The wealthy get healthy, the poor get poorly? Lay perceptions of health inequalities

"Power, control, strain": Lay perceptions of health inequalities across England's 'North South divide'

People in the North of England live shorter, less healthy lives than those in the South. Despite the significance of this 'North South health divide', regional health inequalities in England are under-researched qualitatively. Existing literature on geographical inequalities in health is largely confined to the neighbourhood level, is quantitative, and consists of very little lay knowledge. The current study is the first to examine lay perspectives of health inequalities on a regional level: exploring how people living in two urban areas of the North and South of England experience and perceive the North South health divide - including its causes and solutions. Using three focus group discussions with a total of 34 participants, and conducting participatory analysis, we identified three key themes: 'inequalities of power', 'lack of control over lived environment' and 'communities under strain'. Findings align with existing research on lay perspectives of health inequalities at the neighbourhood level - identifying a network of material-structural and psychosocial factors. Participants across both regions discussed political and economic structures as central to understanding regional health inequalities, supporting calls to adopt a political economy approach in understanding health and place. Deindustrialisation, unemployment, loss of community facilities, and disengagement from politics were more present in Northern narratives than Southern. Findings add important 'social meaning' to emerging research on the North South health divide, reinforcing the urgency of public health professionals' recommendations for fair redistribution of power, wealth and resources to reduce regional health inequalities. In the context of government policy which diverges from public health evidence, this study sparks questions of how health inequalities research can intersect with wider social and political movements organising for systemic change.

Coproduction of a resource sharing public views of health inequalities: An example of inclusive public and patient involvement and engagement

BACKGROUND

UNderstanding Factors that explain Avoidable hospital admission Inequalities-Research study (UNFAIR) addresses how to reduce health inequalities, particularly for avoidable hospital admissions. Our Patient and Public Involvement and Engagement (PPIE) members broached that health inequalities are complex, challenging to understand and communicate. They identified a need to explore diverse views, including people who have a higher risk of health inequalities. With limited public-facing resources relating to the public's understanding or emotions around health inequalities, this project aimed to fill this gap using co-leadership and co-production.

METHODS

Members of the public worked with researchers to co-produce and run PPIE workshops. This project was co-led by a member of the public and a researcher. One online workshop open to anyone in England accompanied by three face-to-face workshops were held. Public contributors, including people living in diverse communities, were invited. Inclusive involvement opportunities were offered including flexible ways of involvement and remuneration. To strengthen the key messages' rigour, transcriptions of the audio-recordings from each workshop, with facilitator notes, were analysed using thematic analysis. From the key messages, an animation was co-produced with public contributors with the public's voice being integral throughout.

KEY MESSAGES

A total of 58 people took part capturing intersecting and multiple dimensions of marginalisation including people with a range of ages, genders, ethnicities, socioeconomic backgrounds, and members of communities who face exclusion (including people with learning difficulties and experiencing ill-health). The animation highlighted powerful lived experience, for example, some people are dying earlier than expected. Health inequalities conjured up powerful emotions, such as anger and hopelessness. Public views of how to address health inequalities included respecting, accepting and valuing everyone, regardless of, for example, where people live. The animation is publicly available for use by anyone, including decision makers across the health and care system.

CONCLUSIONS

Through co-leadership and co-production, this project is an example of inclusive PPIE. This project provided a way for the public's voice to influence policy and practice to inform understanding and action to address health inequalities. The animation provides powerful insights into what health inequalities mean to people with examples of lived experience and corroborates the moral argument for action by decision makers.

PATIENT AND PUBLIC CONTRIBUTION

Members of the public, including people who were affected or at higher risk of health inequalities, co-led this project and were involved as co-creators and developers from the inception of the project to completion. Their involvement was integral and documented in full throughout the project.

Young people's perspectives on addressing UK health inequalities: utopian visions and preferences for action

INTRODUCTION

It is increasingly recognised by UK researchers and population health advocates that an important impetus to effective policy action to address health inequalities is activation of public dialogue about the social determinants of health and how inequalities might be addressed. The limited body of existing scholarship reaches varying conclusions on public preferences for responding to health inequalities but with consensus around the importance of tackling poverty. Young people's perspectives remain underexplored despite their increasingly visible role in activism across a range of policy issues and the potential impact of widening inequalities on their generation's health and wellbeing.

METHODS

Six groups of young people (39 in total) from two UK cities (Glasgow and Leeds) were engaged in online workshops to explore views on health inequalities and potential solutions. Inspired by calls to employ notions of utopia, artist-facilitators and researchers supported participants to explore the evidence, debating solutions and imagining a more desirable society, using visual and performance art. Drawing together data from discussions and creative outputs, we analysed participants' perspectives on addressing health inequalities across four domains: governance, environment, society/culture and economy.

FINDINGS

Proposals ranged from radical, whole-systems change to support for policies currently being considered by governments across the United Kingdom. The consensus was built around embracing more participatory, collaborative governance; prioritising sustainability and access to greenspace; promoting inclusivity and eliminating discrimination and improving the circumstances of those on the lowest incomes. Levels of acceptable income inequality, and how best to address income inequality were more contested. Individual-level interventions were rarely presented as viable options for addressing the social inequalities from which health differences emanate.

CONCLUSION

Young people contributed wide-ranging and visionary solutions to debates around addressing the enduring existence of health inequalities in the United Kingdom. Their reflections signal support for 'upstream' systemic change to achieve reductions in social inequalities and the health differences that flow from these.

