1 Introduction

Within England it has been identified that individuals living in deprived areas are more likely to develop poor health [2, 3] and engage in unhealthy behaviours [4, 5]. Better understanding of the unique issues facing individuals living in these deprived areas has been suggested as the first step necessary in addressing these health inequalities [2, 3]. Reviewal of current literature suggests that there are several interconnected issues facing individuals from these deprived backgrounds. Including: physical inactivity, unhealthy diets, excessive consumption of food and alcohol [6], as well as raised blood pressure, obesity, hyperglycaemia and hyperlipidaemia [7]. English policies have taken a proactive approach in addressing these health concerns, implementing many programs designed to curtail or eliminate unhealthy behaviours, including excessive alcohol consumption, smoking, overeating, and tackling mental health problems. Despite this, health issues relating to the above continue to rise in many deprived areas. To investigate why meaningful change towards a healthier lifestyle has been slow to happen, the researchers formulated focus group and interview questions based on HEAL and SEM literature, participants from a deprived area in the north of England were then invited via snowball sampling to respond to these questions.

The researchers were specifically interested in discovering the origins of negative HEAL behavior, how effective any interventions have been in addressing health disparities in the area, and how negative HEAL behaviours impact participants.

2 Methodology

2.1 Defining the terminology

Several terms are used throughout this paper which underpinned the entirety of the research project. This opportunity will be taken to briefly explain these terms and their meanings.

Healthy Eating and Living (HEAL) is used to refer to the complex and often interlocking factors that constitute a holistic understanding of health. Principally, HEAL, for our purposes, refers to behaviours that are used to mitigate the effects of Non-Communicable Diseases [8]. As such, when examining behaviours relating to HEAL, we were looking for behaviours relating to food and alcohol consumption, mental health, access to unhealthy foods and drinks, and how participants reacted towards governmental interventions seeking to promote HEAL.

Non-Communicable Diseases (NCD) were of interest to the research project as the ultimate outcome of unhealthy behaviours relating to HEAL. NCDs, account for 70% of deaths globally [8], and are generally characterised as diseases that have a long to lifetime duration and a typically slow pace of progression [7]. The four main types include cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes [7], all of which have been demonstrated to occur more regularly in individuals from deprived backgrounds. As demonstrated in previous research, controlling progression of NCDs can be done by focusing on reducing the risk factors that are associated with said NCDs [6, 8]. Therefore, understanding how HEAL intersects with NCDs can be considered a starting position in reducing the impact of NCDs.

Social determinants of health (SDH) are non-medical factors that have an effect on health [2].

Table 1 lists the levels of influence as documented in the Social Ecological Model that was drawn from during this research.

Table 1 The Social Ecological Model adapted from Glanz and Rimer, 2005 [2]
Full size table

2.2 Context

The town of Barnsley was chosen as the research location, owing to its overall high level of deprivation as reported in the Indices of Deprivation (IOD) report [9], ranking 39th of 326. Of the lower output areas (LOAs) that make up the district, 21% of them are amongst the 10% most deprived in England. All participants were sourced from this location. Data collection occurred between 6th of December 2018–7th April 2019.

2.3 Sampling strategy

Participants were collected via snowball sampling for focus groups and one-to-one interviews, six local authority staff working within the research area were contacted and served as participant gatekeepers and no incentive was used during the study. In total, 13 focus groups with an average of 6 participants were conducted. Total participants involved in the focus group research was 72, of which 61 were female and 11 were male. Participant age range was 23–99, average age was 65. All participants reported English or White English as their ethnicity. Alongside focus groups, one-to-one interviews were conducted with 25 participants, of which 17 were female and 8 were male. Interview participants had an age range of 39–88 average age was 54. Reported ethnicity for interview participants was either English or White English. A combination of focus groups and interviews was chosen as the data collection method following the advice of Hennink [10] who suggested that these methods encourage a greater range of responses, which in turn provide a much more in-depth understanding of the attitudes, behaviours and opinions of participants.

2.4 Ethical issues pertaining to human subjects

Ethical guidance to conduct this research was granted by the University of Huddersfield. All research was carried out in compliance with their ethical guidelines. Authors confirm that all participants involved in the research provided informed written consent to both participate in the research and have their resultant data published.

