Although it is definitely true that we are all going to die, some of us will die sooner rather than later – our life chances are closely connected to our social and economic state of affairs, which are insolvably allied to influences of behaviour and intergenerational by constructive and destructive aspect. Over and above social inequality in health, there is also an interlinked geographical dimension to health: masses living in different places have differing life chances, irrespective of their social status. The body of literature proposes that not only is there inequality in health between regions and areas in Britain but that the coverage of this inequality is increasing. Expected elucidations for the geographical techniques assessed are briefly discussed. Consideration is given upon the methodological issue of changing geographical boundaries, and how this process of area redefinition may have obscured the observation of underlying methods of inequality. Invariable geographical boundaries are constructed to allow for the comparison of standardised mortality ratios (SMRs) over the period 1951-1991. The conclusions indicate that alterations in the description of boundaries have led to the underestimation of geographical inequalities in health (at least in terms of mortality) in contemporary Britain (Blaxter, 1997, p. 747).
There is now an important body, which will research on lay perceptions of health and illness. Little of this work, nevertheless, has focused directly upon lay concept and understandings of the nature and roots of social inequalities in the experience of health and illness. Reﬂecting on these circumstances, Blaxter has stated: Considerable progress is being made in research that tries to explain social inequalities in health. But what people themselves think about the question? What kinds of causal attributions do they use: what or whom do they blame for liable for this ill health? The answers may have importance both for social policy and its public acceptance, and for individual choices relevant to health. It detects ‘lay theories’ about the roots of inequalities in the health experience of people living in different areas, and the techniques in which these ‘explanations’ differ amongst masses living in contrasting socio-economic localities. In so doing, it light up how the research process in general, and in particular different methods and questions, inﬂuences the understandings generated (Dorling, 1996, p.1)
In early research lay perceptions on health and illness were conceptualised as separate from the formal scientific expertise that clued-up medical practice. From the time when then, however, the diversity of ‘lay’ and ‘scientific’ knowledge’s, the interpretative and critical affiliation that subsists between different forms of information’s, and the reliant nature of the notion of ‘expertise’ have all been emphasized.
Over the same era, a richer, thicker description of lay concepts of health and illness has accumulated – reflected in the changing lexicon, from ‘lay beliefs’ to ‘lay knowledge’ or even ‘lay epidemiology’ (Davison et al., 1991, p.1).
In a of late paper Mildred Blaxter (1997) has believed what insight this larger body of work on lay theorising about health and illness has to offer to our understanding of lay viewpoints on health inequalities. She argues that findings from survey-based research suggest that all social groups have a propensity to neglect structural causes of health and illness giving dominancy to individual responsibility as promulgated in health promotion activity. On the other hand, quoting a study by Calnan, which unusually focused specifically on lay perceptions of health inequalities, Blaxter also points out that the superior socio-economic groups appear to be more probable to highlight those same structural factors – For instance income, work, the environment – that are emphasised in social epidemiological evidence. As the qualitative research reviewed by Blaxter powerfully evince, explanations lay people proffer for health inequalities cannot be simply dichotomised into individualistic/structural throughout the research evidence, lay respondents tend to a certain extent to move back and forwards between concepts of cause which seem opposed but which individuals can keep in equilibrium (Blaxter 1997, p.750)
Qualitative research also highlights the necessity to make a difference between health and illness and the importance of the context within which questions are created. Above all, there appears to be a powerful moral very important associated with health and the familiarity of health. As Blaxter interprets, ‘health is a more inclusive concept which people prefer to claim if at all possible’. People may for that cause offer unusual explanations for their experience of health as opposed to illness and still different explanations for other people’s experiences.
Blaxter’s try to delve lay views about health inequalities obliquely through a review of existing research on lay concepts of health and illness is an important starting point. In general, she consummates that lay people have rarely talked about health inequalities in the context of research, implying that this: genuinely represents a feeling of disbelief or unease at the notion, or a conceptual difficulty, especially amongst those most at risk (Blaxter 1997, p.753).
The tentative conclusions she draws, however, about the probable response of lay people to facts of health inequalities, the feasible material of lay theories of causality and the probability of social delineation in these theories, need to be further explored. Especially, there is a need to deem the way in which people act in response to questions that focus specifically and directly on inequalities in the experience of health and illness. Of late examination involving qualitative methods by Davidson and colleagues has sought to do this and preliminary results from this study suggest that people are sensitive to the ‘ontological’ connotation that flow from an acceptance that their disadvantaged circumstances could adversely affect their health. On the other hand, they also appear to be willing and capable to acknowledge a causal relationship between social and material inequalities and health inequalities. There are also apt to be crucial dimensions of lay ‘theories’ about health inequalities that existing research on lay conceit of health and illness in most cases cannot illuminate, for instance the salience of time and place. Score of the studies reviewed by Blaxter involved paradigm of people in particular places at particular times and give some prominence to historical and predominantly biographical time. In an important sense, on the other hand, the material places in which people lived out their lives in these studies were largely presented as ‘the canvas on which events happen’ (Jones & Moon 1993, p. 515) more willingly than being conceptualised as a focus for comprehensive enquiry in the course of the research. Given the growing interest in the relationship among health and place and the need for additional exploration of lay theories about health inequalities, research giving greater attention to lay perceptions of the role of ‘area effects’ is timely.
