The education gap and policy relevance
Although a number of healthy behaviours occur frequently in the Netherlands, unhealthy behaviour is still fairly widespread in the Dutch population. This means there are still many health gains to be made by promoting healthier lifestyle habits. But is policy that focuses on health promotion and lifestyle likely to succeed? And how can the education-related disparities that we have established throughout this study be taken into account?
Persistent differences in health-related behaviour
The fact that there are differences in health in the Netherlands is in itself not surprising, and has been demonstrated in several studies; see also Education as a dividing line. What is however disconcerting is that there are substantial and significant differences in healthy and unhealthy habits between different educational groups (Ruwaard 2011). Our study also reveals a fairly robust social dividing line between those with high and low education, which remains after correcting for other background characteristics (sex, age) and contextual factors (family, neighbourhood, country).
The most risky behaviour – smoking – is for example most common among those with a low level of education, whereas intensive physical activity and healthy eating are less common in this group; this very probably also results in a higher BMI. Conversely, on average we find that those with a university education in particular exhibit more healthy behaviour and have on average a BMI that does not indicate being overweight. One exception to this is consumption of alcohol, which is relatively frequent precisely among those with the highest educational level.
Our results thus support the idea that health-related behaviour is culturally determined; it forms part of the lifestyle and identity of a social group or class. Since education, lifestyle and culture are so closely interwoven, the differentiation in health-related behaviour presented here is also a strong indicator of robust differences between social groups in the Netherlands.
Differences can be bridged, however, and policy could and should play a role to obtain this goal. Despite lifestyle and cultural differences, good health is and always will be of essential importance for everyone. And where certain individuals or social groups have few opportunities to improve their health through their own efforts, the government and society can play a role in offering help and support (McCartney et al. 2013).
Prevention and public information are the best-known examples of this, but also the most intractable. Greater efforts than ever before are now being made to develop policy focusing on prevention rather than cure, and on behaviour rather than illness. A major first step in this direction was provided in the publication by the Council for Public Health and Health Care (RVZ) of the discussion paper ‘From illness and care to behaviour and health’ (Van ziekte en zorg naar gedrag en gezondheid) (RVZ 2010). More recently, in a report entitled ‘Desire for cohesion’ (Verlangen naar samenhang), the Dutch Council for Health and Society (RVS) again stressed that differences in personal, economic, social and cultural capital mean that people have differentiated care and help needs (RVS 2016).
A role for government and care providers
Care providers are increasingly being assigned a role in influencing personal health-related behaviour. As a consequence, increasing attention is being given in the training of care professionals in the socio-communicative aspects of the profession. Under the motto ‘the art of saying no’, care professionals are increasingly playing a guiding and supporting role, with responsibility being placed on the individual citizen where possible.
How can public information on diet, smoking, drinking, exercise and physical activity reach the lower educational groups who need this help the most? And are these target groups then able to take the step towards healthier behaviour and a different lifestyle? These are relevant questions, as we see that differences in health-related behaviour between educational groups are linked to lower competencies, more financial constraints, smaller social networks and various aspects of cultural identity; see also Education as a dividing line. It is logical to assume that these factors also explain why policy may sometimes have less impact on this most vulnerable group.
The goal of the government has of course always been to promote the health of the population. This study shows once again that investing in (differentiated) policy to limit unhealthy lifestyle habits is an essential part of this. The assumption with regard to many lifestyle habits is that providing information and knowledge can turn behaviour around. Accordingly, providing information and knowledge forms the basis of the recently deployed National Prevention Agreement (Nationaal Preventieakkoord). The idea is that if people are first made more aware of their behaviour and its possible harmful consequences, they can then be encouraged to manage their own behaviour. As unhealthy lifestyle factors are clustered mainly in the group with a low educational level, prevention policy could target this group specifically (in this regard see e.g. Centre for Healthy Living).
Development of health skills
Health-related skills can be developed, although people with a low educational level have less often learned these skills in childhood and the prevailing norms in their social networks are less open to them. In our study, for example, we find that a person's partner and family have a fairly strong influence on their health-related behaviour. However, this could also provide an opportunity for policy, by targeting not just individual citizens about their unhealthy lifestyle, but involving their partner and other family members as well. Social support, provision of information and financial incentives could all form part of this, if not at national level, then at regional or local level. More and more local authorities are working with care providers and health insurers to develop campaigns and projects to promote healthier behaviour in hard-to-reach population groups.
People with a low educational level generally have less trust in information that comes from the government, and their attitude towards centrally run organisations (health insurers) tends to be more one of antipathy than warmth (Hoefman et al. 2015; Rademakers 2014). Working through the neighbourhood and social networks could then offer a route for giving practical meaning to abstract concepts such as ‘positive health’, ‘precaution’ and ‘health skills’. The role of care providers and support workers should not be underestimated here, both in primary care and in community social care teams. Specific policy aimed at reaching and persuading groups with a low educational level on aspects such as health awareness, courses on quitting smoking and exercise programmes thus requires local customisation, in which the social setting (partner, family) is also involved (see: Health in).
Hoefman, R.J., A.E.M. Brabers & J.D. de Jong (2015). Vertrouwen in zorgverzekeraars hangt samen met opvatting over taken zorgverzekeraars. Utrecht: NIVEL.
McCartney, G., C. Collins & M. Mackenzie (2013). What (or who) causes health inequalities: theories, evidence and implications? In: Health Policy, vol. 113, nr. 3, p. 221-227.
RVS (2016). Verlangen naar samenhang. The Hague: Raad voor de Volksgezondheid en Samenleving.
RVZ (2010). Van zz naar gg. Acht debatten, een sprekend verhaal. The Hague. Raad voor de Volksgezondheid en Zorg.
Ruwaard, D. (2011). Ongezonde leefstijl: wiens zorg. In: Tijdschrift voor gezondheidswetenschappen, vol. 89, no. 6, pp. 293-295.