PUBLIC CONTRIBUTION

An advisory group of young people informed the development of project plans. Participants shaped the direction of the project in terms of substantive focus and were responsible for the generation of creative project outputs aimed at influencing policymakers.

Subjective socioeconomic status and agreement that health is determined by distal and proximal factors

This report examines whether a person's subjective view of their rank relative to others in society-subjective socioeconomic status (SES)-is systematically related to views on distal and proximal determinants of ill-health. This was tested using cross-sectional data from 28,718 respondents from 27 countries who took part in the International Social Survey Programme (ISSP) in 2011. Adjusting for age and gender as well as income and education, mixed logistic regression models showed that subjective SES was negatively associated with the likelihood of agreeing with distal explanations for poor health (being poor or because of work/life environment) and positively associated with the likelihood of agreeing with health-related behaviours as a cause for poor health. Subjective SES was not related to agreement that genes influence health. These analyses introduce a social psychological factor into the lay understanding of health determinants and extend models of subjective status and attributional style to health explanations.

Socioeconomic differences in the perception of inequalities in healthcare utilization and health in South Korea

This study investigated the lay perception of inequalities in society, healthcare utilization, and health in Korea. We also examined the association between socioeconomic status (SES) and perception of inequalities. Data from an online survey on the perception of health and healthcare inequalities related to cancer conducted between October 19, 2021, and November 12, 2021, were used. Data of 3,769 participants aged 20 to 74 years from 17 provinces were analyzed. We examined the perceived level of inequalities according to SES or residential area using frequency analysis, a t-test or analysis of variance (ANOVA), multiple linear regression analysis, and multiple logistic regression analysis. The mean score for perception of social inequality was 5.99 [Standard Deviation (SD) = 1.95] and that for perception of healthcare utilization inequality was 4.75 (SD = 1.96). The perception rate of health inequality according to SES and residential area was approximately 59 % and 61 %, respectively. Higher the income level, lower the level of perception of social inequalities β = -0.22, p < 0.01). Higher the education level, higher the level of perception of healthcare utilization inequalities (β = 0.21, p < 0.01). Higher the education level, higher the level of perception of health inequalities according to SES or residential area [adjusted odds ratio (aOR): 2.33 (95 % CI: 1.48, 3.66); aOR: 2.73 (95 % CI: 1.73, 4.31)]. Socioeconomic inequalities were observed in the perception of inequalities in healthcare utilization and health. Policymakers should establish policies to bridge the gap between perceived healthcare utilization inequalities and health inequalities. Future research should investigate the perception of healthcare utilization and health inequalities.

Maternal Health Care Service Utilization in the Post-Conflict Democratic Republic of Congo: An Analysis of Health Inequalities over Time

This study assessed inequality in maternal healthcare service utilization in the Democratic Republic of the Congo, using the Demographic and Health Surveys of 2007 and 2013-2014. We assessed the magnitude of inequality using logistical regressions, analyzed the distribution of inequality using the Gini coefficient and the Lorenz curve, and used the Wagstaff method to assess inequality trends. Women were less likely to have their first antenatal care visit within the first trimester and to attend more antenatal care visits when living in eastern Congo. Women in rural areas were less likely to deliver by cesarean section and to receive postnatal care. Women with middle, richer, and richest wealth indexes were more likely to complete more antenatal care visits, to deliver by cesarean section, and to receive postnatal care. Over time, inequality in utilization decreased for antenatal and postnatal care but increased for delivery by cesarean sections, suggesting that innovative strategies are needed to improve utilization among poorer, rural, and underserved women.

Communicating about the social determinants of health: development of a local brand

BACKGROUND

Successful comprehensive population-based approaches to chronic disease prevention leverage mass media to amplify messages and support a culture of health. We report on a community-engaged formative evaluation to segment audiences and identify major themes to guide campaign message development for a transformative health communication campaign.

METHODS

Four key phases of campaign development: (I) Formative evaluation to identify priorities, guiding themes, and audience segments (interviews/focus groups with residents, N = 85; representatives of community-based partner organizations, N = 10); (II) Brand development (focus groups and closed-ended surveys; N = 56); (III) Message testing approaches to verbal and visual appeals (N = 50 resident intercept interviews); (IV) Workshop (N = 26 participants representing 15 organizations).

RESULTS

Residents were engaged throughout campaign development and the resulting campaign materials, including the campaign name and visual aesthetic (logo, color schemes, overall look and feel) reflect the diversity of the community and were accepted and valued by diverse groups in the community. Campaign materials featuring photos of county residents were created in English, Spanish, and Hmong. Plain language messages on social determinants of health resonate with residents. The county was described as a sort of idyllic environment burdened by inequality and structural challenges. Residents demonstrated enthusiasm for the campaign and provided specific suggestions for content (education about disease risks, prevention, management; information about accessing resources; testimonials from similar people) and tone.

CONCLUSIONS

Communication to support a policy, systems, and environmental change approach to chronic disease prevention must carefully match messages with appropriate audiences. We discuss challenges in such messaging and effectiveness across multiple, diverse audiences.

Perceived social status, socioeconomic status, and preventive dental utilization among a low-income Medicaid adult population

OBJECTIVES

Perceived Social Status (PSS) is a measure of cumulative socioeconomic circumstances that takes perceived self-control into account. It is hypothesized to better capture social class compared to socioeconomic status (SES) measures (i.e., education, occupation, and income). This study examined the association between PSS and dental utilization, comparing the strength of associations between dental utilization and PSS and SES measures among a low-income adult Medicaid population.

