Health inequalities

The evidence bearing on the nature and extent of health inequalities documented globally and in the UK is addressed, twin foci within the UK being (a) associations between socioeconomic classification and health and longevity, and (b) the notion of a 'social gradient'. A consideration of the various 'models' that have been developed by sociologists and their allies - most conspicuously social epidemiologists - to account for (a) and (b) is offered, drawing on government-sponsored commissions and reviews as well as the peer-reviewed literature. This is followed by a portrayal of specifically sociological theories of health inequalities, featuring those that hold social structures as well as cultural shifts in convention and behaviour to be causally efficacious for health inequalities. The summary and conclusions of the review incorporate an outline of pertinent questions the sociological community has so far been reluctant to address and an agenda for future research.     

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.     

Nutrition and inequalities. A note on sociological approaches

BACKGROUND: This article provides an overview of three approaches taken to illuminate the sociological contribution to the field of nutrition and inequalities, in the hope of prompting future researchers to pursue the lines of enquiry suggested. APPROACHES: Under the heading of inequalities in food use, the paper first exemplifies the utility of 'political arithmetic', possibly the sociological approach best known in public health. This includes socio-economic patterning in food purchases as well as disadvantage in access, where studies of poverty represent a longstanding focus. A rural/urban dimension has, however, been left dormant. A second approach is illustrated by work on public understandings of nutrition, encompassing primarily small-scale studies of beliefs about nutrition, which emphasise the plurality of lay definitions of diet and health. Lacking are studies which build on this work to uncover the relation to health inequalities. Third to be introduced is sociological work on the social distribution of taste, which illuminates the potential for examining enduring, shared ideas of styles in eating embedded in forms of the social organisation of the home that is associated with different socio-economic levels. CONCLUSION: The paper ends with comment on practical implications for public health practice and policy designed to reduce inequalities in nutrition.     

Social capital,from sociology to epidemiology: critical analysis of a transfer across disciplines

In recent years, social capital has emerged in epidemiological studies as a new concept, improving our understanding of the relationships between social inequalities and health inequalities. This concept, borrowed from social sciences, has three distinct sociological sources. However, only the most recent theory, which emphasizes the role of civic trust and is useful for analysis at community level, has been used in epidemiological studies. Social capital poses three kinds of problem: i) theoretical problems, because it is defined by its effects rather than by its causes, and because it is presumed that these effects are positive, although they can in fact be negative; ii) methodological problems, because of the heterogeneity of empirical scales, from micro to macro, and because of the diversity of its semantic content, including contradictions; iii) political problems, because of the emphasis placed on individual responsibility and due to the imposition of a model of civic virtue, to the detriment of structural analysis.     

Capitals and capabilities: linking structure and agency to reduce health inequalities

While empirical evidence continues to show that low socio-economic position is associated with less likely chances of being in good health, our understanding of why this is so remains less than clear. In this paper we examine the theoretical foundations for a structure-agency approach to the reduction of social inequalities in health. We use Max Weber's work on lifestyles to provide the explanation for the dualism between life chances (structure) and choice-based life conduct (agency). For explaining how the unequal distribution of material and non-material resources leads to the reproduction of unequal life chances and limitations of choice in contemporary societies, we apply Pierre Bourdieu's theory on capital interaction and habitus. We find, however, that Bourdieu's habitus concept is insufficient with regard to the role of agency for structural change and therefore does not readily provide for a theoretically supported move from sociological explanation to public health action. We therefore suggest Amartya Sen's capability approach as a useful link between capital interaction theory and action to reduce social inequalities in health. This link allows for the consideration of structural conditions as well as an active role for individuals as agents in reducing these inequalities. We suggest that people's capabilities to be active for their health be considered as a key concept in public health practice to reduce health inequalities. Examples provided from an ongoing health promotion project in Germany link our theoretical perspective to a practical experience.     

