Health Inequalities Research Research Articles

Addressing health inequalities in the United Kingdom: a case study.

Health inequalities research has a long history in the United Kingdom, and the development of government policies that are intended to explicitly address the existing health inequalities has been gathering pace since the Labour Party returned to power in 1997. In this paper, using the influential Acheson Report as a reference point, one of us (D.N.) describes how health inequalities policies have been developed, and the other (A.O.) assesses how, ideally, such policies ought to be developed. Although progress in the development of health inequalities policies has been made, the policies, and the evidence that has informed them, have been less than ideal.

Historical Data for Health Inequalities Research: a Research Note

In 1999–2000, a pilot study was conducted to assess the feasibility of using local historical archives and oral histories to map historical factors that may be important in understanding contemporary variations in health. Focusing on housing clearances in the 1950s, 1960s and 1970s, the pilot study drew on a wide range of materials (documentary and oral) to explore how changes to local housing impacted upon the local social and psychological landscape. This research note considers methodological issues relevant to the use of documentary and oral history resources and illustrates the value of the historical resources we identified. We suggest that, on the basis of this pilot research, future explorations of the link between places and inequalities in health should incorporate an historical analysis.

Making sense of symptom checklists: a latent class approach to the first 9 years of the British Household Panel Survey.

In health inequalities research there is a growing impetus to examine the development of inequalities in health over time. However, many of the sources of longitudinal data in Britain are not designed specifically for health research. Typically, health status is assessed by self-reported problems and the use of symptom checklists. The British Household Panel Survey (BHPS) is an annual survey of approximately 5500 private households containing 9000 men and women, which began in 1991. Each year, the BHPS contains a checklist of 13 health problems and symptoms. The findings presented here are based on adult participants aged 16 years and over in 1991. Using eight waves of data from the BHPS, we use latent class analysis (LCA) to model latent health status from a set of observed binary variables. Individuals are assigned to a latent health class on the basis of LCA estimated probabilities of class membership given their response patterns and the estimated unconditional class frequencies. The predictive value of latent health class membership is assessed for self-reported health status and functioning, health and welfare service use, and mortality 1 year later. The LCA supported a suitable four-class model of health status representing good health, psychosomatic health problems, physical health problems and comorbid health problems. Members of the good latent health class were predicted to have better self-reported health and functioning, less health and welfare service use, and lower risk of mortality 1 year later than members of the three problem health classes. Those with comorbid health problems were predicted to have particularly poor outcomes. A latent class approach to modelling self-reported health problems and symptoms has allowed for both quantitative and qualitative dimensions of health status to be captured. This may motivate better informed models of health by users of general population surveys.

'Just do it': An analysis of accounts of control over health amongst lower socioeconomic status groups

Recent interest in health inequalities research has focused upon psychosocial factors such as a sense of control. Previous work has sought to measure or describe personal beliefs about control over health without addressing the contradictory and rhetorical dimensions of such accounts. These issues are explored through an analysis of interviews with 30 lower socioeconomic status (SES) participants drawn from two qualitative studies of health inequalities. Key findings concern the rhetorical construction and interweaving of two contrasting positions regarding control over health: fatalism and positive thought. Fatalistic talk provided a means by which participants acknowledged their limited control over health, although not in an exclusively negative manner. Talk about thinking positively enabled participants to present themselves as having agency in the face of adversity. The creative interweaving of these two positions in accounts of control over health enabled participants to navigate the moral imperative of responsibility for health in the context of adverse and capricious circumstance. By foregrounding the social character of accounts of control the significance of moral and ethical dimensions for health inequalities research and practice are highlighted.

Me and my heart.

The Health Variations Programme is a research programme focused on the social determinants of health inequalities. It was funded by the Economic and Social Research Council from 1996 to 2001. Its aims were to undertake multi‐disciplinary social science research to advance the understanding of the social processes that underlie and mediate socio‐economic inequalities in health, and to advance the methodology of health inequalities research. Having been chairman of an MRC board, I am aware of what you might call competitive pressure for grants, and the years of battle at Board and on the Council have left me scarred. This has lead to an unreasonable caution (no—those are weasel words—a suspicion) of work where endpoints or outcome measures are difficult to define. The kind of work supported in this initiative is difficult to constrain in these terms but rather, lends itself to the discovery of things that are hard to quantify and hard to deal with in the remedial sense. They are, however, clearly important to the community. In looking at a number of reports from the initiative to see how the new biology might help to resolve some of the difficulties of research in this area, it was interesting to see a good many methodological studies designed to resolve some of the difficulties outlined above, but one study in particular is compelling since it defines, for me, another set of problems. Under the title ‘The role of perceptions of family history in persisting inequalities in health and lifestyle’, Watt has looked at coronary heart disease (CHD). People's ideas about their ‘family histories' …

Population production and modelling mortality—an application of geographic information systems in health inequalities research

Much research into spatial inequalities in health has sought the balance between compositional and contextual influences on observed patterns. Research published recently by the authors sought to determine whether composition of areas alone might account for the changing geography of mortality in Britain, between 1983 and 1993. The research required data describing Britain in terms of the numbers and location of people with every possible combination of age group, sex, social class and employment status. This paper describes the approach and the custom written geographic information system which estimated these data, and their subsequent application.