METHODS

A cross-sectional survey was administered to a random sample of low-income adults in Iowa, United States with Medicaid dental insurance (N = 18,000) in the spring of 2018. Respondents were asked about PSS, dental utilization, and demographics. A set of multivariable logistic regression models examined the relative effects of PSS and SES measures on dental utilization, controlling for age, sex, health literacy, whether the respondent was aware they had dental insurance, transportation, and perceived need of dental care.

RESULTS

The adjusted response rate was 25%, with a final sample size of 2252. Mean PSS (range 1-10) was 5.3 (SD 1.9). PSS was significantly associated with dental utilization (OR = 1.11; CI = 1.05, 1.18) when adjusting for control variables, whereas other SES measures-education, employment, and income-were not.

CONCLUSIONS

PSS demonstrated a small positive association with dental utilization. Results support the relative importance of PSS, in addition to SES measures, as PSS may capture aspects of social class that SES measures do not. Results suggest the need for future research to consider the effects of PSS on oral health outcomes and behaviors.

Developing Indicators to Measure Critical Health Literacy in the Context of Norwegian Lower Secondary Schools

A critical health literacy (CHL) approach is recommended for promoting health in the school context. This construct is complex and includes three interconnected domains: (A) appraisal of critical information, (B) awareness of the social determinants of health (SDH), and (C) collective action to promote health and well-being. In recent literature reviews, no measurement instrument that covers all three domains of CHL in the school-context was found. Our aim was to develop self-reported measurement scales for each domain of CHL. The development process reported in this study was conducted in two stages. In the first stage, an initial item pool was generated based on literature reviews and focus group interviews (N = 15) with adolescents (steps 1–2). In the next steps, items were adjusted and removed based on the feedback from an expert panel and from representatives from the target group (steps 3–5). In stage two, we aimed to reduce the number of items and develop scales for each domain. We then piloted the current draft, which consists of 28 items (N = 114). A sub-sample (N = 10) of the participants were interviewed after they completed the survey to examine the instrument’s face validity. Cronbach’s α was used to assess the internal reliability of the scales; the reliability was promising for scales A (α = 0.83) and C (α = 0.85) but was below the recommended value for scale B (α = 0.61). The model fit indices were promising (TLI_scaleA = 0.97, RSMEA_scaleA = 0.055, TLI_scaleB = 1.05, RMSEA_scaleB = 0.00, TLI_scaleC = 0.95, RMSEA_scaleC = 0.074). The piloted version of scales A and C were positively correlated with subjective health literacy, health-related quality of life, and subjective health; however, we found no such correlations for scale B. The post-survey group interviews led to some adjustments in scales A and B. The revised version of CHLA-Q must be tested using a larger sample; this will enable more robust statistical testing of the properties of the items and the scale.

'Known to be unhealthy': Exploring how social epidemiological research constructs the category of low socioeconomic status

We examine how the category of low socioeconomic status (LSES) was constructed in European social epidemiological research and policy advice from 1977 to 2019. We analysed 22 empirical social epidemiological research publications on LSES and health, as well as six scientific advisory reports that offered government officials an overview of scientific evidence on health inequalities. We show the construction and reification of LSES as a problematic group in dominant thought, which consists of the following components: 1) the proliferation of SES concepts, indicators and groups labelled LSES; 2) generalisation through which LSES is constructed as a single population; 3) problematisation through which LSES is constructed as an inherently unhealthy population; and 4) individualisation by which a LSES personality is presented as an explanation of health differences. We also show how this knowledge is extrapolated into the policy domain in the form of scientific advisory reports. These findings provide evidence of the construction of LSES as an inherently unhealthy population through hyperproliferation and references to the objectivity of scientific research. With respect to the LSES category, the dynamics of research and policy resemble those regarding categories of ethnicity and gender. We conclude that if the construction of LSES remains unquestioned, social epidemiology might continue to (re)produce what it examines: LSES populations 'known to be unhealthy'.

Contextualising lifestyles: how socially contrasting places in Fife, Scotland influence lay understandings of lifestyle and health behaviours in relation to coronary heart disease

Coronary heart disease (CHD) is a significant public health issue showing persistent geographical health inequalities. However, little attention has focussed on lay perspectives of how contrasting social contexts influence lifestyles and health behaviour in relation to CHD. The aim of this qualitative study is to explore lay perspectives of lifestyle and behaviour in socioeconomically contrasting places, with women and men who had survived a heart attack in Fife, Scotland. This study contributes to knowledge on CHD health inequalities and health promotion, particularly cardiac rehabilitation, emphasising the importance of situating experiences and understandings of health, geographically.

Reframing inequality? The health inequalities turn as a dangerous frame shift

Background

Politicians in many countries have embraced the notion that health inequalities derive from socioeconomic inequalities, but European governments have for the most part failed to enact policies that would reduce underlying social inequalities.

Methods

Data are drawn from 84 in-depth interviews with policy-makers in four European countries between 2012 and 2015, qualitative content analysis of recent health inequalities policy documents, and secondary literature on the barriers to implementing evidence-based health inequalities policies.