The study account on here took place in the cities of Salford and Lancaster in the North West of Britain. There were four study localities taken as a whole, two in each city – one comparatively disadvantaged, the other relatively advantaged. Three of the localities include a number of enumeration districts (EDs) inside electoral wards, at the same time, as the fourth encompass a set of EDs across two electoral wards. The data are haggard from two strands of the study’s pragmatic work; a survey of a random sample of people living in the four areas and a series of in-depth interviews with purposively sampled individuals haggard from these survey samples. As explain below, each strand of the pragmatic work directly asked respondents about their opinions of health inequalities and in particular the liaison between place and health across the four localities, two thousand names and addresses were selected from the electoral registers, 600 in every of the more poor areas and 400 in the relatively affluent localities. Each person was get in touch with letter and subsequently on the doorstep, when they were asked to take part in a short interview concerning their own health and that of other members of the household. Data on household type, age, gender and ethnicity were moreover collected. They were then demanded for to complete, and to return by post, a questionnaire (Haynes, 1991, p.361). A total of 777 questionnaires were returned and scrutinized. The response rate ranged from 35 per cent to 56 per cent across the four study areas. Table 1 provides comparative data on the response rates and material circumstances in the areas (Eames, Shlomo, and Marmot, 1993, p.1097)
Table 1 The survey: response rates, material circumstances, and age distribution across the four localities.
|area 1:||area 2:||area 1:||area 2:|
|% (n)||% (n)||% (n)||% (n)|
|Survey Response Rate||47.2 (247)||36.5 (191)||56.2 (207)||34.6 (132)|
|Indicator of material conditions|
|Social Class 4 & 5||30 (74)||30 (57)||8 (16)||13 (17)|
|Rate of unemployment||7 (17)||9 (17)||1||(2)|
|Income < £6k||27 (66)||29 (54)||8 (15)||12 (15)|
|Rented housing||27 (66)||32 (61)||8 (15)||5|
|Between 75% & 100%||36 (89)||36 (69)||8 (15)||5 (17)|
|income from benefits|
|Age distribution of respondents|
|Under 25 years||6.1||(15)||6.3 (12)||6.3 (13)|
|25- 44 years||45.5 (112)||51.8 (99)||39.3 (81)||28.8 (38)|
|45- 64 years||24.4||(60)||26.2 (50)||34.5 (71)|
|65- 74 years||14.2||(35)||10.5 (20)||12.6 (26)|
|Over 75 years||9.8||(24)||5.2 (10)||7.3 (15)|
The self-completion postal questionnaire concluded comprehensive data on the respondent’s health, home, work status, family finances, levels of support and how they felt about living in their neighbourhood. In this paper we focus specifically on the replies given to an open-ended question (see Box 1) that aimed to explore respondents’ perceptions of social inequalities in health, focusing particularly on differences in the experience of people living in the distinct study areas, subsequent participation in the survey fifty one people took part in in-depth interviews. This sub-set of people was selected purposively to ensure social
Box 1. Survey question on perceptions of social inequalities in health
|In the self-completion questionnaire respondents were asked to provide free text answers to the following question: |
We are interested in why people in some places have worse health than people from other places. In general people living in (name of deprived city locality) have poorer health than people living in (name of affluent city locality). For example, more men in their forties have heart attacks and more children have accidents. What do you think are the three most important reasons for worse health in some places?
diversity, and integrated lone parents, people aged 25 or younger, older people who had retired and parents in two-parent families. Of these respondents, nineteen were asked to take part in a second interview focusing on health inequalities, of which twelve were from the relatively deprived study localities, and seven from the relatively affluent. Conclusions from these second interviews are reported here. These respondents included four lone parents, two younger people aged below twenty-five, six older people who had retired and seven parents in two-parent families.
The interviews were taken in respondent’s homes and were conducted by two researchers. The interviewer kicked off by indicating that they were interested in obtaining peoples’ opinions of why research was finding differences in health status between people who lived in different areas, and this was often enough to initiate the discussion. Three types of ‘prompt’ substance were taken into the interviews to kindle discussion: illustrative findings from the research in the study areas; findings from other research representing inequalities in health; and newspaper cuttings reporting on health inequalities. Examples of the material taken into the interviews are shown in Box 2.
The amount and category of prompt material used speckled between interviews, and depended on the way in which each individual responded. Prompts were typically used to clarify opinions expressed by respondents or to initiate further discussion.
Box 2. Examples of prompt material
Worsley and Boothstown are relatively affluent compared to Weaste, Seedley and Langworthy. Poor housing, unemployment and poverty are the most important reasons for ill health’ ‘(Areas need) good housing, secure employment prospects and proper neighbour relationships and a sense of community’.