A public health model of the social determinants of health

Summary As we move forward in the new century, epidemiologists and public health practitioners are faced with the challenge of reviewing the current direction of epidemiology and its links with public health. While the history of epidemiology has been a successful and productive one, there is a danger that modern epidemiology is becoming too narrow in its scope, concerned primarily with the analysis of risk factors in individuals, while ignoring sociological and ecological perspectives of health. We argue that a theoretical framework to guide the practice of epidemiology is needed which encompasses a role for social determinants of health while simultaneously also acknowledging the importance of behaviour and biology, and the inter-connectedness of all these factors. This paper presents a public health model of social determinants of health, which provides a framework for testing the causal pathways linking social determinant variables with health care system attributes, disease inducing behaviours and health outcomes. This approach provides an improved opportunity to identify and evaluate evidence-based public health interventions, and facilitates stronger links between modern epidemiology and public health practice.     

European health inequality through the ‘Great Recession’: social policy matters

This paper investigates the association between the Great Recession and educational inequalities in self‐rated general health in 25 European countries. We investigate four different indicators related to economic recession: GDP; unemployment; austerity and a ‘crisis’ indicator signifying severe simultaneous drops in GDP and welfare generosity. We also assess the extent to which health inequality changes can be attributed to changes in the economic conditions and social capital in the European populations. The paper uses data from the European Social Survey (2002–2014). The analyses include both cross‐sectional and lagged associations using multilevel linear regression models with country fixed effects. This approach allows us to identify health inequality changes net of all time‐invariant differences between countries. GDP drops and increasing unemployment were associated with decreasing health inequalities. Austerity, however, was related to increasing health inequalities, an association that grew stronger with time. The strongest increase in health inequality was found for the more robust ‘crisis’ indicator. Changes in trust, social relationships and in the experience of economic hardship of the populations accounted for much of the increase in health inequality. The paper concludes that social policy has an important role in the development of health inequalities, particularly during times of economic crisis.     

Lifestyle drift and the phenomenon of ‘citizen shift’ in contemporary UK health policy

Despite political change over the past 25 years in Britain there has been an unprecedented national policy focus on the social determinants of health and population‐based approaches to prevent chronic disease. Yet, policy impacts have been modest, inequalities endure and behavioural approaches continue to shape strategies promoting healthy lifestyles. Critical public health scholarship has conceptualised this lack of progress as a problem of ‘lifestyle drift’ within policy whereby ‘upstream’ social contributors to health inequalities are reconfigured ‘downstream’ as a matter of individual behaviour change. While the lifestyle drift concept is now well established there has been little empirical investigation into the social processes through which it is realised as policies are (re)formulated and implementation is localised. Addressing this gap we present empirical findings from an ethnography conducted in a deprived English neighbourhood in order to explore: (i) the local context in the process of lifestyle drift and; (ii) the social relations that reproduce (in)equities in the design and delivery of lifestyle interventions. Analysis demonstrates how and why ‘precarious partnerships’ between local service providers were significant in the process of ‘citizen shift’ whereby government responsibility for addressing inequity was decollectivised.     

The economic analysis of inequalities in health

The paper explains the economist's concept of human capital, and uses it to analyse some of the problems raised in the Black Report on inequalities in health. Individuals are assumed to have an optimal 'stock' of health, defined as the level of stock for which the marginal benefits of further investment in the stock falls below its marginal cost. Differences in marginal benefits and costs between individuals will thus lead to differences in their health stocks. Use of this simple model and its associated concepts can be used to help explain, for instance, why social class differences in mortality are steepest in early adulthood and shallowest in the decade before retirement or why manual workers who 'need' more health than non-manual workers are nonetheless in general less healthy. The model can also contribute to the discussion of normative issues, for instance, to refine the concept of equality of access. However, while it has great potential in organising and analysing hypotheses concerning health behaviour, the model is in no way a substitute for other approaches; indeed it only becomes meaningful when interpreted in sociological, epidemiological and medical terms.     