Results

Institutional and political barriers are important barriers to effective policy. Both policy-making institutions and the ideas and practices associated with neoliberalism reinforce medical-individualist models of health, strengthen actors with material interests opposed to policies that would increase equity, and undermine policy action to tackle the fundamental causes of social (including health) inequalities.

Conclusions

Medicalizing inequality is more appealing to most politicians than tackling income and wage inequality head-on, but it results in framing the problem of social inequality in a way that makes it technically quite difficult to solve. Policy-makers should consider adopting more traditional programs of taxation, redistribution and labor market regulation in order to reduce both health inequalities and the underlying social inequalities.

What do the British public think of inequality in health, wealth, and power?

Despite the importance of public opinion for policy formation and the political salience of inequality, the public's views about the desirability of equality, not only in health but also in economics and politics, has attracted little attention. We report the results of an on-line survey administered in late 2016 in Great Britain (N = 1667 with a response rate of 35-50%). The survey allowed for testing the sensitivity of public opinion across two other variables: absolute versus relative (everyone should have the same versus inequality should be reduced) and bivariate versus univariate (inequality in one domain is judged in relation to inequality in another versus inequality in a domain is judged independently of other domains). It also allowed examination of how far support for equality in one domain overlaps with support for equality in another. We find that for health, economic and political equality a relative conception of equality attracts more support than an absolute conception, and that for health and political equality a bivariate conception attracts more support than a univariate conception. We also find that conceptions of equality affect how much overlap exists between support for different forms of equality, with a bivariate and relative conception resulting in more overlap than a univariate and absolute conception. We also find evidence for Walzer's 'complex equality' theory in which people tolerate inequality in one domain if it does not control inequality in another.

Qualitative exploration of sociocultural determinants of health inequities of Dalit population in Dhaka City, Bangladesh

OBJECTIVES

In recent years, Bangladesh has made remarkable advances in health outcomes; however, the benefits of these gains are unequally shared among citizens and population groups. Dalits (jaat sweepers), a marginalised traditional working community, have relatively poor access to healthcare services. This study sought to explore the sociopolitical and cultural factors associated with health inequalities among Dalits in an urban setting.

DESIGN

An exploratory qualitative study design was adopted. Fourteen in-depth interviews, five focus group discussions and seven key informant interviews were conducted. The acquired data were analysed using an iterative approach which incorporated deductive and inductive methods in identifying codes and themes.

SETTINGS

This study was conducted in two sweeper communities in Dhaka city.

PARTICIPANTS

Participants were Dalit men and women (in-depth interviews, mean age±SD 30±10; and focus group discussions), and the community leaders and non-governmental organisation workers (key informant interviews).

RESULTS

The health status of members of these Dalit groups is determined by an array of social, economic and political factors. Dalits (untouchables) are typically considered to fall outside the caste-based social structure and existing vulnerabilities are embedded and reinforced by this identity. Dalits' experience of precarious access to healthcare or poor healthcare is an important manifestation of these inequalities and has implications for the economic and social life of Dalit populations living together in geographically constrained spaces.

CONCLUSIONS

The provision of clinical healthcare services alone is insufficient to mitigate the negative effects of discriminations and to improve the health status of Dalits. A better understanding of the precise influences of sociocultural determinants of health inequalities is needed, together with the identification of the strategies and programmes needed to address these determinants with the aim of developing more inclusive health service delivery systems.

'Hopeful adaptation' in health geographies: Seeking health and wellbeing in times of adversity

Living with adversity can create wide-ranging challenges for people's health and wellbeing. This adversity may arise through personal embodied difference (e.g. acquiring a brain injury or losing mobility in older age) as well as wider structural relations that shape a person's capacity to adapt. A number of dichotomies have dominated our understanding of how people engage with health and wellbeing practices in their lives, from classifying behaviours as harmful/health-enabling, to understanding the self as being defined before/after illness. This paper critically interrogates a number of these dichotomies and proposes the concept of 'hopeful adaptation' to understand the myriad, often non-linear ways that people seek and find health and wellbeing in spite of adversity. We highlight the transformative potential in these adaptive practices, rather than solely focusing on how people persist and absorb adversity. The paper outlines an agenda for a health geography of hopeful adaptation, introducing a collection of papers that examine varied forms of adaptation in people's everyday struggles to find health and wellbeing whilst living with and challenging adversity.

Assessing Health Literacy Among Chinese Speakers in the U.S. with Limited English Proficiency

Background:

Limited English proficiency compounds the problem of low health literacy, making certain population groups in the United States especially vulnerable to health disparities.

Objective:

This study clarified the mechanisms underlying low health literacy among people with limited English proficiency using a modified theory-based health literacy assessment survey.

Methods:

We modified and tested the All Aspects of Health Literacy Scale (AAHLS) with a sample of Chinese speakers who have limited English proficiency in the U.S. The AAHLS is a theory-based health literacy survey assessing functional health literacy, interactive health literacy, information appraisal, and empowerment. We adapted the survey, created dual language scenarios (English and Chinese), translated the questions into Chinese, and conducted cognitive interviews to revise the questions. We examined the health literacy score distributions and performed Confirmatory Factor Analysis (CFA) to evaluate the appropriateness of our modified AAHLS to elicit valid data.

