A world where no-one is left behind in health and well-being. This is the goal which WHO’s 194 Member States have set for the years to come.¹ In a world in which health inequities are the norm, it is a bold and ambitious objective. Glaring inequities exist between countries – the risk of dying prematurely from the four main non-communicable diseases2 is below 10% in some countries of the WHO European Region and as high as 31% in others.² There are also inequities in health within countries, associated with social determinants; i.e. the conditions of daily life in which people are born, grow, live, work and age such as education, living standards and environmental exposures.³ Health crises such as the current COVID-19 pandemic expose both local and national health inequities and bring into stark relief the need to rethink health policies and planning.^{4 5 6 7}

Attaining ambitious health goals, battling major public health crises and overcoming health inequity all depend on individuals and communities accessing health services and adopting healthy lifestyles. We argue that this, in turn depends on how well health authorities apply a people-centred approach: engage, listen to and understand the communities they serve, as well as responding to user-needs in their policy, service delivery and health communication. To do this efficiently they need to embrace disciplines outside of the bio-medical sphere.

It is well established that the barriers people face in accessing services and taking up healthy practices can be complex, not least for communities experiencing disadvantage. Understanding people and their contexts has long been recognized as critical for affecting any behaviour or practice^{8 9 10}, but still today is often not well integrated into health policy planning. Drawing on multidisciplinary approaches – including psychology, anthropology, sociology, cultural studies, behavioural economics, communication and history – offers nuanced insight ¹¹¹² which strengthens and supplements biomedical approaches to policy and planning.

Methods and research from social science and medical humanities can be used to identify the barriers and drivers that people experience in leading healthy lives and accessing and utilizing health services. For example, the reasons why some people do not vaccinate can relate to hesitancy, misinformation or fears related to vaccine safety, but they may just as well relate to indirect, inconvenient opening hours, lack of reminder system or the way parents and children are being received, taken care of, respected and informed by health providers.¹³ Only when we understand which barriers are key can we invest in the right solution. These insights allow evidence-informed changes to health systems, policy, services and communication aiming at accessibility, affordability and convenience, which can be thoroughly monitored and evaluated for their impact^{14 15}.  An additional objective is more cost-effective investment.

Rarely has the critical urgency of human behavior and easy access to health services and socio-economic support in combination been demonstrated more clearly than during the current coronavirus pandemic. Controlling virus transmission relies on people receiving, understanding and being able to respond based on¹⁶ information about recommended behaviours such as physical distancing and self- isolation, on appropriate risk perceptions, trust and social norms, and on efficient and accessible systems, including for testing and contact tracing and future COVID-19 vaccination, and for fair and efficient compensation and social support – all of which must address the barriers people face and take into account the cultural, social and socio-economic context in which they live.

Faced with such complex challenges, the use of multidisciplinary approaches becomes critical. At worst, a poorly timed and managed pandemic response can have devastating impacts on health as well as the economy^{17 18 19} which again may affect disproportionately those already most disadvantaged. Supplementing classic epidemiological responses, governments need to draw on the evidence from a diversity of academic disciplines and lessons learned from past epidemics²⁰ to plan appropriate mitigation measures, and to adjust and qualify these continuously based on real-time behavioural insights evidence.

Such evidence can be achieved via for example, population surveys²¹, media and social media monitoring, ethnographic studies, COVID-19 hotline monitoring or various types of rapid assessments with priority population groups. To meet this need, at WHO Reginal Office for Europe we developed a COVID-19 behavioural insights survey tool used in 24 Member States within the Region, and many beyond, and provide tailored technical support to countries that need it. Insights from these surveys have allowed a people perspective and an understanding of the experienced COVID reality and protection behaviours among the populations in each country, informing national COVID response and policies.

The value of behavioural and cultural insights in strengthening health and increasing health equity is not only evident in crisis response or vaccination. These approaches have shown value in areas as different as smoking cessation, road safety, substance abuse, sexual and reproductive health and nutrition policy²²

A number of governments should be applauded for valuing and long-term investment in these approaches with dedicated budgets and social science and medical humanities experts engaged in what is often referred to as behavioural insights units. WHO is also scaling up this work with dedicated teams working closely with global experts. In the WHO European Region, behavioural and cultural insights are a flagship priority in the Programme of Work towards 2025 and a unit has been established to provide support to national governments.²³

If we are to overcome the big global health challenges of the next decade, it is critical we invest in identifying the barriers experienced and the drivers for healthy lives and behaviours. Equally critical is planning health services according to people’s needs. The investment may seem considerable, but the public health gains and cost-saving outweigh the costs. We argue we will only be able to reach the ambitious health goals of tomorrow when governments understand how people behave in social situations and in relation to health systems and structures. Only when there is recognition of these and how they relate to people’s lives, environment and health, will we be able to make the claim that we are leaving no-one behind.