Social Class for Collective Health Research: A Conceptual and Empirical Challenge

ABSTRACT

Social Determination of Health (SDH)/Collective Health is a Latin American framework that sees the Marxist core concept of social class as fundamental for understanding health inequalities. In contrast to social stratification approaches, Marxist proposals seek to understand health as part of the historical transformations of capitalism’s mode of production. In this article we aim to analyze the relationship between social class and health inequalities using data from the IV Oral Health National Study in Colombia. We conducted hierarchical cluster analyses to classify the population in five class positions and three living conditions clusters, which reflect how the spheres of production and social reproduction relate to social classes in Colombia. To measure oral health we use DMFT, as well as care and treatment needs indexes. Through variance analysis models we found that people from more exploited class positions and worse living conditions have more active disease and higher treatment needs. Despite technical and conceptual challenges, we conclude that a social class analytical framework can be operationalised via the interrelated spheres of production and social reproduction, which sheds light on the relationship between health inequalities and the class structure of the capitalist system.     

Theory in rural health

Objective: This paper offers theories to explain persistent rural health challenges and describes their application to rural health and research. Methods: Review of theories from several disciplines. Findings: Key issues in rural health are poorer health status and access to health care, staff shortages, relationship‐based health provision and the role of health services in community sustainability. These could be fruitfully addressed by applying theory and findings around social determinants of health, economic sociology, the role of culture and capitals approaches to measuring assets. In particular, the concept of rural health might be a barrier to progressing knowledge; and relational approaches, common in geography, offer a more useful conceptual framework for studying health and place. Conclusions: To move beyond its current stage, rural health needs to look to other disciplines' theories and ideas; particularly, it needs a more contemporary understanding of what place means so that health status and service provision can be improved by more thoughtful research.     

The context of coping: a qualitative exploration of underlying inequalities that influence health services support for people living with long‐term conditions

Coping with chronic illness encapsulates both practical and emotional aspects of living life in relation to one's long‐term health condition(s). Dominant health psychology approaches for understanding coping, which underpin a more recent policy discourse on ‘self‐management’, focus sharply on the person affected by illness and potentially mask the influence of overarching social structure. In this paper we draw on qualitative interviews with 48 people living with long‐term conditions (LTCs), in order to highlight the role that structural configurations such as healthcare systems may play in either helping or hindering people's efforts to cope with chronic illness. We argue that coping is a social process in which health and related services, situated within their wider political‐economic contexts, play an active role in shaping people's attempts to live well with LTCs. More specifically, health systems are sites of social and cultural capital exchange that can differentially mobilise coping resources through access, continuity of care, and coordination across services. Whilst it is essential to recognise the personal agency of people living with chronic illness, it is also vital to acknowledge the underlying inequalities that affect the ways in which services can support such resourcefulness.     

The use of quantitative medical sociology

Abstract The present article reviews, in relation to quantitative work on the social structure, papers published in Sociology of Health and Illness during its first 25 years. Each issue published during the years 1979–2002 has been examined; and quantitative papers, relating to various aspects of the social structure, have been identified. Such papers are found to have formed a minor but substantively significant theme within the Journal. These contributions situate the journal between sociology and social epidemiology. Articles in the Journal, for example, have been part of sociological debates about the measurement of social class, and of social epidemiological debates about the relationship between income distribution and population health. The contribution of Sociology of Health and Illness to a number of such debates is reviewed. The article concludes that the present situation, in particular the intellectual crisis in social epidemiology and social science investment in large data sets, gives the Journal the chance to build on this distinguished tradition by encouraging, through its publication policy, the further development of quantitative medical sociology.     

The social division of the city and the health promotion: the importance of new information and decoupage levels

The article examines the complex relationships among the sociological concept of socio-spatial segregation, urban poverty and health promotion, suggesting research topics that could contribute to a detailed analysis of the Brazilian social reality within the public health context, underpinning decisions on healthcare. Initially, the main aspects of the social division problems in major cities are examined from the historical and sociological viewpoints. The inaccuracies and problems related to the concept of segregation are then discussed analytically, referenced to discussions of urban sociology. The importance of new information and the decoupage of other levels of social ties are also addressed, taking the problems of health promotion into account. Finally, four themes are listed that might well constitute a research agenda: analysis of socio-spatial segregation structures; comparison of social structures and socialization practices in poverty-stricken neighborhoods; a study of the middle class and its space distribution; and Government policies, regulations curtailing segregation and urban inequalities.     

