All in this together?

Dominic Conroy and Emily Nicholls on health behaviour changes during and beyond lockdown.

Almost daily news reports point to how lockdown, ‘the new normal’ for most, is influencing behaviours relevant to physical health – including alcohol consumption and taking physical activity. But how is health behaviour changing, among whom, and will any changes last post-lockdown? 

We argue that health polarisations are tied with broader social inequalities, with implications for whether any lifestyle changes will endure. Psychological and social science research must respond with creative, collaborative and innovative research to guide health policy and practice in the post-lockdown world serving the interests of all citizens.

Lockdown health behaviours: polarised? 

The closure of drinking establishments has not quelled people’s thirst for drink-related interactions, evident in the popularity of Zoom ‘happy hour’ drinking sessions between friends and the plethora of ‘lockdown drinking’ related memes circulating on social media. A near five-fold increase in access to Alcohol Change UK’s online support pages in April 2020 (relative to March/April 2019) has triggered concern about risks of relapse among service users with historical problem drinking. Some are drinking less during lockdown but the picture is uneven: 47% of pre-lockdown once-a-week drinkers appear to be drinking less or nothing during lockdown, but 18% of pre-lockdown daily drinkers appear to be consuming more than before (Alcohol Change UK, 2020). This kind of polarisation seems to mirror wider, often generational patterns where we are seeing declining drinking rates amongst younger people but continued heavy drinking amongst ‘baby boomers’ (Nicholls, 2019). 

Other health-related behaviours, such as exercise and smoking, may be undergoing changes too. For example, Joe Wicks home workout routine has become a phenomenon during lockdown and experts have pressed the importance of promoting healthy physical activity routines among children during the pandemic (Guan et al., 2020). A ‘lockdown economy’ report, meanwhile, notes that exercise and home workout equipment sales soared in early lockdown, with a 419% increase in demand for kettlebells despite price increases of 55% compared to this time last year (Nagarajan, 2020). 

More evidence of a major change in health behaviour comes from YouGov/Action on Smoking (Ash) survey data (1,004 individuals) implying that 300,000 individuals may have quit smoking while more still may have tried to quit or smoke less during lockdown. 

Yet despite apparent positive trends around drinking, exercise and smoking, a more nuanced understanding is required. While some individuals may take the opportunity to engage in more physical activity during lockdown relative to before, they may drink and smoke more than previously. For example, psychological theory might point to the predictive role of coping motives as predictors of alcohol-related problems with recent evidence pointing to how coping motives explain daily anxiety and depressed mood (e.g. Stevenson et al., 2019). Extending beyond drinking behaviour alone, a recent study exploring health behaviour during periods of stressful uncertainty has demonstrated links between greater positive emotion and diet/exercise and between increased worry and higher alcohol use (Howell & Sweeny, 2020). But what can psychological and sociological theory tell us about whether these behaviours might endure beyond stressful/uncertain situations like the lockdown period?

Lockdown health behaviours: sustainable? 

Questioning where and among whom behaviour changes have occurred is one thing, knowing whether these changes will last is another. Varied scenarios are plausible: when lockdown is slowly relaxed, lockdown-instilled health behaviour change may last decades ahead or may fizzle out abruptly once normal service is resumed. 

Psychology provides diverse theoretical options to help explain. Of central importance to many psychological theories of longer-term behaviour change is ‘self-efficacy’. Schwarzer’s (2008) Health Action Process Approach might highlight how lockdown provides opportunities to gain personal skills in feeling motivated to engage in health-adherent behaviours (i.e. gaining ‘task self-efficacy’) and to carry forward positive changes even when faced with challenges that might be attributable to lockdown like stress (i.e. gaining ‘coping self-efficacy’) or set-backs (i.e. gaining ‘recovery self-efficacy’). The lockdown period might also be conceptualised as a particular kind of 'teachable moment' (e.g. Lawson and Flocke, 2009) – i.e. as an opportunity or context in which health-adherent behaviour can be practiced, mastered and possibly even entrenched in the longer term. 

Psychological theory might also emphasise lockdown-related health behaviour changes in terms of changed social perceptions of health-related behavioural status. For example, lockdown conditions may lead to modified alcohol-related ‘prototypes’ (i.e. the social images we hold of different drinker types like 'non-drinkers'). Evidence has suggested that 91% of young adults hold relatively negative views of 'the typical non-drinker' (Conroy & de Visser, 2016), but increased exposure to housemates or partners who drink little/no alcohol or who have dropped booze for other pastimes during lockdown may have modified these views, with knock-on effects for personal drinking plans and alcohol consumption itself in the longer term post-lockdown era.

Locating how wider issues around class and social inequalities may also impact upon both polarisations and the ability to maintain health behaviours post-lockdown is also important. For example, the ability to access local green spaces where social-distancing can be safely practiced, or the ability to afford home workout equipment, are clearly conditional on socio-economic status. When council-run gyms and swimming facilities will re-open is unclear and when they do limits are likely in terms of the numbers who can access facilities. We also know that those in lower socio-economic groups are more likely to smoke, to start smoking earlier, to smoke for longer and to die prematurely from smoking. Further research is required to explore whether any changes to smoking patterns during lockdown are polarised across class lines, and consider whether any changes might only be short-term ones. Similarly, community services offering support around issues such as substance use and mental health are likely to look different even if lockdown is ‘eased’; demand may increase and disproportionately impact service in the areas already most severely affected by government cuts and deprivation. 