Key Results:

A total of 405 participants completed our AAHLS survey. Compared to the English language scenario, aside from the item assessing if participants would question health care providers, participants had significantly higher health literacy levels when they were immersed in communication using Chinese (p < .001). We also found that more than three-quarters of the participants were not likely to question their doctor's and nurse's advice regardless of language scenarios and most of them had limited empowerment capabilities at the level of community and social engagement. The CFA results showed that the modified Chinese model exhibited good fit (RMSEA [root mean square error of approximation] = 0.06, CFI [the comparative fit index] = 0.98, TLI [Tucker-Lewis index] = 0.97, WRMR [weighted root mean square residual] = 1).

Conclusions:

The results showed that our modified AAHLS yielded reliable and valid data among U.S. Chinese speakers. Researchers should consider native languages and cultural differences before conducting health literacy assessments. Public health professionals should incorporate health interventions and policy approaches to improve Chinese immigrants' English proficiency and empowerment capabilities. [HLRP: Health Literacy Research and Practice. 2018;2(2):e94–e106.]

Plain Language Summary:

To clarify the mechanisms underlying low health literacy among populations with limited English proficiency (LEP) in the United States, this study aims to tailor a theory-based health literacy survey with dual-language scenarios among Chinese speakers with LEP. The modified survey yielded reliable and valid data. Participants had higher health literacy levels when they were immersed in communication using Chinese rather than English.

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.

Redrawing the line: An exploration of how lay people construct child neglect

While there has been an increasing professional and political focus on the prevalence and harmfulness of child neglect, little has been done to explore what child neglect means outside child protection circles. This qualitative study explores lay constructions of child neglect by thematically analyzing focus group discussions between 46 self-defined 'lay' people in England. Participants viewed neglect as extremely damaging for children and as arising when children's physical, emotional, training and supervisory needs were unmet due to abnormal parental behavior. Children with unmet needs were positioned as deprived, unloved, uncontrolled and escaping. They were only positioned as neglected when failure to meet their needs was attributable to a lack of parental knowledge and skill (clueless parents), a lack of appropriate parental disposition (underinvested parents) or both (unsuitable parents). 'Normal' parents - those with the appropriate parental disposition, skills and knowledge - who failed to meet their children's needs were not seen as neglectful but rather as overburdened. As 'normal parenting' has fragmented in late modernity, society wide consensus on child neglect was felt by participants to have retreated to child protection definitions, alienating lay understandings. If child neglect really is 'everybody's business', then it is important that lay people are included in forging new definitions of and responses to meeting the needs of children.

"How the other half live": Lay perspectives on health inequalities in an age of austerity

This paper examines how people living in two socially contrasting areas of Stockton on Tees, North East England experience, explain, and understand the stark health inequalities in their town. Participants displayed opinions that fluctuated between a variety of converging and contrasting explanations. Three years of ethnographic observation in both areas (2014-2017) generated explanations which initially focused closely on behavioural and individualised factors, whilst 118 qualitative interviews subsequently revealed more nuanced justifications, which prioritised more structural, material and psychosocial influences. Findings indicate that inequalities in healthcare, including access, the importance of judgemental attitudes, and perceived place stigma, would then be offered as explanations for the stark gap in spatial inequalities in the area. Notions of fatalism, linked to (a lack of) choice, control, and fear of the future, were common reasons given for inequalities across all participants. We conclude by arguing for a prioritisation of listening to, and working to understand, the experiences of communities experiencing the brunt of health inequalities; especially important at a time of austerity.

Inequalities in a National Health Care System From the Perspective of Social Workers in Israel

This study explores social workers' perceptions of inequalities in Israel's national health care system. Unlike previous studies, which relied on patients' and practitioners' reports, it is based on interviews with 60 social workers in hospitals and ambulatory clinics. The findings show that although Israeli law provides for (almost) free, universal medical care, the treatment of persons lacking in money, education, and social affiliation may be compromised by difficulties in paying for medications, treatments, and travel to and from hospital; by difficulties in understanding doctors' instructions; and by reluctance to ask questions. Most doctors tend to focus exclusively on patients' medical needs, seem to lack sympathy with less educated patients, have little understanding of the life circumstances that impinge on their compliance, and make little effort to speak to them in the language they can understand. Practical suggestions are made with regard to the need to turn doctors' attention to their patients' non-medical needs.

Lay perceptions of health and environmental inequalities and their associations to mental health

Health inequalities are very well documented in epidemiological research: rich people live longer and have fewer diseases than poor people. Recently, a growing amount of evidence from environmental sciences confirms that poor people are also more exposed to pollution and other environmental threats. However, research in the social sciences has shown a broad lack of awareness about health inequalities. In this paper, based on data collected in Portugal, we will analyze the consciousness of both health and environmental injustices and test one hypothesis for this social blindness. The results show, even more clearly than before, that public opinion tends to see rich and poor people as being equally susceptible to health and environmental events. Furthermore, those who have this equal view of the world present lower levels of depression and anxiety. Following cognitive adaptation theory, this "belief in an equal world" can be interpreted as a protective positive illusion about social justice, particularly relevant in one of the most unequal countries in Europe.

Patterns and causes of health inequalities in later life: a Bourdieusian approach

This study explores the relationship between social class and health change in older people in a path analysis, using data from the English Longitudinal Study of Ageing (n = 6241) in a Bourdieusian theoretical framework. Bourdieu drew a distinction between the occupational characteristics by which people are classified and the secondary properties of class that relate to lifestyle (economic, cultural and social capitals). Our path model includes both occupational and secondary characteristics of objective social class as well as a measure of subjective social class. We investigate the effects of the predictors on change in three health outcomes (self-rated health, number of symptoms of depression and number of difficulties with the activities of daily living). The analysis adds to Bourdieusian research by showing how the effects of objective social class on health are partially mediated by perceived social status. It also adds to substantive research on the relationship between class and health by suggesting that class-related health inequalities do persist for older people, even for those who are not in paid employment. It suggests that a large amount of the effect of occupation on the health of older people is not direct but indirect; through their personal wealth and lifestyle.

