Hilary Graham

Health and climate change: policy responses to protect public health

The 2015 Lancet Commission on Health and Climate Change has been formed to map out the impacts of climate change, and the necessary policy responses, in order to ensure the highest attainable stand ...

Evidence for public health policy on inequalities: 1: The reality according to policymakers

Objective: To explore with UK and international policy advisors how research evidence influences public health policy making, and how its relevance and utility could be improved, with specific reference to the evidence on the production and reduction of health inequalities. Design, setting, and participants: Qualitative residential workshop involving senior policy advisors with a substantive role in policy development across a range of sectors (mainly public health, but also including education, social welfare, and health services). In four in depth sessions, facilitated by the authors, focused questions were presented to participants. Their responses were then analysed thematically to identify key themes, relating to the availability and utility of existing evidence on health inequalities. Main results: The lack of an equity dimension in much aetiological and evaluative research was highlighted by participants. Much public health research was also felt to have weak underlying theoretical underpinnings. As well as evaluations of the effectiveness and cost-effectiveness of policy and other interventions, they identified a need for predictive research, and for methodological research to further develop methods for assessing the impact on health of clusters of interventions. Conclusions: This study reinforces the view that there is a lack of information on the effectiveness and cost-effectiveness of policies, and it uncovered additional gaps in the health inequalities evidence base. A companion paper discusses researchers’ views of how the production of more relevant public health evidence can be stimulated.

Will Cardiovascular Disease Prevention Widen Health Inequalities

Simon Capewell and Hilary Graham review different population strategies for preventing cardiovascular disease and conclude that screening and treating high-risk individuals may be ineffective and widen social inequalities.

Smoking prevalence among women in the European community 1950-1990.

The paper reviews trends in tobacco use among women in the European Community (EC) between 1950 and 1990. The data suggest that EC countries occupy different points on what appears to be a common prevalence curve. Southern EC countries are represented in the early phases of this curve, marked out by sharply rising prevalence. In northern EC countries, female smoking prevalence appears to have peaked. Across the EC, the commodification of tobacco use, and the production and promotion of manufactured cigarettes in particular, underlies this prevalence curve. Young women in higher socio-economic groups have led the way into cigarette smoking in both northern and southern Europe, with smoking prevalence declining first among women who are privileged in terms of their education, occupation and income. Because the decline in prevalence has yet to be repeated among women in more disadvantaged circumstances, cigarette smoking among women in the EC is likely to become a habit increasingly linked to low socio-economic status.

Building an inter-disciplinary science of health inequalities: the example of lifecourse research

Across the post-industrial world, new public health strategies are being developed with the goal of reducing the socio-economic gradient in health. These new strategies are distinguished by a commitment to tackling the macro determinants of health inequalities through policies informed by scientific evidence. The engagement with macro determinants and with scientific evidence presents a major challenge to the health inequality research community. This is not only because of the complexity of the links between distal causes, proximal risk factors and health outcomes. It is also and more importantly because of the narrow disciplinary base of health inequality research. Grounded in social epidemiology, health inequality research has illuminated the pathways which run from individual socio-economic position to health-but has left in shadow the factors which influence socio-economic position. Broadening the evidence base to include these structural processes requires a new science of health inequalities, resourced both by epidemiological research and by research on social inequality and social exclusion. The paper demonstrates how such an inter-disciplinary science can be constructed. Taking lifecourse research as its example and the UK as its case study, it nests epidemiological research within social policy research: setting evidence on the health consequences of cumulative exposures within research on lifecourse dynamics, and locating both within analyses of how state policies can amplify or moderate inequalities in socio-economic position.

Pathways of disadvantage and smoking careers: evidence and policy implications

Objectives: To investigate in older industrialised societies (a) how social disadvantage contributes to smoking risk among women (b) the role of social and economic policies in reducing disadvantage and moderating wider inequalities in life chances and living standards. Methods: Review and analysis of (a) the effects of disadvantage in childhood and into adulthood on women’s smoking status in early adulthood (b) policy impacts on the social exposures associated with high smoking risk. Main results: (a) Smoking status—ever smoking, current smoking, heavy smoking, and cessation—is influenced not only by current circumstances but by longer term biographies of disadvantage (b) social and economic policies shape key social predictors of women’s smoking status, including childhood circumstances, educational levels and adult circumstances, and moderate inequalities in the distribution of these dimensions of life chances and living standards. Together, the two sets of findings argue for a policy toolkit that acts on the distal determinants of smoking, with interventions targeting the conditions in which future and current smokers live. Conclusions: An approach to tobacco control is advocated that combines changing smoking habits with reducing inequalities in the social trajectories in which they are embedded. Policies to level up opportunities and living standards across the lifecourse should be championed as part of an equity oriented approach to reducing the disease burden of cigarette smoking.