Whether individuals who work multiple jobs on irregular/long hours, can maintain any new exercise regimes developed during lockdown into the longer-term seems highly uncertain. Other wider structural changes in a ‘post-lockdown’ world, including a near-certain precarious employment scenario will also make health behaviour changes harder to maintain and are likely to disproportionately affect certain groups including those from lower socio-economic backgrounds and those working in precarious industries or facing unemployment or underemployment.

With enduring uncertainty about when lockdown will end and what exactly a post-lockdown UK will look like, there is much uncertainty about the long-term sustainability of health-related behaviour change. Yet amongst all the uncertainty, one thing is clear; further research is required to understand the nuances of health behaviour changes, how long they might endure and – crucially – the ways in which longer term changes intersect with issues of social inequalities and social justice.

Using psychology to guide a post-lockdown health promotion approach committed to social justice

As a society we are drawn toward 'convenient headlines' (such as those about changing drinking habits in lockdown) but as researchers we need to look behind the headlines and consider research designs that can identify and articulate nuance. Research within psychology and the social sciences more widely must strive to frame understanding of individual behaviour change in the context of the wider structural factors which shape and constrain health behaviours and practices.

Social science can help us to understand the enduring and conditional nature of health inequalities. We have long known of a ‘gradient’ effect where lower socio-economic status is associated with poorer health outcomes across a range of measures (Broom, 2000). Adopting a critical sociological lens, we can recognise how health inequalities can be perpetuated under a capitalist system (Scambler, 2019). This can help us to appreciate the ways in which health behaviour changes are stratified and affected by class, and how attempts to make any longer-term changes to lifestyles may be hindered by factors such as poverty, unemployment or lack of economic or social capital. Our ‘capital’ can affect our ability to access anything from fresh fruit and vegetables to safe, open spaces to walk with our families. Indeed, Scambler (2019) outlines a system of different forms of ‘assets’ (including bodily, material, spatial and cultural) that may all significantly affect health outcomes and contribute to health inequalities. 

With more time indoors with family and co-habiters, we can also ask how social context influences health behaviour. For example, people may now drink more as households than before or, conversely, may drink more alone than before. Similarly, the passage of time has acquired new meanings during lockdown: some will have more disposable time or a reconfigured relationship with daily routines during lockdown, potentially relaxing the “5 o’clock rule”. Contextual, spatial and temporal changes are likely to hold implications for other health behaviours including smoking, diet and physical exercise and these potential changes warrant research attention.

The post Covid-19 era presents serious challenges and likely far-reaching costs, but also offers a powerful opportunity to invigorate an inter-disciplinary social science health research agenda across fields such as psychology and sociology. This co-operative approach can help position an understanding of individualised behaviour changes enacted in a wider context involving social structures and within local communities that is cognisant of social inequalities pre-, during and beyond societal lockdown. 

Dominic Conroy (University of East London)

Emily Nicholls (University of Portsmouth)

References

Broom, D. (2000) The Sociology of Health Inequalities. Health Promotion International. Volume 15, Issue 2, June 2000, Pages 179–180

Conroy, D. & de Visser, R.O. (2016). Understanding the association between relative sociability prototypes and university students’ drinking intention. Substance Use & Misuse, 51(14), 1831-1837. https://doi.org/10.1080/10826084.2016.1197939

Guan, H. et al. (2020). Promoting healthy movement behaviours among children during the COVID-19 pandemic. The Lancet Child & Adolescent Health, April 29, 2020; DOI: 10.1016/52352-4642(20)30131-0

Howell, J. L., & Sweeny, K. (2020). Health behavior during periods of stressful uncertainty: associations with emotions, cognitions, and expectation management. Psychology & Health, 1-21.

Lawson, P. J., & Flocke, S. A. (2009). Teachable moments for health behavior change: a concept analysis. Patient education and counseling, 76(1), 25-30.

Nagarajan, S. (2020) Yoga mats, beard trimmers, and loungewear: Here's what online shoppers in the UK have been splurging on during the past two weeks of lockdown. Business Inside. Available at: https://www.businessinsider.com/what-online-shoppers-uk-splurged-on-duri...

Nicholls, E. (2019) Baby boomers are keeping booze Britain afloat – but the young are drinking less. The Conversation. Available at: https://theconversation.com/baby-boomers-are-keeping-booze-britain-afloat-but-the-young-are-drinking-less-121659

Scambler, G. (2019). Sociology, Social Class, Health Inequalities and the Avoidance of ‘Classism’. Frontiers in Sociology, 4, 56.

Schwarzer, R. (2008). Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors. Applied Psychology: An International Review, 57(1), 1–29.

Stevenson, B. L., Dvorak, R. D., Kramer, M. P., Peterson, R. S., Dunn, M. E., Leary, A. V., & Pinto, D. (2019). Within-and between-person associations from mood to alcohol consequences: The mediating role of enhancement and coping drinking motives. Journal of abnormal psychology, 128(8), 813.

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