four - Explaining inequalities in health: theoretical, conceptual and methodological agendas

Summary

Introduction

How are we to explain inequalities in health? Are some pathways more important than others? Are there limits to current epidemiological research? What light does lay knowledge shed on inequalities in health, both past and present? Do we need to dig deeper into the causes of inequalities? How do these issues translate into future policies and practices designed to tackle inequalities in health and ‘narrow the gap’? These are some of the questions confronting health inequalities researchers today. The importance of these questions, moreover, seems to have grown rather than diminished in the light of the UK government White Paper for England (DH, 2004), tellingly entitled Choosing health: Making healthier choices easier: a side-stepping, effectively, of anything but behavioural/lifestyle explanations, couched in the rhetoric of consumer choice.

Recent years have witnessed what might be termed a ‘reinvigorated’ debate around potential pathways and explanations for health inequalities, including the limits of epidemiological approaches and a reassessment of the role of different types of knowledge and expertise. Richard Wilkinson's work on income distribution and social relativities, in particular, has been an important influence here, both before and since the Acheson Inquiry (Acheson, 1998), generating much discussion and debate. It is with a detailed exposition of this discussion and debate, therefore, together with other new lines of thinking and research on inequalities in health, that this chapter is concerned. Following a brief account of Wilkinson's so-called ‘psychosocial’ perspective on income distribution, social relativities and health, we then proceed to discuss recent research on lay knowledge and life-course approaches respectively. We also return, towards the end of the chapter, to some further thoughts and reflections on Choosing health in the light of these debates, paying particular attention to future research and policy agendas for tackling health inequalities and reducing ‘the gap’. While Choosing health is very much an English public health White Paper, analysis of Scottish and Welsh health documents (Raphael and Bryant, 2006) highlights a similar emphasis on a behavioural/lifestyle approach to improving inequalities in health (see Scottish Executive, 2004; Welsh Assembly, 2004).

The psychosocial perspective

Since the Black Report (DHSS, 1980) presented its findings, scepticism has grown as to the explanatory power of its materialist explanations for inequalities in health.