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.     

Young people's views on sharing health-related stories on the Internet

There is an increasing interest in the use of stories in healthcare practice and education. However, there are few stories from young people concerning health and little is known about their views on sharing such stories on the Internet. The aim of this study was to explore young people's perspectives in this area. A qualitative method was used and a project website was purposely built to facilitate data collection. An online focus group with 13 young people was carried out in an asynchronous format. Participants valued highly the therapeutic effect of storytelling and the use of digital stories to share feelings and experiences with a wide range of audiences, suggesting that well-produced stories could be a useful learning resource. A number of concerns were also raised, including embarrassment, reaction of other people and online safety. Having stories available on the Internet can be beneficial; however, concerns especially about safety associated with Internet use and support for storytellers should be taken into consideration. A better understanding of young people's perceptions can provide valuable insights for future work with this age group on storytelling.     

Young people's views of mental health education in secondary schools: a Scottish study

Background   This exploratory study used mixed methods to investigate young people's preferences in the delivery of mental health education and to investigate possible age and gender differences.
Method   Information was gathered about the delivery of mental health education in three secondary schools. Nine pupil focus groups were carried out to identify key themes which were then further developed and administered through questionnaires to a larger sample of 773 pupils.
Results   Gender and age differences were found in young people's preferences about who should deliver mental health education, and what, when, where and how this should be delivered.
Conclusion   Mental health education should reflect the needs of young people. Age and gender preferences should be considered when designing these programmes.     

Young people's perspectives on the use of reverse discourse in web-based sexual-health interventions

Web-based sexual-health promotion efforts often utilise reverse discourse – the acknowledgement and rejection of shame associated with stigmatised terms – both to challenge judgments about ‘risky’ behaviours (e.g., casual sex) and to appeal to young people. This study examines the use of reverse discourse in Internet-based sexual-health promotion and analyses young people's perspectives on this approach. During in-depth interviews and focus groups with young people (aged 15–24), participants shared their perspectives on written (e.g., clinical language; colloquial language) and visual (e.g., generic, stock images; sexualised images) depictions of sexual-health topics on the websites. More explicit styles elicited negative responses from young people in terms of perceived appeal, trust and quality of websites. Negative social mores were associated with some of the more explicit portrayals of young people's sexual lives on the websites, revealing how reverse discourse re-stigmatises young people by re-emphasising young people's sexual activity as inherently risky or immoral. Reverse discourse was perceived to have negative effects on the saliency and credibility of online sexual-health information. We discuss the theoretical basis for the operationalisation of reverse discourse in this context, and discuss the importance of considering sociotechnical aspects of Internet-based sexual-health interventions.     

Tackling health inequalities in Norway: applying linear and non-linear models in the policy-making process

This article follows the Norwegian policy-making process on social inequalities in health applying models for policy development with focus on linear and non-linear movements. The focus is process-oriented following the introduction of a comprehensive, cross-sectoral strategy to tackle socioeconomic health inequalities in Norway. A case study design was selected and two theoretical frameworks have guided the research. Whitehead's model for health inequality intervention (2007) follows a linear theory-based logic, underpinning the idea that implicit or explicit theories or formulation of a distinct problem causally predicts design and outcome of policy programmes. The second approach is based on Kingdon's (2003) perception that policy-making often occurs unpredictably within independent streams of the policy formulation process. The model focuses on the non-linearity of the flow and timing of policy action. The present case suggests that both linear and non-linear models are necessary for understanding of the Norwegian policy-making process on social inequalities in health. Whitehead's model is a conceptual model focussing on the linear structure of the policy process, useful for identifying the different entry points for choice of direction in policy-making. Kingdon's multiple streams model is useful for gaining insight into the agenda-setting process that may be predictable, but may also be unpredictable and steer non-linear movements. The model identifies components necessary for a problem to rise on the political agenda with a particular focus on the role of policy entrepreneurs.     

Framing health inequalities for local intervention: comparative case studies

This article explores how health inequalities are constructed as an object for policy intervention by considering four framings: politics, audit, evidence and treatment. A thematic analysis of 197 interviews conducted with local managers in England, Scotland and Wales is used to explore how these framings emerge from local narratives. The three different national policy regimes create contrasting contexts, especially regarding the different degrees of emphasis in these regimes on audit and performance management. We find that politics dominates how health inequalities are framed for intervention, affecting their prioritisation in practice and how audit, evidence and treatment are described as deployed in local strategies.     

