What can a singing cowboy teach us about policymaking?

Developing guidance for policymakers on culturally informed approaches to public health is central to the work of the University of Exeter’s WHO Collaborating Centre on Culture and Health. It is a key challenge, but learning from others, such as those involved in addressing the social determinants of health, will help expedite progress. Acknowledging that culture affects the health of individuals and communities is relatively straightforward; understanding the contribution of culture to these health outcomes requires more effort; doing something about it is much more difficult. Just like relationships. Ask Hobie Doyle, the singing cowboy from the Coen Brothers latest movie. Cast out-of-type as a disappointed romantic lead, life is a little beyond him. He wishes that life was simpler, but is forced to conclude that “it’s complicated”.

Life’s Complicated

Something similar holds for policymakers. The lament that “it’s complicated” is likely to be at the forefront of policymakers’ minds when confronted with calls for action that takes account of cultural contexts.

It seems simple enough to recognise the link between culture and health. Indeed, policymakers want to harness all aspects of health – cultural, environmental and social – in order to improve health outcomes and reduce health inequalities. But, policy intervention is always more complicated, not least because of the way that responsibility is divided among policymakers and government departments. Health is a shared responsibility across state departments in most of Europe in a way that is not always recognised by governments themselves. While health departments are often more preoccupied with delivering healthcare services than tackling the factors that shape people’s health, other government departments also need persuading that these wider health issues are of relevance. The risk is that policymakers place these wider aspects of health in the ‘too difficult’ box, blocking further consideration.

Work on the social determinants of health has shown how the wider aspects of health can be made relevant to policymakers. The first step involved gaining recognition that social determinants have an impact as the ‘causes of the causes’ of poor health and clarifying the existence of a social gradient where the lower a person’s social position, the worse his or her health.

The second – and harder – step is to encourage policymakers to believe that it is possible to develop effective policy responses to improve population health and reduce health inequalities. This is one reason why the Marmot reviews for England and Europe are never far from a policymaker’s desk. There are lessons here for the development of policy guidance on cultural aspects of health.

Health inequalities are in large part due to a failure to act on the social – and cultural – dimensions of health. For many individuals and communities, the result is shorter lives with a greater proportion of these lived in poor health, compared to other groups.

Learning from the work on social determinants and its role in shaping public health policies can be used to guide emerging research on the cultural contexts of health. It will also help distinguish the distinct contribution that action on the cultural contexts of health can make to improving health and reducing health inequalities.

Cultural factors, such as ethnicity, provide a better understanding of the impact on individual communities of social determinants like poverty and deprivation. Understanding culture can help to identify policies that mediate the effects of social determinants on health outcomes. As an example, the London Borough of Tower Hamlets in the east of the capital is one of the most ethnically-diverse places in the UK. It has the largest proportion of children in poverty in the country and uses a social determinants approach to maximise health outcomes and reduce the health inequalities associated with poverty and deprivation. The positive impact of culture in Tower Hamlets is shown in the much better health outcomes for mothers and children than might be expected from the degree of child poverty. In spite of high levels of poverty, rates of infant mortality, smoking in pregnancy and teenage pregnancy are at – or around – the national average. This improvement reflects cultural factors within local communities, the priorities in the borough’s health and wellbeing strategy, and action, advocacy and community engagement on the ground.

Such factors also shape people’s expectations about the quality of their lives. The expectation of poor health and acceptance of earlier death, whether in former coalfield communities or inner-city Birmingham, can frustrate even the most determined policy maker.

A cultural focus augments and complements a social determinants approach through a greater emphasis on equality, including the experiences and negative health pressures faced by socially excluded groups who sit at the end of the social gradient, in danger of being forgotten. It also builds on the positive ways people and communities live their lives that deliver better health outcomes, such as among the women and children in Tower Hamlets, defying experiences of wider disadvantage.

Gathering the evidence is, of course, crucial, in terms of both understanding and addressing the origins, causes and extent of health inequalities. Three principles of policy practice emerge from the English experience of tackling health inequalities that can be of value to a cultural context approach:

  • winning support – strong leadership is vital to winning support for a health inequalities/social determinants approach and includes promoting the issues, lobbying and influencing key stakeholders, and building political support;
  • making health inequalities everybody’s business – aligning inequalities with the mainstream business objectives of policymakers in government departments and organisations in a way that will help these organisations fulfil their ambitions is always a persuasive factor; and
  • delivering results – showing an impact, even against limited objectives, is crucial to sustain support and build long-term commitment to action. The Exeter approach of narrowing the policy focus to four areas (nutrition, mental health and well-being, migration, and environment) will improve the likelihood of making an impact.

It is 20 years since the setting up of the independent Acheson inquiry on health inequalities in England. There is still some way to go to break the link between ‘health and wealth’. Effective policy guidance on the cultural aspects of health could speed things up, filling gaps and developing complementary approaches. Action will remain challenging – and complicated – but neither a 10 gallon hat, nor a song or a horse is needed for this journey.

This post was written by Dr Ray Earwicker, honorary research fellow at the Centre for Medical History, University of Exeter, and formerly a senior policy adviser at the Department of Health