Public views about health causation, attributions of responsibility, and inequality

Success in addressing health disparities and their social determinants will require understanding public perceptions of health causation, attributions of responsibility, and potential solutions. To explore these perceptions, the authors conducted 12 focus groups (6 with liberals, 6 conservatives; N = 93 participants) in a large U.S. Northeastern state. Participants communicated highly nuanced views about health causation and disparities, identifying layers of responsibility for health. However, individual behaviors and personal responsibility dominated the discussion and served as a counterargument to the significance of social determinants. Participants also showed limited awareness of the range of policies that could be adopted to address health disparities. As policy initiatives benefit from public support in gaining political traction, the authors suggest research paths and possible communication strategies for scholars and advocates.

Children's understanding of family financial resources and their impact on eating healthily

Socioeconomic inequalities in childhood are linked to childhood and adult health inequalities. They are particularly closely associated with inequalities in nutritional and consequently health status. Recent research links this to the high cost of nutrient-rich and low cost of nutrient-poor foods and explores how parents negotiate food purchase on a limited budget. However, we know little of children's perspectives on the material and social realities of their lives and their involvement in health-relevant behaviour. This contrasts with a growing body of research which emphasises children's active role in making sense of and participating in health practices while growing up and their potential to act in continuity with and as agents of change in family health cultures. This paper explores children's understanding of family finances and how they perceive this to relate to eating healthily. It draws upon data from a qualitative study of 53 children aged 9-10 from two socioeconomically contrasting schools in the North of England during 2010 and 2011. Data were generated in friendship group interviews and debates at school and individual interviews in the home, and analysed thematically. Children incorporated a variety of media information into their understandings and sought explanations from their personal experience. They had sophisticated ideas about the interrelationships between diet, cost and health and were acutely aware of how family finances influenced food purchase. Children proposed different strategies to facilitate eating healthily on a budget, but prioritised state and corporate responsibility in ensuring that eating healthily is affordable. This contrasts with current health-related policy, which does not address cost as a potential barrier to eating healthily in the home. Children also consistently conflated healthy eating with eating fruit and vegetables, highlighting a need to reinforce other important nutritional messages.

Exploring interpretation of complexity and typicality in narratives and statistical images about the social determinants of health

This article explores public responses to narratives and statistical images, predominantly graphs and maps, designed to raise awareness of social determinants of health and health disparities. We focus particular attention on respondents' interpretation of the complexity of health causality and the typicality of the situations described. We conducted 24 focus groups with liberal and conservative adults (n = 180 participants) living in a large U.S. northeastern state. Although some narratives showed potential for communicating the complex causality connecting social determinants of health (SDH) to health outcomes, contextual details sometimes disrupted generalization to a broader thematic message. Statistical images often prompted useful speculation about how the factors portrayed might be related, but tended to be regarded with suspicion and criticized for oversimplifying what were perceived to be extremely complex issues. These findings lend theoretical insight to narrative and visual persuasion in the context of social issues with complex causation. We discuss practical implications for those seeking to communicate about the social determinants of health.

Public awareness of income-related health inequalities in Ontario, Canada

Introduction

Continued action is needed to tackle health inequalities in Canada, as those of lower income continue to be at higher risk for a range of negative health outcomes. There is arguably a lack of political will to implement policy change in this respect. As a result, we investigated public awareness of income-related health inequalities in a generally representative sample of Ontarians in late 2010.

Methods

Data were collected from 2,006 Ontario adults using a telephone survey. The survey asked participants to agree or disagree with various statements asserting that there are or are not health inequalities in general and by income in Ontario, including questions pertaining to nine specific conditions for which inequalities have been described in Ontario. A multi-stage process using binary logistic regression determined whether awareness of health inequalities differed between participant subgroups.

Results

Almost 73% of this sample of Ontarians agreed with the general premise that not all people are equally healthy in Ontario, but fewer participants were aware of health inequalities between the rich and the poor (53%–64%, depending on the framing of the question). Awareness of income-related inequalities in specific outcomes was considerably lower, ranging from 18% for accidents to 35% for obesity.

Conclusions

This is the first province-wide study in Canada, and the first in Ontario, to explore public awareness on health inequalities. Given that political will is shaped by public awareness and opinion, these results suggest that greater awareness may be required to move the health equity agenda forward in Ontario. There is a need for health equity advocates, physicians and researchers to increase the effectiveness of knowledge translation activities for studies that identify and explore health inequalities.