Building the evidence base to address health inequalities.

The Australian Health Inequalities Research Collaboration (HIRC) was established by the Commonwealth Government in 1999. In the July 2001 issue of the NSW Public Health Bulletin (Volume 12, Number 7), Dixon and Sibthorpe, from the National Centre for Epidemiology and Population Health, reviewed the work of HIRC in its first 18 months. Here we provide an update of its activities.

Building an inter-disciplinary science of health inequalities: the example of lifecourse research

Across the post-industrial world, new public health strategies are being developed with the goal of reducing the socio-economic gradient in health. These new strategies are distinguished by a commitment to tackling the macro determinants of health inequalities through policies informed by scientific evidence. The engagement with macro determinants and with scientific evidence presents a major challenge to the health inequality research community. This is not only because of the complexity of the links between distal causes, proximal risk factors and health outcomes. It is also and more importantly because of the narrow disciplinary base of health inequality research. Grounded in social epidemiology, health inequality research has illuminated the pathways which run from individual socio-economic position to health—but has left in shadow the factors which influence socio-economic position. Broadening the evidence base to include these structural processes requires a new science of health inequalities, resourced both by epidemiological research and by research on social inequality and social exclusion. The paper demonstrates how such an inter-disciplinary science can be constructed. Taking lifecourse research as its example and the UK as its case study, it nests epidemiological research within social policy research: setting evidence on the health consequences of cumulative exposures within research on lifecourse dynamics, and locating both within analyses of how state policies can amplify or moderate inequalities in socio-economic position.

On the methodological, theoretical and philosophical context of health inequalities research: a critique

The integration of survey data with psycho-social theories is an important and emerging theme within the field of health inequalities research. This paper critically examines this approach arguing that the respective models of health inequality which these approaches promote, the related concepts of ‘social cohesion’ and ‘social capital’ suffer from serious methodological, theoretical and philosophical flaws. The critique draws particular attention to the limitations of survey-derived data and the dangers of using such data to develop complex social explanations for health inequalities. The paper discusses wider epistemological issues which emerge from the critique addressing the fundamental but neglected question of ‘what is inequality’? The paper concludes by introducing a structure for questions regarding health inequalities emphasising the need for those question to be attached to real communities.

Income inequality, the psychosocial environment, and health: comparisons of wealthy nations

The theory that income inequality and characteristics of the psychosocial environment (indexed by such things as social capital and sense of control over life's circumstances) are key determinants of health and could account for health differences between countries has become influential in health inequalities research and for population health policy. We examined cross-sectional associations between income inequality and low birthweight, life expectancy, self-rated health, and age-specific and cause-specific mortality among countries providing data in wave III (around 1989-92) of the Luxembourg Income Study. We also used data from the 1990-91 wave of the World Values Survey (WVS). We obtained life expectancy, mortality, and low birthweight data from the WHO Statistical Information System. Among the countries studied, higher income inequality was strongly associated with greater infant mortality (r=0.69, p=0.004 for women; r=0.74, p=0.002 for men). Associations between income inequality and mortality declined with age at death, and then reversed among those aged 65 years and older. Income inequality was inconsistently associated with specific causes of death and was not associated with coronary heart disease (CHD), breast or prostate cancer, cirrhosis, or diabetes mortality. Countries that had greater trade union membership and political representation by women had better child mortality profiles. Differences between countries in levels of social capital showed generally weak and somewhat inconsistent associations with cause-specific and age-specific mortality. Income inequality and characteristics of the psychosocial environment like trust, control, and organisational membership do not seem to be key factors in understanding health differences between these wealthy countries. The associations that do exist are largely limited to child health outcomes and cirrhosis. Explanations for between-country differences in health will require an appreciation of the complex interactions of history, culture, politics, economics, and the status of women and ethnic minorities.

Developing a UK Health Equity Network

The UK Health Equity Network (HEN) was established in 1999 to encourage and facilitate multidisciplinary and multi-stakeholder collaboration in health inequalities research. This paper briefly details the history, objectives and location of HEN. Public Health (2001) 115, 87–88.

How can a government research and development initiative contribute to reducing health inequalities?

The Health Inequalities Research Collaboration (HIRC) is a research initiative to address health inequalities, established in July 1999 by the Commonwealth Minister for Health and Aged Care. Its ability to offer policy options to the government, like similar initiatives in other countries, is circumscribed by numerous factors. They include lack of consensus about the causes of health status differentials, inadequate evidence on how to intervene to reduce health inequalities, and an infrastructure that is underdeveloped in terms of intersectoral action. This article reflects on the work done during the first eighteen months of the Collaboration; on the dynamics that need to be accounted for in any research and development (RD and on some opportunities offered by the Collaboration in meeting these challenges.

