Theorizing health inequalities: The untapped potential of dialectical critical realism

Beyond Information Provision: Analysis of the Roles of Structure and Agency in COVID-19 Vaccine Confidence in Ethnic Minority Communities

People from Black and Asian backgrounds are more likely to die from COVID-19 but less likely to be vaccinated, threatening to exacerbate health inequalities already experienced by ethnic minority groups. The literature suggests that mistrust rooted in structural inequality (including socioeconomic position and experience of racism) may be a key barrier to COVID-19 vaccine uptake. Understanding and addressing structural inequality is likely to lead to longer-term impacts than information alone. The aim of this study is to draw on health and sociological theories of structure and agency to inform our understanding of how structural factors influence vaccine confidence. We conducted qualitative interviews and focus groups with 22 people from London and the surrounding areas from December 2021 to March 2022. Fourteen participants were members of the public from ethnic minority backgrounds, and seven were professionals working with the public to address concerns and encourage vaccine uptake. Our findings suggest that people from ethnic minority backgrounds make decisions regarding COVID-19 vaccination based on a combination of how they experience external social structures (including lack of credibility and clarity from political authority, neglect by health services, and structural racism) and internal processes (weighing up COVID-19 vaccine harms and benefits and concerns about vaccine development and deployment). We may be able to support knowledge accumulation through the provision of reliable and accessible information, particularly through primary and community care, but we recommend a number of changes to research, policy and practice that address structural inequalities. These include working with communities to improve ethnicity data collection, increasing funding allocation to health conditions where ethnic minority communities experience poorer outcomes, greater transparency and public engagement in the vaccine development process, and culturally adapted research recruitment processes.

An analysis of English national policy approaches to health inequalities: 'transforming children and young people's mental health provision' and its consultation process

BACKGROUND

A national policy for England, published in 2017, entitled 'Transforming Children and Young People's Mental Health Provision' aimed to address the increasing prevalence mental health problems in children and tackle inequalities. In the context of this policy's implementation as ongoing and the effects of the Covid-19 pandemic, the need for appropriate, timely and ongoing national government commitment is vital.

METHODS

A narrative review using a problem representation evaluation [1], we critiqued the policy and related consultation documents using a social determinants of health perspective. We also reviewed wider policy discourses through engaging with stakeholder responses, providing an innovative methodological contribution to scholarship on public health policy and health inequalities.

RESULTS

We found absences and oversights in relation to inequalities (most notably the lack of acknowledgement that mental health can cause inequalities), access, workforce capacity, and the impacts of cuts and austerity on service provision. We suggest these inadequacies may have been avoided if stakeholder responses to the consultation process had been more meaningfully addressed. We illustrate how 'problems' are discursively created through the process of policy development, justified using specific types of evidence, and that this process is politically motivated. Local policy makers have a critical role in translating and adapting national policy for their communities but are constrained by absences and oversights in relation to health inequalities.

CONCLUSIONS

This narrative review illustrates how policy discourse frames and produces 'problems', and how the evidence used is selected and justified politically. This review contributes to the existing transdisciplinary field of knowledge about how using methods from political and social science disciplines can reveal new insights when critiquing and influencing policy approaches to health inequalities.

Let's Campaign for a Fairer Society in the Aftermath of COVID-19

In this paper I ground a brief account of the impact of COVID-19 on the United Kingdom in an understanding of a decade of austerity politics from 2010 to 2020, itself a product of the advent and consolidation of post-1970s financialised or rentier capitalism. I argue that such an analysis is essential if realistic plans are to be laid for a "better"-understood here as a more equitable or "fairer"-society. I go on to consider the contributions that sociology can, and arguably should, make to this end. This involves a range of engagements from scholarship at one end of the spectrum to action or muckraking sociology at the other. In addition to plotting a role for sociology, I suggest a set of criteria for recognizing a "fairer society"; postulate a series of institutional reforms that might characterize the attainment of such a society; and outline and confront social structural, cultural and agential obstacles to its realization. A theme running throughout the paper is that the delineation and promulgation of the "good society" remains central to any credible-that is, post-Enlightenment reconstruction of - the sociological project.

Exploring the local policy context for reducing health inequalities in children and young people: an in depth qualitative case study of one local authority in the North of England, UK

Background

Improving children and young people’s (CYP) health and addressing health inequalities are international priorities. Reducing inequalities is particularly pertinent in light of the Covid-19 outbreak which has exacerbated already widening inequalities in health. This study aimed to explore understandings of inequality, the anticipated pathways for reducing inequalities among CYP and key factors affecting the development and implementation of policy to reduce inequalities among CYP at a local level.