2.5 Data collection methods

All data collected was qualitative, focus group data was produced between 6/12/18–6/3/19, interview data was produced between 6/2/19–7/4/19. Participants were recorded using an encrypted hand-held recorder and recordings were transcribed using otter.ai an online speech-to-text transcription application. During data collection, participants were encouraged to speak about questions examples included: “Were you supported when you decided to stop [smoking]?”, “Was there support available?”, and “How would you like the council to support this community.” Participants were also asked to share their understanding of what HEAL was. Questions were designed to be broad in order to avoid leading participants. Examples include: “What do you think helps you to engage in healthy behaviour?”, “When you think about healthy living, what does that mean to you?”, and “what does healthy eating mean to you?”.

2.6 Data analysis

All data gathered during focus groups and interviews was recorded and transcribed. Following this, a Deductive Thematic Analysis following the guidance provided by Braun and Clarke [1] was carried out. Deductive Thematic Analysis is a top down approach where the researchers have preestablished themes that are then used to analyse the dataset. Themes were generated from codes that were identified from reviewing the SDH, HEAL framework and SEM.

The following themes were generated after reviewing the above material, Diet and access to unhealthy options, mental health and governmental interventions. Codes and themes were agreed upon by the research team, Deductive analysis was conducted by the lead author. During the analysis, transcripts were analysed and data that corresponded to these codes identified.

2.7 Findings

When searching for information that fit the themes, it quickly became apparent that most participants possessed HEAL beliefs in line with current governmental guidance at time of research, the Eatwell guidance [11]. This was backed with similarly high levels of nutritional and mental health awareness. Whilst participants displayed good knowledge of what HEAL should be, many presented reasons as to why they were not able to engage in these behaviors as often as they would like. These reasons included pre-existing attitudes towards HEAL behviours carried over from childhood, as well as the ready availability of unhealthy options, including takeaways and off-licenses. Participants reported that the high density of unhealthy options often allowed them to engage in unhealthy behaviours and the cheapness of this was another large incentive. However, some participants did believe that eating healthily was cheaper than engaging in unhealthy eating habits. Participants frequently citied time constraints as a reason for poorer dietary choices.

Alcohol consumption as part of a healthy diet was also investigated. Again, many participants were aware of recommended levels of alcohol consumption, but felt that overconsumption was influenced by external factors, including ease of access and peer pressures. In our research area, participants believed that there was an unhealthy culture surrounding the consumption of alcohol, that promoted unhealthy behaviours.

Other findings, relevant to themes, was the knowledge many participants had of mental health and its impact on multiple aspects of life. Participants felt that mental health had a strong impact on, and was heavily affected by, HEAL. Further, participants linked the deprived state of their local surroundings as a key factor in worsening mental health. This is in keeping with current literature on mental health, which demonstrates a clear link between socio-economic status and mental health [2, 3]. When asked if poor mental health affected HEAL, participants overwhelmingly responded that it did, claiming that rates of smoking, alcohol abuse and poor dietary choices increased when mood decreased.

Information relating to the governmental interventions theme was also interesting, there was a general consensus that national government interventions were inferior compared to local government interventions, however participants acknowledged that the local government interventions were often prone to failure due to lack of funding and resources. Many participants felt that the national government had abandoned their area and did not believe that any attempts to improve the local area would have to come from somewhere other than nationwide projects.

These findings, strongly link back to the theories discussed at the start of the paper, suggesting that there is still merit in evaluating deprived areas with SEM and SDH framework. We present empirical evidence below to further expand on findings.

2.8 Links to empirical data

2.8.1 Diet and access to unhealthy options.

We found that participants did want to engage in HEAL behaviours, but external factors often prevented them from doing so, when considering diets, time to prepare, lack of skills and cost of healthy meals were often reported as influencing unhealthy behaviours:

“I think sometimes it's how expensive the fruit and vegetables can actually be and maybe the knowledge of not knowing how to cook, because they've never been really shown by the parents, or grandparents

“It's hard to cook a proper meal if you've been working all week. And if the adults are making bad decisions about what they're eating, [be]cause there's a lot of adults that are overweight, then you know for a fact that their kids are not going to, because they are just getting whatever they're given.”

