Lifestyle has an influence on health – but what influences lifestyle?

Smoking, alcohol consumption, an unbalanced diet and lack of exercise are crucial health factors associated with a number of non-communicable diseases such as cancer or cardiovascular disease. According to estimates by the WHO (World Health Organization), up to 80 percent of cases of coronary heart disease, 90 percent of type-2 diabetes cases and a third of all cancer cases could be prevented if people engaged in more physical activity, followed a healthier diet and quit smoking.

The worse-off are in poorer health
Health is the greatest good – and, like all goods, it is unevenly distributed in society. The question as to whether or not we stay healthy has long since been determined by factors that go beyond biological or genetic determinants or individual health-risk behaviour.
Health inequalities are an omnipresent, universal phenomenon. In social terms, life expectancy and premature mortality are unequally distributed in all countries for which relevant data are available. This effect is found independently of the indicator of social inequality used, whether it be educational, occupational or income status. The more unfavourable the socio-economic status, the higher the mortality rate and the lower the life expectancy.

Which factors do mostly shape a healthy lifestyle?
In which direction does the relation between the effects of socio-economic and health inequalities progress? According to a meta-analysis commissioned by the Federal Office of Public Health (FOPH), it is primarily socio-economic status that impacts on health, rather than vice versa. Low socio-economic status is associated both directly and indirectly with a greater health risk.

What's the cause: behaviour or circumstances?
In this context, "directly" means that individuals with a low level of education or low occupational status share a culture that promotes patterns of behaviour harmful to health. This approach is also referred to as the cultural-behavioural approach. It includes cigarette smoking, alcohol consumption, an unhealthy diet and physical inactivity. Such patterns of behaviour are closely associated with physiological and biomedical parameters such as high blood pressure or high cholesterol levels, which are risk factors of many chronic diseases.
It is assumed that 30 to 50 percent of health disparities can be attributed directly to health-risk behaviour. This approach therefore does not suffice on its own to explain health inequality. The materialist/structural approach is considered to be an effective explanatory model. It argues that the health of people at the lower end of the status hierarchy is influenced indirectly. Not only do they have less in the way of financial resources, they also tend to live and work in environments that are more harmful to health compared with people further up the social scale.
More recent research has increasingly broadened efforts to find an explanation and has added new approaches. Of the latter, the psychosocial approach is the most highly developed. This more psychological approach was taken up because of growing doubts as to whether behavioural and material factors were sufficient to explain the social gradients of health. This hypothesis was supported by research findings confirming that clear health disparities also exist in groups in which health risks such as unfavourable living and working conditions tend to be unlikely, for instance in public-sector employees. As a result, psychological and psychosocial factors have increasingly been added to material factors to explain health inequalities. These include, for instance, critical life events, chronic everyday pressures such as stress (e.g. lack of participation in decision-making, insufficient scope for action), social support and social networks, self-confidence and coping resources. Numerous studies have shown that uneven distribution applies not only to psychosocial pressures, but also to the resources for coping with them. This means that people of low socio-economic status are doubly affected. Generally speaking, psychosocial pressures and resources are attributed a level of importance comparable to that of material factors in efforts to explain health inequality.

Prevention: focus on structural conditions
Behavioural, material and psychosocial factors are therefore responsible for a large part of the inequalities in health. Where must preventive action be taken in order to achieve the maximum effect? Studies indicate that the independent effect of health-risk behaviour and of psychosocial factors is less than that suggested in the separate analyses. Conversely, this means that health inequalities are due primarily to material factors because the latter have a much stronger effect than health-risk behaviour and psychosocial factors.
In other words,  measures that target health-risk behaviour are helpful in improving health overall.  But they will not be successful enough to reduce health-related inequalities of opportunity because material living conditions and psychosocial factors play a greater role than health-risk behaviour in explaining socio-economic health distinctions. Health-risk behaviour is more a consequence of material/structural living conditions and psychosocial pressures. This means that behavioural prevention primarily addresses the consequences rather than the causes.