Understanding lay perspectives on socioeconomic health inequalities in Britain: a meta‐ethnography

The links between socioeconomic circumstances and health have been extensively studied in Britain but surprisingly few studies consider lay perspectives. This is problematic given popular efforts to reduce health inequalities appear to be based on assumption that public understanding is limited (this is evident in efforts to raise awareness of both ‘upstream’ causes of health inequalities and health‐damaging behaviours). The results of this meta‐ethnography, involving 17 qualitative studies, fundamentally challenge this assumption. We show, first, that people who are living with socioeconomic disadvantage already have a good understanding of the links between socioeconomic hardship and ill‐health. Indeed, participants’ accounts closely mirror the research consensus that material‐structural factors represent ‘upstream’ determinants of health, while ‘psychosocial’ factors provide important explanatory pathways connecting material circumstances to health outcomes. Despite this, people living in disadvantaged circumstances are often reluctant to explicitly acknowledge health inequalities, a finding that we suggest can be understood as an attempt to resist the stigma and shame of poverty and poor health and to (re)assert individual agency and control. This suggests that work to increase public awareness of health inequalities may unintentionally exacerbate experiences of stigma and shame, meaning alternative approaches to engaging communities in health inequalities discussions are required.     

The limitations of targeting to address inequalities in health: a case study of road traffic injury prevention from the UK

So-called ‘Third Way’ responses to inequalities in health have encouraged the ‘targeting’ of evidence-based interventions at those communities at high risk in order to improve health outcomes. In the UK, one area of persisting inequalities in mortality and morbidity risk is from injury, and there have been recent national and local incentives for relevant agencies to ‘address deprivation’ in delivering reductions in injury through ‘targeting’ particular communities in the context of an evidence-based approach to policy making. This case study draws on interviews with those responsible for implementing policy in London in order to explore the tensions inherent in such approaches. We suggest that ‘taking deprivation into account’ by targeting is unlikely to be a fruitful route for addressing inequalities in health, as it devolves responsibility to a level which has no power to address the determinants of inequality.     

Barriers to addressing the societal determinants of health: public health units and poverty in Ontario, Canada

Despite Canada's reputation as a leader in health promotion and population health concepts, actual public health practice for the most part remains wedded to downstream strategies focussed on behaviour change. In Canada's largest province this has led to the implementation of a heart health promotion approach focussed on diet, activity and tobacco use. This is so despite increasing evidence that these approaches are generally ineffective, particularly for those at greatest risk. In addition, these strategies appear to divert public and governmental attention away from addressing the broader societal determinants of health. Examples of Ontario public health units that have begun to address societal determinants of health provide a counterbalance to the dominant paradigm that frames health as an individual responsibility. These new approaches focus attention upon the health-threatening effects of governments' regressive social and economic policies in a manner consistent with the best principles of health promotion.     

Childhood disadvantage and health inequalities: a framework for policy based on lifecourse research

Tackling health inequalities is moving up the policy agenda of richer societies like the UK, with governments looking for evidence to guide policy review and development. Observational studies of how childhood disadvantage compromises health in adulthood are an important part of the evidence base, but are largely inaccessible to the policy community. We develop a framework which captures the findings of these studies. Our framework highlights how disadvantage in childhood adversely affects both socio-economic circumstances and health in adulthood through a set of interlocking processes. Key among these are children's developmental health (their physical, cognitive and emotional development) and health behaviours, together with the associated educational and social trajectories. In breaking down the link between childhood disadvantage and adult health into its constituent elements, the framework provides a basis for understanding where and how policies can make a difference. The paper argues that the process of policy review and development needs to include both new programmes and the mainstream policies in which they are embedded.     