Making a difference to socioeconomic determinants of health in Australia: a research and development strategy.

Disparities in health across the socioeconomic spectrum are now recognised worldwide and demand policy action. Pathways from social disadvantage to health outcomes are poorly understood, and reducing social disadvantage poses crosscutting political, moral and methodological issues. The Health Inequalities Research Collaboration, an initiative of the Commonwealth Department of Health and Aged Care, is establishing a research and development process to support departmental efforts to reduce health inequalities. The collaboration is building research networks in child development, community resources and primary healthcare. Policy action needs to extend beyond the health portfolio and the role of government. Broad strategies are required, as is research to fearlessly evaluate the health effects of government policy, economic activity and cultural change. The Canadian Institute for Advanced Research is a model for national research of the kind needed in Australia.

Income non-reporting: implications for health inequalities research

OBJECTIVESTo determine whether, in the context of a face to face interview, socioeconomic groups differ in their propensity to provide details about the amount of their personal income, and to...

Philosophical problems with social research on health inequalities.

This paper offers a realist critique of social research on health inequalities. A conspectus of the field of health inequalities research identifies two main research approaches: the positivist quantitative survey and the interpretivist qualitative 'case study'. We argue that both approaches suffer from serious philosophical limitations. We suggest that a turn to realism offers a productive 'third way' both for the development of health inequality research in particular and for the social scientific understanding of the complexities of the social world in general.

Genetic, Cultural or Socio‐economic Vulnerability? Explaining Ethnic Inequalities in Health

Most work on ethnic inequalities in health in the UK has focused on genetic and cultural difference, ignoring issues relating to class disadvantage. However, more recent work, and that conducted in the US, suggests that material disadvantage might be crucial. Nevertheless, the wider sociological literature illustrates that ethnicity and ‘race’ cannot simply be reduced to class.This paper uses data from the Fourth National Survey of Ethnic Minorities to examine three alternative approaches to ethnic inequalities in health. Epidemiological approaches are driven by empirical findings and make little explicit acknowledgement of theoretical understandings of ethnicity, but they carry the assumption that ethnicity provides a natural and fixed division between population groups. Consequently, explanations for differences tend to be reduced to ahistoric and de‐contextualised genetic and cultural factors. Structural approaches generally focus on material explanations for inequalities, but there are important methodological difficulties in assessing these. We also need to consider other elements of the structural disadvantage faced by ethnic minority groups, such as their experiences of racism or concentration in particular geographical locations. Approaches that focus on ethnic identity emphasise the importance of group affiliation and culture, while acknowledging the contingent and contextual nature of ethnicity. However, despite the promise carried by identity based approaches, there has been little empirical work undertaken.These varying approaches illustrate how important ethnic inequalities in health might be to a wider understanding of mechanisms producing inequalities in health. However, a concern with mechanisms in health inequalities research can lead to a focus on technical interventions along causal pathways, with the roots of health inequalities, wider social inequalities, being ignored.

Integrating nonemployment into research on health inequalities.

An increasing proportion of the population is not currently employed; health inequalities research should include these people in analyses. Labor market position is the key determinant of health in Western societies; it is essential to clarify the independent effects of the three main components of labor market position: educational qualifications, occupational class, and employment status. These issues are addressed using national data from the British General Household Survey for 1991-1992 and two measures of ill-health: limiting long-standing illness and self-reported health. Occupational class is a stronger predictor than educational qualifications of measures of ill-health for men and long-term illness for women. When employment status is included in the models, the class gradient is weakened, suggesting that omitting the nonemployed from class analyses will produce a seeming weakening of class inequalities in health. The analyses show that class inequalities in health are somewhat greater for nonemployed than employed men, but weaker for nonemployed than employed women. In spite of older people having left the labor market many years earlier, class based on their previous occupation continues to have a major effect on their health. Class should be the primary variable in analyses of inequalities in health, and all groups of the nonemployed should be analyzed using their last main occupation.

The future of research in critical care nursing

Evidence on health inequalities has grown in recent decades, however, the capacity to generate health inequalities research is uneven, worldwide. A recent bibliometric analysis found notable inequalities of the global production of health inequalities scientific research across countries. What determines the capacity to produce high volumes of health inequalities scientific research, in different settings? What mechanisms are involved? To answer these questions requires in-depth knowledge on the health inequalities research production process, in different settings. We plan to conduct two realist explanatory case studies, to understand why and how particular settings (e.g. the United Kingdom and the city of Barcelona) have generated high volumes of health inequalities research over past decades, and identify the potential key contextual conditions and causal mechanisms involved. This study protocol outlines the rationale and methodology involved, highlights the strengths and limitations of the approach, and provides guidance on how to overcome certain operational challenges and ensure validity of research findings. Valuable learning may be derived from these case experiences, with implications for research, policy and practice. This work can serve as a tool for researcher and planners to guide the development of further case studies to evaluate health inequalities research capacities in other settings.