“It takes longer to prepare something from scratch rather than just sticking something in a microwave. So, I think time with people, but I think a lot of it is more than just laziness.”

Older participants frequently reported that when they were growing up, meals were chosen not on their nutritional value, but on ease of preparation and cheapness. Some participants believed these habits have continued, despite wider availability of healthy foodstuffs:

“There were seven or eight of us needing to be fed. So, [the] easiest thing was to have some chips and a beef burger and that’s what caused all my health issues…Too much fatty food.”

“Well, like my mom worked, so my dad would cook, and his idea of cooking a meal was like chips and whatever. Everything was like chips and something and then it would be like in the proper fryer. So, I never learned to cook properly until I was about 16.”

“I was born in 1959…my mom brought me and my brother up and it was a case of basically what she could afford to buy. There wasn’t much option of buying something healthy.”

Alcohol consumption was considered a poor HEAL behavior especially if not done in moderation. Many participants reported that it was the wider drinking culture of the area they lived in that influenced rates of heavy drinking:

“I think the culture around here is like drinking is a fun social activity and it's expected and encouraged and … if you don't drink, people start to ask you why you are ruining all the fun.”

“There's generally heavy smoking, generally heavy drinking, and that is a quite normal council estate behaviour.”

“So, we used to go out every night even when [we were] working. And that's what most people did, particularly [Miners], you know–you work, you go out and have a drink–and I think I got influenced by that.”

“I think a lot of people don't think it's a problem...Like they think, well, if I get drunk and blackout on a weekend, that's fine.”

Participants claimed that the density of unhealthy food and alcohol purveyors had led to the above beliefs manifesting and spreading within the research location:

“There are a million pubs and off licenses. Alcohol is easily accessible; in supermarkets you can buy like a 24-pack of cans of cheap alcohol. It's very easy to get hold of and it's very normalised and it's just considered an everyday part of life. You go out on a weekend, you get drunk, you come home, you have a hangover and you do it again next week.”

“I mean there are not that many places that encourage healthy eating […], there are a lot of takeaways in this ward. I feel there are a lot of takeaways. If I wanted to go out to a restaurant, I can’t think of many that have a really healthy option or push that kind of thing.”

“There are four just on the high street. There [are] about eight or nine takeaways just on the high street. I am not joking. There are three of them right next to each other. [There] used to be six or seven pubs, three have now shut down. All of that on one high street, really, no one needs that many takeaway places or pubs.”

2.9 Mental health affecting HEAL

Participants would often speak of the interconnectedness of mental health, physical health, and environment:

“It’s also about an active mind. It’s having that health and wellbeing as well. It's not just about what we eat. It’s about wellbeing, mental health, physical health and nutrition, diet, everything.”

Additional lifestyle factors were also mentioned as being an interlocking factor, such as financial status, stress arising from uncertainty regarding housing and employment, and social status:

“For myself, healthy living often means being able to cope with the stresses of daily life. So, things like managing my money, although I suppose what I'm saying is I need to look after my mental health… There will be times when I feel alright and times when I feel quite depressed. So, it's just maintaining some sort of stability.”

Participants overwhelmingly believed that poor mental health played a role in influencing behaviour, especially behaviours relating to food, alcohol and cigarette consumption:

“Some people that for instance would use illegal substances, they’ll use alcohol, [and will get] themselves in an absolutely awful state.”

“They were not engaged in looking after themselves. They drank too much, smoked too much, they were even taking drugs.”

2.10 Governmental interventions

To investigate this theme, participants were asked what they felt was being done by both local (LG) and national government (NG) to address unhealthy behaviour in the research location, as well as how effective they felt governmental intervention had been. To avoid bias, participants were not specifically asked to say whether or not they thought the interventions were good or bad.

When speaking about NG, many participants expressed a general sense of disconnect between their everyday lives and NG intervention:

“I wouldn't associate the government with how to live a healthy lifestyle.[…] those two things don't go together for me.”

““I am not very interested in that, in politics and all of that. I don’t know what they are doing.”

When pressed further, participants’ responses became largely similar, with many expressing an underlying feeling that the NG was speaking down to them, and that any interventions would, in the long run, result in a net negative for them:

“I think there's this attitude of we're being preached to, is just going to make food more expensive, we're not going to eat less of it, we are just going to pay more for it.”

