Health inequalities: what is to be done?

The research literature on health inequalities (health differences between different social groups) is growing almost every day. Within this burgeoning literature, it is generally agreed that the UK’s health inequalities (like those in many other advanced, capitalist economies) are substantial. There is, for example, a shocking 28 year gap in life expectancy for working age men living in different areas of Glasgow. There is also agreement that health inequalities are largely preventable (i.e. the factors the cause health inequalities are not randomly distributed but the direct consequence of social, political and economic decisions) and that these substantial differences are, therefore, unjust. Yet, when it comes to answering the obvious question, ‘what should we do to tackle health inequalities?’, specific policy advice often seems limited. Why is this?

The civil servants, policy advisors, politicians and health campaigners I’ve interviewed over the past 12 years have often (understandably) assumed that the lack of clear policy advice emanating from health inequalities researchers reflects a lack of consensus. Yet, I was puzzled by this: my interviews with researchers suggested a high degree of consensus within the research field about both the causes of health inequalities and the main policy levers for reducing health inequalities. This was despite the fact I had tried to ensure I was interviewing researchers with different perspectives on health inequalities (based on their published research).

Surveying researchers about their views on policy proposals for tackling UK health inequalities

To explore the issue further, I worked with a colleague, Mor Kandalik Eltanani, to undertake an online survey of researchers involved in studying health inequalities in the UK which involved asking respondents a series of questions about their views on various potential policy responses to health inequalities. First, we used interview data, focus groups, and published literature and reports to identify 99 distinct policy proposals which we then organised into the ten thematic clusters (this included, for example, a cluster focusing on ‘income and wealth’ as well as various clusters focusing on particular ‘lifestyle’ issues such as alcohol, food, and tobacco). We then developed a two-stage online survey using these 99 proposals. The first stage of the survey asked researchers to indicate their level of agreement (five options, from ‘strongly disagree’ to ‘strongly agree’) with each of the 99 policy proposals according to various criteria: (1) their ‘expert opinion’; (2) the strength of the available evidence; and (3) what they felt, in current economic, political and social context, would be an ‘appropriate policy recommendation for the health inequalities research community to make’. Forty-one researchers completed this part of the survey.

For the second stage of the survey, we identified the most popular 20 proposals from the first stage (combining the responses given for each of the three criteria listed above) and asked respondents to each divide 100 points between these proposals, allocating more points to the proposals they believed would have the greatest impact on reducing health inequalities in the UK. Ninety-two researchers completed this (much quicker) part.

What we found: researchers respond differently when asked about policies based on their ‘expert opinion’ and policies supported by ‘available evidence’

One of our key findings was that researchers generally responded to policy proposals rather differently, depending on the criteria they were being asked to take into consideration. When researchers were asked to say which policy proposals they agreed would be most effective in reducing health inequalities based purely on their expert opinion, most agreed that we need policies to achieve a fairer distribution of income/wealth. When asked to respond to the same policy proposals based on their sense of the strength of the available evidence, the most popular policy proposal remained one concerning tax and benefits policy to redistribute wealth, beyond this, there was far more of a focus on policy proposals intended to reduce lifestyle-behavioural risks (smoking, drinking, etc).

Why did researchers respond differently to the different criteria?

One potentially obvious interpretation of these differences is that researchers’ personal preferences are informed by factors other than the available evidence (e.g. that they are ideologically driven). There may be some truth in this but my interviews and the feedback in the free-text spaces in the survey suggest the differences are, instead, largely a reflection of the fact, as Ted Schrecker argues, that it is simply easier to study the health impacts of policy changes that attempt to change people’s drinking, eating and smoking behaviours than it is to study the health impacts of macro-economic policies, such as tax and benefits policies. As a result, we have more evidence about the former and less about the latter, even though there seems to be a high-level of agreement amongst health inequalities researchers that the latter kinds of policies are more important for health inequalities. This suggests health inequalities researchers, and those who fund this work, need to get better at matching their research activities with their sense of what is likely to be most effective in reducing health inequalities.

Featured image: “Medicine” by DarkoStojanovic. CC0 via Pixabay