Public understandings of potential policy responses to health inequalities: Evidence from a UK national survey and citizens’ juries in three UK cities

Abstract

A substantial body of research describes the distribution, causes and potential reduction of health inequalities, yet little scholarship examines public understandings of these inequalities. Existing work is dominated by small-scale, qualitative studies of the experiences of specific communities. As a result, we know very little about what broader publics think about health inequalities; and even less about public views of potential policy responses. This is an important gap since previous research shows many researchers and policymakers believe proposals for ‘upstream’ policies are unlikely to attract sufficient public support to be viable. This mixed methods study combined a nationally representative survey with three two-day citizens' juries exploring public views of health inequalities and potential policy responses in three UK cities (Glasgow, Manchester and Liverpool) in July 2016. Comparing public opinion elicited via a survey to public reasoning generated through deliberative processes offers insight into the formation of public views. The results challenge perceptions that there is a lack of public support for upstream, macro-level policy proposals and instead demonstrate support for proposals aiming to tackle health inequalities via improvements to living and working conditions, with more limited support for proposals targeting individual behavioural change. At the same time, some macro-economic proposals, notably those involving tax increases, proved controversial among study participants and results varied markedly by data source. Our analysis suggests that this results from three intersecting factors: a resistance to ideas viewed as disempowering (which include, fundamentally, the idea that health inequalities exist); the prevalence of individualising and fatalistic discourses, which inform resistance to diverse policy proposals (but especially those that are more ‘upstream’, macro-level proposals); and a lack of trust in (local and national) government. This suggests that efforts to enhance public support for evidence-informed policy responses to health inequalities may struggle unless these broader challenges are also addressed.

Public perceptions of the effectiveness of income provision on reducing psychological distress

“…In accordance with this, we find that the positive psychological health implications of providing sufficient income was intuitive to participants in our sample. This finding resonates with recent work challenging the view that there is a lack of public support for upstream, macro-economic policies for addressing population health needs (Smith et al, 2021). Nonetheless, we find it remarkable that participants rated income to be as effective as psychotherapy, usually invoked as the first preference of clinical treatment for improving mental health (McHugh et al, 2013).…”

‘It All Kind of Links Really’: Young People’s Perspectives on the Relationship between Socioeconomic Circumstances and Health

“…The context afforded young people a forum in which to develop understandings rather than being solely a means of extracting ideas. This highlights the importance of giving young people time and space to discuss and reflect on their perspectives on health inequalities [ 71 , 72 ]. Perhaps most importantly, we received consistently positive feedback from both participants and youth leaders across the three areas.…”

What shapes local health system actors’ thinking and action on social inequalities in health? A meta-ethnography

“…This point was central to a recent critique of the social determinants of health where it was argued that the desire to avoid victim blaming within health equity discourses has actually served to downplay the role of individual agency to the point where people are effectively reduced to ‘puppets on strings’ (Lundberg 2020 ). These insights, and indeed more recent research with citizen juries in a UK context, point to a challenging balancing act in advancing health equity discourses which can simultaneously counter the problematic tendency for publics to individualise health, but in ways that are neither disempowering nor likely to reinforce prominent fatalistic discourses about the possibility for successfully reducing health inequalities (Smith et al 2021 ).…”

“…Importantly, questions about the utility and impact of health equity ‘counter-discourses’ are not limited to professional groups, but are also increasingly being explored amongst different publics (Smith et al 2021 ; Fairbrother et al 2021 ; Lundell et al 2013 ), with a view to understanding what is needed to generate the grassroots pressure to reduce inequalities which health system actors so often suggest is lacking. A recurrent finding in this research is the paradox between deep and nuanced understandings of the relationship between social inequality and poorer health outcomes, in particular amongst groups most exposed to social injustice, and a reluctance to acknowledge or accept the existence of a social gradient in health (Smith and Anderson 2017 ).…”