Desperately seeking reductions in health inequalities: perspectives of UK researchers on past,present and future directions in health inequalities research

Following government commitments to reducing health inequalities from 1997 onwards, the UK has been recognised as a global leader in health inequalities research and policy. Yet health inequalities have continued to widen by most measures, prompting calls for new research agendas and advocacy to facilitate greater public support for the upstream policies that evidence suggests are required. However, there is currently no agreement as to what new research might involve or precisely what public health egalitarians ought to be advocating. This article presents an analysis of discussions among 52 researchers to consider the feasibility that research‐informed advocacy around particular solutions to health inequalities may emerge in the UK. The data indicate there is a consensus that more should be been done to learn from post‐1997 efforts to reduce health inequalities, and an obvious desire to provide clearer policy guidance in future. However, discussions as to where researchers should now focus their efforts and with whom researchers ought to be engaging reveal three distinct ways of approaching health inequalities, each of which has its own epistemological foundations. Such differences imply that a consensus on reducing health inequalities is unlikely to materialise. Instead, progress seems most likely if all three approaches are simultaneously enabled.     

Epidemiology and inequality: notes on theory and history]

In this paper we present a historical analysis of the concept of inequality, and we also discuss how inequality has been viewed within the field of health. Natural and social inequalities are discussed, along with the concept of equity, theoretical explanations for inequality, and stratification in modern societies. Finally, we focus on the relationships between epidemiology and studies on social inequalities in health since epidemiology was established as a discipline, during the so-called bacteriological era, and at the present time, when there is a growing interest in social inequalities in health.     

Stratified users and technologies of empowerment: theorising social inequalities in the use and perception of diabetes self-management technologies

Medical technologies of various kinds play an increasingly important role in medical treatment, but may also increase health inequalities if they are primarily used by high-status patients. While many have problematised inequalities in the material access to medical technologies, differences in use and perception are also salient for explaining the relationship between medical technologies and health inequalities. This article attempts to theorise these inequalities by bringing health inequality research into dialogue with social constructivist perspectives on user-technology relations. Based on qualitative interview data from a case study of the technological self-management of type 1 diabetes, I construct three clusters of technological practices and perceptions corresponding to three broad user types. These user types are then discussed in the context of patient empowerment and the promotion of the active, autonomous and self-reflective ‘expert’ patient in European health care systems. To the extent that they materialise and enforce institutional expectations which only the most resourceful patients will be able to live up to, medical technologies may serve to entrench and legitimate social inequalities in health and medical care. Research therefore needs not only to consider how medical technologies are distributed, but also their design and appropriation by users.     

European politicans need epidemiologists

This paper reviews some of the recent discussions about public health policy in Europe. In particular it points to the interest in communicable diseases and the need to extend this interest into non-communicable fields. It draws attention to the consequential need for trained and continuously updated epidemiologists.     

Life Course Approach in Social Epidemiology: An Overview,Application and Future Implications

The application of the life course approach to social epidemiology has helped epidemiologists theoretically examine social gradients in population health. Longitudinal data with rich contextual information collected repeatedly and advanced statistical approaches have made this challenging task easier. This review paper provides an overview of the life course approach in epidemiology, its research application, and future challenges. In summary, a systematic approach to methods, including theoretically guided measurement of socioeconomic position, would assist researchers in gathering evidence for reducing social gradients in health, and collaboration across individual disciplines will make this task achievable.Key words: life course approach, social gradients in health, social epidemiology     

Bianca in the neighborhood: moving beyond the ‘reach paradigm’ in public mental health

This article offers a critical analysis of how to address social inequalities in mental health. In public mental health, inequalities are commonly construed as a problem of reach, implying that existing mental health expertise often fails to reach low-income groups. We discuss two critiques on the ‘reach-paradigm’ in mental health promotion: the impoverishment of idioms of distress and the tendency to transform complex political issues into clinical ones that are assumed to be backed by evidence. Furthermore, we present the findings of our ethnographic research of an alternative approach to mental health promotion that used media storytelling focused on local knowledge and social context. Our analysis is guided by anthropological research on idioms of distress and sociological literature on health promotion and social inequalities.