Unravelling the extent of inequalities in health across urban and rural areas: Evidence from a national sample in England

Studies of inequalities in health between rural and urban settings have produced mixed and sometimes conflicting results, depending on the national setting of the study, the level of geographic detail used to define rural areas and the health indicators studied. By focusing on morbidity data from a national sample of individuals, this study aims to examine the extent of inequalities in health between urban and rural areas, as well as inequalities in health across rural areas of England. Multilevel analyses for poor self-rated health, overweight and obesity, and common mental disorders are reported for a sample of 30,776 individuals aged 18 years and older (obtained from the Health Survey for England years 2000–2003 combined) and distributed across 3645 small areas classed in four categories: two groups of urban areas (Greater London area or ‘other cities’) and two types of rural settings (semi-rural areas or villages). Results show that rural dwellers were significantly less likely than residents of urban areas to report their health as being fair or poor and to report common mental disorders, independent of their socio-demographic characteristics. However, as for urban settlements, there were significant variations in health across semi-rural areas and across villages, indicating the presence of health inequalities within rural settings in England. These inequalities were not fully explained by the individual composition of the areas or by the available measures of area socioeconomic conditions, indicating that in rural contexts more specific factors may have significance for health. Different policies and services for health promotion and care may need to be targeted to different types of rural areas.     

Thrills and spills: Young people's sexual behaviour andattitudes in seaside and rural areas

This paper reports on a qualitative study which explored attitudes to sexual risk-taking among young people in rural and seaside areas in England. The research was undertaken in three sites, each comprising a seaside resort and its rural hinterland. Data were collected through group discussions with 341 young people in secondary schools in England and through individual interviews with young people outside school settings, with young parents and with professionals working in the field of sexual health and education. Data analysis adopted a grounded theory approach and incorporated the views of local young people's advisory groups. Key features of the study which appeared specific to the locales studied were the influence of the seaside entertainment industry on young people's sexual behaviour and the high visibility experienced by young people in rural areas. Gender was also identified as playing a crucial role in determining perceptions of risk and influencing behaviour. Sexual health services and health promotion strategies need to acknowledge the relevance of factors such as gender and stigma for young people as well as being responsive to the specific features of local contexts.     

Diet and nutritional status of 4–18-year-olds: public health implications

The National Diet and Nutrition Survey: young people aged 4–18 years, published in June 2000, is the most detailed survey yet to be undertaken in this age group in Britain. It has revealed that Britain's young people are largely inactive and, although the majority appears to have adequate intakes of most vitamins, intakes tended to be lowest in families on benefit. This was particularly the case for folate and vitamin C, reflecting lower intakes of fruit and vegetables. Thirteen per cent of 11–18‐year‐olds had low vitamin D status, the vitamin usually provided via exposure to sunlight and essential for the development of healthy bones. A sizeable proportion of children may have inadequate intakes of a number of minerals, including zinc, calcium, potassium, magnesium and iron. For example, 25% of 11–14‐year‐old girls and 19% of those aged 15–18 years had intakes of calcium that were likely to be inadequate (i.e. lower than the LRNI); in all age and gender groups there was evidence of low zinc intakes; and 14% of girls and 13% of boys had low ferritin levels, suggesting low iron stores and an increased risk of anaemia. On the positive side, fat intakes were close to the population goal of 35% of dietary energy, but intakes of saturated fatty acids exceeded the recommended population level for adults of 11% of energy, and intakes of sugars and salt were also high in many children. This article discusses some of the public health implications of this major survey.     

A nurse practitioner-led farmers' health service: setting up and evaluating a UK project

ABSTRACT: The farming community in the UK have significant unmet health-care needs that have traditionally remained invisible. The project that is the subject of this paper is an attempt to improve access to health care for farmers and make their needs visible. It is based in an upland area of England and involves two nurse practitioners (NPs) and two support workers who provide health care for the farming community. The main targets of the project are farm accidents, mental health and occupational diseases. The NPs visit farms, on request, for consultations and also attend auction marts, agricultural shows and other farmers' meetings. Evaluation is by a telephone follow-up interview with a sample of clients seen by the N P, who will be compared with a group from a similar area who do not receive the service. A farm accident survey is underway, case notes are being audited and the NPs are keeping a reflective diary as further sources of data.     

Developing an evidence base for policies and interventions to address health inequalities: the analysis of "public health regimes"

Systematic reviews have become an important methodology in the United Kingdom by which research informs health policy, and their use now extends beyond evidence-based medicine to evidence-based public health and, particularly, health inequalities policies. This article reviews the limitations of systematic reviews as stand-alone tools for this purpose and suggests a complementary approach to make better use of the evidence. That is, systematic reviews and other sources of evidence should be incorporated into a wider analytical framework, the public health regime (defined here as the specific legislative, social, political, and economic structures that have an impact on both public health and the appropriateness and effectiveness of public health interventions adopted). At the national level this approach would facilitate analysis at all levels of the policy framework, countering the current focus on individual interventions. It could also differentiate at the international level between those policies and interventions that are effective in different contexts and are therefore potentially generalizable and those that depend on particular conditions for success.     