Evidence for public health policy on inequalities: 2: Assembling the evidence jigsaw

Study objective: To garner research leaders’ perceptions and experiences of the types of evidence that influence policy on health inequalities, and their reflections on how the flow of such research evidence could be increased. Design, setting, and participants: Qualitative two day residential workshop with senior research leaders, most of whom were currently involved in evaluations of the health effects of major policies. In four in depth sessions, facilitated by the authors in turn, focused questions were presented to participants to reveal their views and experiences concerning evidence synthesis for policy on inequalities. These were analysed thematically. Main results: Five types of evidence for policy on health inequalities were felt to be particularly persuasive with policymakers: observational evidence showing the existing of a problem; narrative accounts of the impacts of policies from the household perspective; controlled evaluations; natural policy experiments; and historical evidence. Methods of improving the availability and use of these sources of information were put forward. Conclusions: This paper and its companion have considered the current evidence base for policies to reduce health inequalities, and how this could be improved. There is striking congruence between the views of the researchers in this study and policy advisers in paper 1, suggesting that a common understanding may be emerging. The findings suggest significant potential for rapid progress to be made in developing both evidence based policy, and policy relevant evidence to tackle inequalities in health.

Pathways and mechanisms in adolescence contribute to adult health inequalities

Aims: This paper presents a model that encompasses pathways and mechanisms working over adolescence that contribute to adult health inequalities. We review evidence on the four mechanisms: socially differential exposure, tracking, socially differential tracking, and socially differential vulnerability. Methods: We conducted literature searches in English-language peer-reviewed journals using PubMed (from 1966 to May 2009) and PsycINFO, and combined these with hand-searches of reference lists, journals, and authors of particular relevance. Results: Most health indicators are socially patterned in adolescence and track into adulthood, with higher risks of adverse outcomes among individuals from lower socioeconomic positions. Adolescent health behaviours track into adulthood. Smoking, physical activity, and especially fruit and vegetable intake are socially patterned, while evidence for social patterning of alcohol use is less consistent. Relational dimensions like lone parenthood and bullying are socially patterned and track over time, and there are indications of a socially differential vulnerability to the effects of these types of relational strain. Very little research has investigated the social patterning of the above indicators over time or studied social vulnerability of these indicators from adolescence to adulthood. However, all four mechanisms seem to be active in establishing social differences in adult educational attainment. Conclusions: We find the Adolescent Pathway Model useful for providing an overview of what elements and mechanisms in adolescence may be of special importance for adult health inequalities. There is a lack of knowledge of how social patterns of health, health behaviours, and social relations in adolescence transfer into adulthood and to what extent they reflect themselves in adult health.

Tackling Inequalities in Health in England: Remedying Health Disadvantages, Narrowing Health Gaps or Reducing Health Gradients?

Socioeconomic inequalities in health have moved up the policy agenda of older industrial societies. The paper turns the spotlight on this development by exploring how the goal has been represented in Englands national policy documents. Rather than one approach, there appears to be a range of understandings of what it means to tackle health inequalities. These understandings can be placed on a continuum, which runs from improving the health of poor groups, through closing the health gaps between those in the poorest circumstances and better-off groups, to addressing the association between socioeconomic position and health across the population. The paper points to common ground between the three approaches to tackling health inequalities, but also to important differences in the moral arguments and causal models on which they rest, and therefore in their policy goals and anticipated policy impacts.

Resilient Young Mothering: Social Inequalities, Late Modernity and the ‘Problem’ of ‘Teenage’ Motherhood

This paper draws on a systematic review of qualitative research to explore the resilient mothering practices that young, British, working-class mothers employ to care for their children. The synthesis of studies of UK mothers under the age of 20 demonstrates how young working-class women must mother in impoverished circumstances, at the same time as being discursively positioned outside the boundaries of ‘normal’ motherhood. Consequently, they utilize the only two resources to which they may have access: their families and their own personal capacities. Engaging with debates regarding the extent of the transformations of the social in late modernity, the paper discusses the most prominent of the young mothers’ practices: investment in the ‘good’ mother identity, maintaining kin relations, and prioritization of the mother/child dyad. The paper argues that, while the young mothers’ practices display reflexivity and individualism, they are also deeply embedded in, and structured by, social inequalities.