meta-analysis on the topic.
So, why all this effort to look for an association which would be puzzling if not present? Well, the answer is that the idea has some important implications. One of these implications is something I like to call the double dividend of safety.
The double dividend of safety
The idea of the double dividend of safety is simply that, if we make people safer by reducing those risks which they can’t avoid for themselves, we can expect that they will become more motivated to take care of their own health. So, we get the primary benefit of the initial improvement in safety, and the additional, secondary benefit of improved health from better health behaviour. That’s two benefits. A double dividend. If you think you’ve heard of the double dividend concept before, it may well be because you’ve encountered it in the context of environmental taxes. In this context, “double dividend” refers to the idea that environmental taxes should not only reduce pollution (the first dividend), but also reduce overall tax system costs if the revenue generated is used to displace other taxes that slow economic growth (the second dividend).
Understanding the double dividend of safety (rather than environmental tax) is important for numerous reasons. Among them, the fact that public health goals are often approached in silos. Behaviour-change programmes tend to operate in isolation, with practitioners rarely able to address the wider problems affecting those whom they seek to serve. This is not news, of course. Healthcare leaders have pointed out the need to break down this siloed approach. However, the double dividend of safety gives us another reason to call for joined-up thinking.
The concept could also be used to “sell” safety. You might think this unnecessary. Isn’t the importance of safety another one of those things that should be blindingly obvious? However, in a recent conversation with a Campaigns Manager at a global safety charity, I was surprised to learn that it can be difficult to persuade those in power that safety is important. “Safety isn’t sexy”, he said. This came as a surprise to me, but perhaps it shouldn’t have. Those who have the power to make change for others, on average, probably don’t have much experience of being unsafe. As Daniel mentioned in a recent blog on inequality, when the ruling classes have so little contact with what the majority experience it becomes difficult for them to make decisions that work for the public good. Yet, it remains true that public health funds are spent on giving the general public information and tools (usually in the form of websites and apps) in attempts to improve health behaviour. For example, the UK Government’s Better Health Campaign, which purportedly cost £10m. Such efforts make it clear that there is a desire to improve health behaviour.
What if, we were to instead shift our focus to making people safer? The double dividend of safety suggests that they would automatically be more motivated to take care of their health: a double win. Whilst this might initially seem like the harder (and probably more expensive) path to take, I’m willing to bet that it would also be the more gainful one in the long run.