Methods

We carried out a qualitative case study of one local government region in the North of England (UK), comprising semi structured interviews (n = 16) with service providers with a responsibility for child health, non-participant observations of key meetings (n = 6 with 43 participants) where decisions around child health are made, and a local policy documentation review (n = 11). We employed a novel theoretical framework, drawing together different approaches to understanding policy, to guide our design and analysis.

Results

Participants in our study understood inequalities in CYP health almost exclusively as socioeconomically patterned inequalities in health practices and outcomes. Strategies which participants perceived to reduce inequalities included: preventive support and early intervention, an early years/whole family focus, targeted working in local areas of high deprivation, organisational integration and whole system/place-based approaches. Despite demonstrating a commitment to a social determinants of health approach, efforts to reduce inequalities were described as thwarted by the prevalence of poverty and budget cuts which hindered the ability of local organisations to work together. Participants critiqued national policy which aimed to reduce inequalities in CYP health for failing to recognise local economic disparities and the interrelated nature of the determinants of health.

Conclusions

Despite increased calls for a ‘whole systems’ approach to reducing inequalities in health, significant barriers to implementation remain. National governments need to work towards more joined up policy making, which takes into consideration regional disparities, allows for flexibility in interpretation and addresses the different and interrelated social determinants of health. Our findings have particular significance in light of Covid-19 and indicate the need for systems level policy responses and a health in all policies approach.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10782-0.

The changing governance of welfare: revisiting Jessop's framework in the context of healthcare

This paper revisits Jessop's governance of welfare framework, suggesting that in the post-financial crisis era of austerity we need to look again at its analytical dimensions. The paper reformulates Jessop's Schumpeterian Welfare Postnational Regime ideal-type framework through critique, and then applies its reformulated Galbrathian, Affluent Postnational Oligarchy ideal-type to the case of the English NHS to present a new political economy of health.

Developing a critical realist informed framework to explain how the human rights and social determinants of health relationship works

Background

That there is a relationship between human rights and health is well established and frequently discussed. However, actions intended to take account of the relationship between human rights and social determinants of health have often been limited by lack of clarity and ambiguity concerning how these rights and determinants may interact and affect each other. It is difficult to know what to do when you do not understand how things work. As our own understanding of this consideration is founded on perspectives provided by the critical realist paradigm, we present an account of and commentary on our application of these perspectives in an investigation of this relationship.

Findings

We define the concept of paradigm and review critical realism and related implications for construction of knowledge concerning this relationship. Those implications include the need to theorise possible entities involved in the relationship together with their distinctive properties and consequential power to affect one another through exercise of their respective mechanisms (ways of working). This theorising work enabled us identify a complex, multi-layered assembly of entities involved in the relationship and some of the array of causal mechanisms that may be in play. These are presented in a summary framework.

Conclusion

Researchers’ views about the nature of knowledge and its construction inevitably influence their research aims, approaches and outcomes. We demonstrate that by attending to these views, which are founded in their paradigm positioning, researchers can make more progress in understanding the relationship between human rights and the social determinants of health, in particular when engaged in theorizing work. The same approaches could be drawn on when other significant relationships in health environments are investigated.

Social practice, plural lifestyles and health inequalities in the United Kingdom

Persistent health inequalities pose a continued research and policy challenge in the United Kingdom and elsewhere. Current approaches to health research and promotion are predicated on a distinction between wider, social structural causes and individual, health-related behaviours often conceived of as lifestyle choices. Drawing on Bourdieu's theory of social practice, this paper develops an integrated perspective by observing associations between health and structured lifestyle practices. Using the UK Understanding Society household survey, a taxonomy of eight lifestyle clusters is identified, which exhibit significant health inequalities on a number of indicators. But the plurality of practices and subjective orientations inherent in the taxonomy reveals a finer, more complex differentiation of the social gradient in health. In addition, lifestyle appears to at least in parts mediate the relationship between social, material conditions and health. A feature of the taxonomy is that it admits a relational and contextual apprehension of health-relevant, behavioural aspects within a more holistic notion of lifestyles. Based on this view, strategic approaches can be developed that respond to group-specific situations and pathways and their varying roots in upstream or downstream domains of policy.