Critical health literacy: a review and critical analysis

Though there has been a considerable expansion of interest in the health literacy concept worldwide, there has also been criticism that this concept has been poorly defined, that it stretches the idea of "literacy" to an indefensible extent and more specifically, that it adds little to the existing concerns and intervention approaches of the better established discipline of health promotion. This paper takes as a starting point the expanded model of health literacy advanced by Nutbeam (2000) and addresses these concerns by interrogating the concept of "critical health literacy" in order to draw conclusions about its utility for advancing the health of individuals and communities. The constituent domains of critical health literacy are identified; namely information appraisal, understanding the social determinants of health, and collective action, and as far as possible each are clearly delineated, with links to related concepts made explicit. The paper concludes that an appreciation of work undertaken in a range of different disciplines, such as media studies, medical sociology, and evidence-based medicine can enhance our understanding of the critical health literacy construct and help us understand its usefulness as a social asset which helps individuals towards a critical engagement with health information. There is some evidence that aspects of critical health literacy have indeed been found to be a resource for better health outcomes, but more research is needed in this area, both to develop quantitative and qualitative approaches to evaluating health literacy skills, and to offer convincing evidence that investment in programmes designed to enhance critical health literacy are worthwhile.

From causes to solutions--insights from lay knowledge about health inequalities

Background

This paper reports on a qualitative study of lay knowledge about health inequalities and solutions to address them. Social determinants of health are responsible for a large proportion of health inequalities (unequal levels of health status) and inequities (unfair access to health services and resources) within and between countries. Despite an expanding evidence base supporting action on social determinants, understanding of the impact of these determinants is not widespread and political will appears to be lacking. A small but growing body of research has explored how ordinary people theorise health inequalities and the implications for taking action. The findings are variable, however, in terms of an emphasis on structure versus individual agency and the relationship between being 'at risk' and acceptance of social/structural explanations.

Methods

This paper draws on findings from a qualitative study conducted in Adelaide, South Australia, to examine these questions. The study was an integral part of mixed-methods research on the links between urban location, social capital and health. It comprised 80 in-depth interviews with residents in four locations with contrasting socio-economic status. The respondents were asked about the cause of inequalities and actions that could be taken by governments to address them.

Results

Although generally willing to discuss health inequalities, many study participants tended to explain the latter in terms of individual behaviours and attitudes rather than social/structural conditions. Moreover, those who identified social/structural causes tended to emphasise individualized factors when describing typical pathways to health outcomes. This pattern appeared largely independent of participants' own experience of advantage or disadvantage, and was reinforced in discussion of strategies to address health inequalities.

Conclusions

Despite the explicit emphasis on social/structural issues expressed in the study focus and framing of the research questions, participants did not display a high level of knowledge about the nature and causes of place-based health inequalities. By extending the scope of lay theorizing to include a focus on solutions, this study offers additional insights for public health. Specifically it suggests that a popular constituency for action on the social determinants of health is unlikely to eventuate from the current popular understandings of possible policy levers.

Beyond (financial) accessibility: inequalities within the medicalisation of infertility

There is a significant class disparity within the provision of medical treatments for infertility in the United States. Common explanations attribute this inequality to financial inaccessibility due to sparse insurance coverage and exorbitant costs. However, little is known as to why disparities still exist without the presence of such constraints, such as in states with comprehensive insurance coverage of infertility treatments. Drawing on in-depth interviews with women of low socioeconomic status (SES), this paper aims to explore the structural and political barriers to receiving medical care for infertility within the United States context. The paper argues that much of the invisible, unidentified treatment disparities of infertility stem from the social control mechanism of medicalisation. Medicalisation perpetuates the stratified system of reproduction through its structural inaccessibility and the institutionalised classism apparent within medicine's reproductive health practices and policies. The women in this study, however, actively and creatively identified ways to overcome the reproductive limits with which they were faced. In doing so, their solutions served both to accept and reject dominant norms of motherhood and medicine.

Modeling coronary heart disease prevalence in regional and sociodemographic contexts

The mortality rates from coronary heart disease (CHD) have been documented extensively in the United States and substantial disparities in CHD mortality rates exist by age, sex, race/ethnicity, socioeconomic status, and geographic location. The prevalence of people living with CHD, however, is relatively unexplored in part due to the lack of data. Using data from the Behavioral Risk Factor Surveillance System for 2005-2007, this study develops a logistic regression model to estimate the probability of CHD prevalence while incorporating key factors associated with CHD mortality rates. The findings highlight that older white males with lower socioeconomic status are more likely to be diagnosed with CHD, compared to their black counterparts. Areas of higher probability of CHD prevalence coincide with areas of higher CHD mortality rates. The lower probability of CHD prevalence among blacks, however, may be directly influenced by their higher CHD mortality rates.

“Trying my Hardest”

Despite what is known about gender inequalities and the links between smoking, smoke exposure, and poverty, mothers who fail to protect their children from exposure to environmental tobacco smoke (ETS), are often stigmatized as uncaring mothers by the media. Here I describe the process of talking to mothers of young children about the wider social context(s) within which the act of smoking takes place, and their reflections on the paradox of why many women caring for young children still expose their children to tobacco smoke in home environments. By articulating the complex interrelationship between smoking, the maintenance of social relationships, caring for children, and coping with poverty, the women present an alternative conceptualisation as to why and how mothers direct their agency to enable them to care for their children in poverty, which questions the timing, messages and ultimate effect of giving home smoking advice to mothers with young children.

Location, location, location: The role of experience of disadvantage in lay perceptions of area inequalities in health

This paper examines how people see and express their experience of inequalities through place and how they understand the impact of place on health. Drawing on focus group discussions with participants from varying socio-economic backgrounds, we show, in contrast to a nascent received wisdom, how people from more deprived areas more readily discuss the adverse effects on health and well-being of structural and contextual features, whereas those with least experience of deprivation or hardship were more likely to draw on behavioural explanations of area inequalities. People living in more deprived areas also more readily accept statistics on area inequalities in health than those based in more affluent areas. We discuss these findings in the light of people's constructions of differences and distance between contiguous areas. We conclude by discussing some methodological and contextual features of our study which may explain why our findings both support and challenge those from earlier studies.