This article is an extract taken from the Parliamentary Network publication ‘Just Transitions’. You can download a pdf version of the full document here.

1. Resolution WHA71.1: WHO’s thirteenth general programme of work, 2019–2023.
2. WHO Regional Office for Europe 2020. United action for better health in Europe Draft European Programme of Work, 2020–2025
3. World Health Organization Regional Office for Europe. Review of social determinants and the health divide in the WHO European Region. Available at: http://www.euro.who.int/en/publications/abstracts/review-of-social-determinants-and-the-health-divide-in-the-who-european-region.-final-report [accessed 21.12.17].
4. Crystal Johnson-Mann et al 2020. COVID-19 pandemic highlights racial health inequities. DOI: https://doi.org/10.1016/S2213-8587(20)30225-4
5. Crystal Johnson-Mann et al 2020. COVID-19 pandemic highlights racial health inequities. DOI: https://doi.org/10.1016/S2213-8587(20)30225-4
6. United Nations, 2020. Shared responsibility, global solidarity: Responding to the socio-economic impacts of COVID-19
7. United Nations, 2020. Policy Brief: A Disability-Inclusive Response to COVID-19
8. Napier AD, Depledge M, Knipper M, Lovell R, Ponarin E, Sanabria E et al. Culture matters: using a cultural contexts of health approach to enhance policy-making. Copenhagen: WHO Regional Office for Europe; 2017
9. Michie et al 2014. The Behaviour Change Wheel. A guide to designinginterventions. London: Silverback Publishing
10. Brewer et al 2017. Increasing vaccination: putting psychological science into action. Psychol Sci Public Interest 2017;18(3):149-207. Doi: 10.1177/1529100618760521
11. Stein C, et. al. European Health Report 2018: more than numbers – evidence for all. Copenhagen. WHO Regional Office for Europe; 2018.
12. https://apps.who.int/iris/bitstream/handle/10665/279904/9789289053433-eng.pdf
13. Habersaat KB, Jackson C: Understanding vaccine acceptance – and ways to increase it. Bundesgesundheitsblatt. Special issue “Impfen: Globale Aspekte und Strategien”; 2019. http://link.springer.com/article/10.1007/s00103-019-03063-0
14. Strategic Advisory Group of Experts on Immunization (SAGE) 2014. Report of the SAGE working group on vaccine hesitancy
15. Tailoring Immunization Programmes (TIP). Copenhagen: WHO Regional Office for Europe; 2019. License CC BY-NC-SA 3.0 IGO
16. Stellmach et al. 2018, Anthropology in public health emergencies: what is anthropology good for? BMJ Global Health 2018;3:e000534
17. Jakab, Zsuzsanna 2019. A road to equity: health literacy from a public health perspective.In Public Health Panorama Volume 5, Issue 2-3, June-September 1019
18. The World Bank 2020. The Global Economic Outlook During the COVID-19 Pandemic: A Changed World
19. World Health Organization, Regional Office for Europe. Strengthening and adjusting public health measures throughout the COVID-19 transition phases. Policy considerations for the WHO European Region, 24 April 2020. (2020).
20. Anderson, R. M., Heesterbeek, H., Klinkenberg, D. & Hollingsworth, T. D. How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet 395, 931–934 (2020).
21. Habersaat, Katrine Bach et al (2020), Ten considerations for effectively managing the COVID-19 transition. Nature Hum Behav. 2020 Jun 24. doi: 10.1038/s41562-020-0906-x
22. Betsch, C., Wieler, L. H. & Habersaat, K. Monitoring behavioural insights related to COVID-19. The Lancet (2020) doi:10.1016/S0140-6736(20)30729-7.
23. Oliver, Adam: Oliver (2015), Behavioural Public Policy. Cambridge University Press OR Oliver, A. (2017). The Origins of Behavioural Public Policy. In The Origins of Behavioural Public Policy (pp. I-Ii). Cambridge: Cambridge University Press.