People from Weaste, Seedley and Langworthy were almost twice as likely to report fair or poor health than people in Worsley or Boothstown’
‘Where you live has a big effect on when you die’
Survey data – lay ‘theories’ on the causes of health inequalities
Even though illustrated by one respondent as ‘the most difficult question in the questionnaire’, 89 per cent (n 691) of the survey sample completed the open-ended question asking for their judgments on why health differences are observed between people who live in different places (Box 1). The unrestricted responses were coded into four broad categories on the basis of the type of causal factors given prominence: macro-structural (including poverty and employment issues); individual (including health related behaviours, attitudes and lifestyles); place-based factors (including pollution, traffic, access to facilities, housing and crime); and other factors (including family history, psychological factors and stress in general).
Only fifteen of these respondents (2.2 percent) said they did not know why the differences existed and only two (0.3 percent) refuted the existence of area inequalities in health. A fifth (N = 149) chose to focus on just one of the four categories of causal factors, while the rest of (n = 525) ranged across categories and ofttimes discovered the liaison between them (Gould and Jones, 1996, p.857).
As Table 2 illustrates, the greater part of those respondents choosing to converge on a single category of cause highlighted place-based factors, with some people offering a single factor, for instance, ‘encroachment, dog grime and unclean streets’ (ID4) or ‘Not enough places for kids to play’ (ID20). Others listed disparate area factors for instance ‘[In poorer areas you have] a higher population density, a lack of leisure facilities, more pollution and poorer housing’ (ID21). Explanations centering on individual health behaviours for instance ‘Beer, fags, egg and chips’ (ID1201) were the 2nd most common amongst responses converging on a single causal category, subsequently those focusing on macro-structural causes for instance poverty and unemployment. Inevitably perhaps, references to stress and hereditary factors were infrequently made independently of other factors.
Ancient scholar’s research has exposed the reporting to which lay theories about health and illness differ across social groups. Taking into account this nut in association to the minority of respondents in every of our study areas choosing to lay emphasis on a single fundamental category in their response, significant differences between the areas were found as shown in Table 3.
Table 2 Explanations for health inequalities offering a single causal category.
|Type of Explanation||Percentage||N|
|Place based factors||55.0||82|
Table 3 Single causal category responses in the four areas.
|Percentage of Responses|
|Relatively disadvantaged||Relatively Advantaged|
|Type of |
Significance level: * p < 0.05, **p < 0.01, ***p < 0.001, NS – Not significant
Amongst people choosing to center of attention on a single category of causes those living in the relatively disadvantaged study localities were more likely to explain health inequalities in conditions of area-based factors (x2 21.08 p < 0.001) match up to with those from the more advantaged areas who were more likely to mention individual factors (x2 21.26 p < 0.001). Even though there were dissimilarities across the four areas in the proportions highlighting macro-structural factors and, to a lesser extent, other factors for instance stress or heredity, for instance, these were not considerably different between the disadvantaged and advantaged areas.
This sort of analysis is more problematic in relation to the awe-inspiring majority of respondents who integrated different categories of reasons in their explanations, as these replies are not easily classified as primarily individualistic, macro-structural or area-focused. Some people did give particular weight to individual responsibility whilst acknowledging – sometimes begrudgingly – wider factors. More often, however, these explanations recommended complex relationships between individual lifestyle factors, macro-structural factors and place-based factors. Some respondents living in the privileged study areas also tinted the causal role of macro-structural and place-based factors in generating health inequalities. Even so, distance from the lived experience of health destructive places gave these responses a more sterile and dispassionate quality (Duncan & Jones, 1995, 27).
This study has sought to explore these perspectives using quantitative data from local appraisals and data from in-depth interviews. Particularly, throughout a postal self-completion appraisal and in-depth interviews, the research has been concerned to ask respondents living in comparatively advantaged and disadvantaged areas to consider why people living in different areas have different health experiences (Popay, 1996, p.759).
When asked, the majority of people in the survey sample made some effort to explain the inequalities in the health experience of people living in different places that were described in the questionnaire. Not amazingly, given the format of the question asked, characteristics associated with particular places – referred to in the literature as ‘area effects’ – were more prominent in these explanations than aspects of individual behaviour, such as smoking or diet. A minority of those responding – around twenty per cent – chose to focus on one of the four categories of causes used in the analysis: macro-structural, place-based factors, individual factors and other factors, including hereditary and stress. Surrounded by these respondents’ place-based effects were twice as likely to be highlighted in the genesis of inequalities compared with aspects of individual behaviour. In addition, these respondents, people living in underprivileged areas were more likely to suggest place-based reasons for inequalities in health, for instance poor housing and pollution, whilst those living in more privileged conditions were more likely to offer individualistic explanations.
Significantly, however, the vast majority of respondents in these surveys offered clarification that encompassed more than one causal category and frequently articulated linkages between these. Unavoidably, therefore, these responses defy any simple categorisation by cause. It was clear, however, that place-based factors were prominent (Popay, 1998, 305).
If the ways to ill health are conceptualised as psychosocial then the means to evade ill health (framed in terms of individual resilience and strength of character) are, potentially as a minimum, within an individual’s control. In distinction, it is difficult to envisage what a valuable individual response would be to any direct causal relationship between structural factors, area effects and ill health.
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