The influence of subjective social status on vulnerability to postpartum smoking among young pregnant women

OBJECTIVES

Associations between subjective social status, a subjective measure of socioeconomic status, and predictors of risk for postpartum smoking were examined among 123 pregnant women (aged 18-24 years) who stopped smoking because of pregnancy. The goal was to identify how subjective social status might influence the risk for postpartum smoking and to elucidate targets for intervention.

METHODS

We used multiple regression equations to examine the predictive relations between subjective social status and tobacco dependence, self-rated likelihood of postpartum smoking, confidence, temptations, positive and negative affect, depression, stress, and social support. Adjusted analyses were also conducted with control for race/ethnicity, education, income, and whether participant had a partner or not (partner status).

RESULTS

In unadjusted and adjusted analyses, subjective social status predicted tobacco dependence, likelihood of postpartum smoking, confidence, temptations, positive affect, negative affect, and social support. Adjusted analyses predicting depression and stress approached significance.

CONCLUSIONS

Among young pregnant women who quit smoking because of pregnancy, low subjective social status was associated with a constellation of characteristics indicative of increased vulnerability to postpartum smoking. Subjective social status provided unique information on risk for postpartum smoking over and above the effects of race/ethnicity, objective socioeconomic status, and partner status.

People, other animals and health knowledges: towards a research agenda

By serving as experimental models for human disease, animals have been instrumental to constructing biomedical knowledge. On the other hand, animals themselves increasingly benefit from biomedical expertise and technologies, as patients in their own right. Healthy companion animals have recently come to be viewed explicitly as potential sources of human health, which contrasts with the potential for animals to injure people or transmit infectious disease. In studies of biomedical and other health knowledges, nevertheless, only the animal model role has been explored in any depth. In this review article, we sketch and discuss three research concerns that currently inform studies of biomedical knowledge: medicalization and biomedicalization; constructing biomedical knowledge; and a concern with heterogeneity. We conclude that a more comprehensive and nuanced account of contemporary societies will result from further consideration of the importance of animals for how people understand health.

The psychosocial versus material hypothesis to explain observed inequality in disability among older adults: data from the West of Scotland Twenty-07 Study

OBJECTIVES

The possible mechanisms for explaining health inequality are subject to debate. This study considers the roles of psychosocial and material mechanisms in observed inequalities in disability among older people.

DESIGN

Cross-sectional analysis of cohort study.

PARTICIPANTS

723 respondents aged 63 years from the West of Scotland Twenty-07 Study.

MAIN OUTCOME MEASURE

The Office of Population Census and Surveys Multidimensional Disability Severity Score. Respondents were dichotomised to the highest scoring tertile, and compared with the lowest and mid-tertiles combined.

EXPLANATORY MEASURES

Socioeconomic position across adulthood was measured in three ways. Respondents reported perceptions of their own financial position (perceived financial hardship) across four decades of adult life. Data on possession of several indicators of material wealth (eg, ownership of television and washing machine; material conditions) during the same periods were also ascertained. Standard occupational classification was also recorded, based on longest held occupation. The relationship between the measures of socioeconomic position and disability was examined using logistic regression, adjusting for sex, morbidity and lifestyle factors.

RESULTS

Perceived financial hardship and material conditions in earlier decades of life were found to be associated with reported disability. However, in the fully adjusted model, there was stronger evidence for material conditions as a predictor of disability: across four decades they remained an independent risk factor for disability after adjustment for sex, morbidity, lifestyle factors and perceived financial hardship. Those in the most deprived material conditions group had 2 1/2 times the odds of reporting severe disability than those in the reference group. After adjustment, evidence for an association between perceived financial hardship and reported disability was not convincing.

CONCLUSION

The data provide evidence to support the "material" explanation for observed inequalities in reported disability among older people.

Self-rated life expectancy and lifetime socio-economic position: cross-sectional analysis of the British household panel survey

BACKGROUND

The association between mortality risk and socio-economic position (SEP) across the lifecourse is established. This study investigates whether people's own ratings of their life expectancy are also associated with lifetime SEP. Health behaviour messages, which often emphasize the long-term benefits of behavioural change, may be received differently depending on people's perceptions of their life chances.

METHODS

Cross-sectional analysis of 4780 adults aged 25-64 interviewed in the British Household Panel Survey in 2001.

RESULTS

Just under a quarter of respondents did not think it likely they would live to 75 or older. People in lower SEPs were more likely to be pessimistic about their life expectancy. This applied across a number of socio-economic measures (father's social class, educational achievement, own social class, and household income). Eight socio-economic lifecourse pathways were compared. In comparison to those following the most advantaged pathway, those experiencing sustained socio-economic disadvantage were most likely to be pessimistic about their longevity, but those experiencing sustained upward mobility did not differ. Comparisons with measures of self-rated general health and limiting illness suggest that self-rated life expectancy is at least partially independent of current health status.

CONCLUSIONS

This study shows that people's own perceptions of their life expectancy are associated with lifetime SEP. Self-rated life expectancy, in part, appears to reflect something over and above current health status and smoking behaviour. Given its ease of collection, it would be informative to include self-rated life expectancy in future studies.