Most participants spoke favorably about the effort that LG was putting into interventions. There was, however, an almost unanimous agreement that the efforts of the LG were being hampered by the policies of the NG:

“I think that although they are doing their best and they are amazing, it’s just with the exercise, with the NHS, with the food, everything is just stretched so far, and sometimes they need that little bit more. I think government could spend a bit more money on other stuff, on these key things.”

“You know, local authorities don't have much money I'm sure if you sort it out, they will be doing lots of things, but it never bubbles over the surface.”

“But the fact is, if you're showing me these flyers and things and I take it away, and I go on the internet, not happening, not happening, no funding, no funding.”

3 Discussion

With reference to our themes, we encountered several findings that aid in understanding the issues facing deprived areas within the England. Importantly, we discovered that most participants are very aware of HEAL behaviours but struggled to maintain them due to environmental and societal pressures. We also found that poor mental health plays a strong role in influencing poor HEAL behaviours and that governmental interventions are often underfunded and unsuccessful in implementing long term change.

Currently, the UK’s primary means of promoting healthy eating and drinking is through the Eatwell guidance [11]. This guidance follows previously established literature in promotion of both healthy and balanced eating habits. For example, the guidance echoes Stipanuk and Caudill [12] who defined a healthy diet as one in which macronutrient consumption is appropriate in relation to supporting physiological needs whilst remaining within calorific requirements. Given that our findings show that most participants do understand the importance of HEAL, this suggests that the Eatwell guidance has been successful in increasing knowledge. However, issues remain with converting knowledge into behavior, we provide some insight into these issues, but more work is required to address this moving forward.

We found that participants disagreed on the cost of healthy eating, with some believing that healthy eating was cheaper than unhealthy eating. Haws, Reczek and Sample [13] argue that despite a widespread perception that healthy eating is expensive, objectively speaking, many healthier options are of similar if not lower price than unhealthy options. The current Eatwell guidance does not list prices for foods; therefore, an immediate fix may be to simply list an average price for staple healthy foods so people can see at a glance how prices compare.

The main reason given by our participants for not engaging with HEAL, was a general lack of time and skill set. Similar results were reported by Withall, Jago and Fox [14] and Bukman et al. [15], suggesting a level of generalisability in these findings. A wider social issue that may be compounding this issue is the removal of Home Economics courses in schools and their replacement with courses that focus less on practical skills.

Our older participants reported that many of experiences in childhood shaped their HEAL behaviours now, suggesting that inherited behaviors remain powerful motivators throughout life. Research by Bukman et al. in 2014 also shows similar results [15]. This raises concerns about the behaviours our young people are currently learning, especially given the removal of food skills from school curriculums and the overall poor quality of school meals available to children who attend schools in deprived areas as reported in O’Neill, Rebane and Lester [16].

Whilst decision making regarding food and diet seems to be largely influenced by extenuating circumstances and personal beliefs, reasons for overconsumption of alcohol were regarded as arising from social pressures and community habits. Participant’s reported the use of alcohol as common in everyday life and believed that many individuals used it as a way of coping with stress, depression and anxiety. The usage of alcohol in these ways is in keeping with findings published by Cucciare and Scarbrough [17]. Participants beliefs that density of alcohol purveyors was a reflection of community attitudes brings results in line with the SEM and the argument that behavior affects and is affected by the social environment [2]. Many deprived areas including our research location, struggle with alcohol related issues, Baron et al. [18] and McLeroy et al. [19], despite writing at very different times, both argued that if changes are made in the social environment this in turn produces a change in individual behavior. Based on our findings, it seems that in order to address alcohol related issues, a change will have to be made at a community level rather than an individual one, as social pressures and easy availability contribute heavily towards individual behavior. Usage of the SEM to evaluate which changes would be most effective may be useful. Given the history of health inequalities in individuals from deprived backgrounds, as documented in Algren et al. [6]; and Hillier-Brown et al. [20] it seems likely that if action is not taken, then as argued in Adams et al. [21]. individuals from deprived backgrounds, may well continue to engage in unhealthy behaviors and suffer worse health outcomes as a result when compared to participants from privileged backgrounds.

