Understanding Health Inequalities

Abstract

This contribution to the burgeoning literature on social inequalities in health is a compilation of different research studies funded under the auspices of the Economic and Social Research Council's 'Health Variations Programme'. Accordingly, the research is virtually all based on data from the UK, but taken together, the studies contained in this book provide a nice snapshot of the broader field of health inequalities research in developed countries. The 13 chapters have been authored by a veritable 'who's who' and include some of the most prominent UK health inequalities researchers. One of the main strengths of the book is that it spans many disciplines (sociology, epidemiology, psychology, economics and public policy) and thus presents different approaches to studying health inequalities. There are standard epidemiological and econometric investigations as well as innovative qualitative studies, aggregate geographical and policy analyses. The book is divided into four sections that correspond to the most prominent themes in contemporary health inequalities research—race, ethnicity and gender, life course; place; and policy. There are many valuable contributions in this volume but I will mention only a few that struck a particular chord with my subjective view of what was most interesting. From the first section on race, ethnicity and gender, a study by Karlsen and Nazroo examined the contribution of 'ethnic identity' to observed health inequalities. This topic is receiving ever increasing attention in the US as a potential explanatory vehicle for observed race/ethnic health differences. They provide an elegant and thoughtful discussion of the construct of ethnic identity and how it might affect health, but most interestingly, they find relatively little effect of ethnic identity on health. They conclude that, 'Ethnicity as structure (both in terms of racialization and class experience), rather than ethnicity as identity, is strongly associated with health for ethnic minority people living in Britain' (p.55). In the same section, Mel Bartley and colleagues convincingly demonstrate how different indicators of the socioeconomic position of women (based on occupational class, general social advantage and material deprivation) have different associations with behavioural, work-related and physiological outcomes. This is important work because it helps inequalities researchers think about how different markers of the multi-dimensional nature of social inequality may plausibly exhibit varying empirical associations with known risk factors and outcomes. This helps tie social theory to what is known about risk factors for particular outcomes and helps move us away from a miasma of general psychosocial susceptibility to thinking more about how structural features of the society are translated into morbidity and mortality. This certainly does not preclude a role for psychosocial factors in disease causation but it does help to sharpen precisely where they may fit in terms of particular patterns and trends in risk factors and health outcomes. Thus, this seems to be a very profitable way forward for research in health inequalities. The chapter by Berney and colleagues in the life course section of the book, shows how innovative 'life grids' can be used to establish a time line of sentinel events within which to locate potential life course influences on health. The conclusion by the authors of this study is worthy of note because they found that, 'The effects of lifecourse influences are more apparent on objective rather than on self-reported measures of health' (p.92). This observation may have implications for what types of outcomes need to be included if we are to develop further our understanding of health inequalities. In the same section, Benzeval and colleagues describe how early life factors influence both the accumulation of 'health capital' and 'income potential' and how these can jointly contribute to adult socioeconomic conditions, behaviours and health outcomes. The qualitative study by Hunt and colleagues provides an innovative example of how questions deliberately included in the design of a quantitative survey were used to identify subsequently a sub-sample for intensive qualitative follow-up with regard to perceptions of familial risk of heart disease. Such intensive qualitative investigations are important to deepening and contextualizing knowledge that can be gained from traditional epidemiological study and is a good example of how both methods complement each other. In the section dealing with place effects on health, Macintyre and colleagues pursue their interesting work on the role of housing tenure on health and show in fine-grained detail how owner-occupiers differ from renters along a variety of socioeconomics, demographic, psychosocial and health characteristics. They deepen our knowledge of this empirically important exposure by showing that owning a home may be much more than a simple proxy for social class or income. Other chapters in this section flesh out the myriad characteristics of places, such as migration, social capital and de-industrialization that might be important in understanding geographical differences in health in Scotland and Britain. Interestingly, unlike other recent contributions in health inequalities, there is no section specifically devoted to the study of stress and other psychosocial factors, but these topics are reflected in some of the chapters. For instance, in Chapter 11, Elspeth Graham and colleagues invoke Richard Wilkinson's ideas of 'relative deprivation' to investigate processes of local social comparison, anxiety and low self-esteem, in an attempt to link the geography of socioeconomic disadvantage to the psychological processes that influence recovery from myocardial infarction (MI). While these are preliminary analyses of an incomplete sample, they surprisingly find that recovering MI patients actually do better when living in communities where they are surrounded by relatively more ill as opposed to well people. They state that this finding does not appear to be due to psychological factors like social comparisons, self-esteem or anxiety. Nevertheless, they suspend disbelief and conclude that social comparisons and the negative affective states they produce are nevertheless likely to be important in improving recovery from MI. The book concludes with a chapter by Whitehead and colleagues which provides a useful example of policy research by comparing the trends in the self-rated health of lone and couple mothers in the very different social policy environments of Sweden and Britain. They present convincing evidence that not only do couple mothers have better self-rated health in both countries, but that on average, lone mothers in Sweden rate their health more positively than couple mothers in Britain. In addition to these important empirical findings, the authors present a conceptual model, developed by Finn Diderichsen, for researching policy impacts on health inequalities. I find this model to be the most useful conceptual tool I have yet seen presented in the literature, and strongly recommend it to all those interested in teaching about and researching health inequalities. My major criticism is that for epidemiologists, there are some chapters that present very rudimentary and in a couple of cases rather weak analyses of the data. Thus, there are some potential mismatches between the conclusions offered by the authors and the empirical analyses used as evidence. Nevertheless, this book is a valuable contribution to the field and because of its broad scope of concepts and methods in health inequalities research, I would recommend it for undergraduate or beginning graduate students, especially in the UK.