Healthier catering initiatives in London,UK: an effective tool for encouraging healthier consumption behaviour?

The increasing amount of ‘unhealthy’ food consumed outside the home is thought to be a major contributory factor to growing levels of obesity. To tackle the problem and promote changes in catering and consumption behaviour, initiatives designed to encourage out-of-home caterers to provide healthier menus or adopt healthier cooking practices have been developed. Such voluntary agreements, rather than legislation, are the UK government’s preferred strategy. This paper reports on and explores issues arising from an evaluation of one such initiative – the Healthier Catering Commitment, piloted with over 80 independent businesses in London in the UK. Analysis of data on take-up of the scheme, and interviews with businesses and those involved in assessing them against the scheme’s criteria, suggests the extent to which businesses are prepared to make changes to their catering practices. Operational barriers as well as aspects of the local trading environment are shown to impact on the level of business commitment to the initiative. In considering the degree to which the scheme’s criteria inform, widen or restrict consumer choice, the paper adds to the debate on effective strategies for encouraging behaviour change. It also comments on the extent to which voluntary agreements are likely to be an effective means of ensuring a healthier food environment, and the extent to which government intervention is justified in the interests of improving public health and tackling health inequalities.     

Critical incidents and invulnerability to risk: Young people's experience of serious health-related incidents and their willingness to take health risks

Previous research has established that young people tend to operate with a sense of invulnerability when it comes to risk-taking behaviour. This paper initially investigates the possibility that this might be a product of their relative lack of exposure to situations or events which involve death or serious threats to health. It then considers the thesis that exposure to such ‘serious health-related incidents’ will act as’ critical incidents' affecting the health-related behaviour of young people. Findings are based on the ESRC-funded research project Critical Incidents and Risk-Taking Behaviour Among Schoolchildren (R000 22 1802) which has investigated perceptions of risk and the consumption of alcohol and tobacco by 15-to 16-year-olds in a central region of England. The research reveals a high level of exposure to ‘serious health-related incidents’ and the findings provide some modest support for this thesis that these act as ‘critical incidents’ shaping the willingness of the young people to take risks with their health. However, the findings also indicate signficant limitations to the thesis. These limitations are discussed and it is concluded that they stem from the use of ‘expert opinion’ and ‘medical models’ of health as the bases for identifying critical incidents.     

Food for thought: menu labeling as obesity prevention public health policy

This article discusses the evidence for menu labeling as obesity prevention public health policy. While sympathetic to providing nutritional information, whether food is consumed at restaurants or purchased for home consumption, the authors raise a word of caution against the assumption that menu labeling will significantly lead to healthier food choices, lower obesity rates, and decreased obesity disparities. The authors find little empirical evidence that this will be the case, critique the theoretical model that informs menu labeling as obesity prevention public health policy, and instead encourage policies that draw on a fundamental social causes approach to obesity prevention and health promotion generally.     

A review of UK housing policy: ideology and public health

OBJECTIVES: The aim of this paper is to review UK public health policy, with a specific reference to housing as a key health determinant, since its inception in the Victorian era to contemporary times. REVIEW: This paper reviews the role of social and private housing policy in the development of the UK public health movement, tracing its initial medical routes through to the current socio-economic model of public health. The paper establishes five distinct ideologically and philosophically driven eras, placing public health and housing within liberal (Victorian era), state interventionist (post World War 1; post World War 2), neoliberal (post 1979) and "Third Way" (post 1997) models, showing the political perspective of policy interventions and overviewing their impact on public health. The paper particularly focuses on the contemporary model of public health since the Acheson Report, and how its recommendations have found their way into policy, also the impact on housing practice. CONCLUSIONS: Public health is closely related to political ideology, whether driven by the State, individual or partnership arrangements. The current political system, the Third Way, seeks to promote a sustainable "social contract" between citizens and the State, public, private and voluntary organizations in delivering community-based change in areas where health inequalities can be most progressively and successfully addressed.