Moving back towards individual level factors, we found that most participants believed that mental health had a strong impact on, and was heavily affected by, HEAL. Participants believed that rates of poor mental health were higher in deprived areas, in keeping with current literature, which demonstrates a clear link between socio-economic status and mental health [22, 23]. Participants also claimed that stress, lack of opportunities for self-expression, and lack of mental healthcare contributed to poor mental. This links back to current theories on determinants of health, which highlight the role of social and economic factors in HEAL and mental health [16]. Overall, findings on causes and impact of mental health did not provide any new information, but they did confirm the role of mental health in HEAL and reinforce existing theories on the interconnectedness of the SEM, DoH and HEAL. In the case of our participants, mental health issues such as depression and anxiety were more likely to lead to excessive consumption of food and alcohol, whilst more severe mental health issues tended to result in the use of harder drugs. The tendency to engage in unhealthy eating and drinking habits when suffering from poor mental health may reflect the values, attitudes and beliefs that have been previously discussed. If so, then in addition to the intergenerational transfer of said factors, the prevalence of mental health problems in poorer and more deprived areas should also be considered a strong influencer in uptake of poor HEAL behaviours [4, 5].

Finally, we examined participants attitudes towards government interventions designed to promote HEAL behaviours. Our research location has received numerous cuts to funding totaling approximately 40–60% of Government funding; unemployment rates are high, and wages and health are low compared to non-deprived areas. At both a national and local level, support is provided for a variety of schemes, including physical exercise, dietary advice, and mental/emotional help. However, as discussed by our participants, many of them are either unaware or unable to access these services. What quickly became apparent is that comparatively few participants deliberately went out of their way to avoid awareness of said schemes, but had, over time, become less and less likely to seek out support in the local area because of a belief that this would ultimately be unproductive. Whilst participants had differing thoughts on governmental interventions, broadly speaking, participants had predominantly negative attitudes towards interventions by the NG and mixed feelings about interventions carried out by the local authority. However, whilst participants’ overall feelings were broadly consistent, individual differences in justification for these feelings were widespread. Ultimately, whilst difficult to pin down a single shared justification, the end result, participants feeling isolated from the national government interventions and disinterested in engaging in local government interventions, was of particular interest to this project, as this serves as a potential factor that has been overlooked when seeking to understand resistance to changing unhealthy behaviors.

Ultimately, this lack of faith in both local and national interventions has no simple solution. This does not mean that interventions do not work; on the contrary, they often succeed in many small but significant ways, despite the natural hesitancy of targeted individuals.

3.1 Limitations

The authors of this research are aware of two key limitations in this study. The first concerns the geographical location of the data collection strategy. The research has focused on one geographical area, namely Barnsley in South Yorkshire. If the project was to be undertaken again in the same manner, the research would examine other geographical areas in the UK that have similar social and economic status. The second concerns the sample size. The methods applied were qualitative focus groups and were at a relatively small sample size. Again, if this project was to be undertaken once more, the authors would extend the data collection by applying a longitudinal study. Here, participants would attend several meetings over an extended period of time. A broader participant group combined with longitudinal data would provide a greater level of insight in changes over time.

4 Conclusion

The vast majority of participants had a clear understanding of what constitutes healthy eating. The UK’s continued usage of governance such as the Eatwell guide has resulted in a broad acceptance of what healthy eating should look like. However, this knowledge does not necessarily convert to actual practice. Based on this, if healthy eating habits are to be continuously promoted, it may be useful to try and pivot away from simply raising awareness of what foods are healthy, as this message already seems well established. Instead, the focus moving forward should be on promoting the quickness and ease of preparation, and the ease with which healthy eating can be accomplished.

there was a connection between the previously discovered inherited attitudes towards healthy eating and living and the density of unhealthy food and drink outlets in the research area. This is in line with the theories put forth by the SEM. When asked how the presence of so many outlets had affected behaviour, participants primarily responded negatively. In the case of outlets providing food, many participants felt that the ease of access contributed to unhealthy eating habits via the provision of unhealthy foods. Additionally, several participants expressed a belief that the presence of these outlets had also led to long-term unhealthy behavior.

Mental health problems continue to negatively affect those living in deprived areas and do seem to be impacting on HEAL behaviours. Governmental interventions are required, but care has to be taken that these are both sustainable and useful.