Editorials |
Health inequalities—the need for explanation and intervention
Eero LahelmaCorrespondence: E-mail: eero.lahelma{at}helsinki.fi
Health inequalities understood as systematic differences in health between socio-economic groups have turned out to be much more persistent and complex than previously thought. The sad thing is that over the past few decades these inequalities have rather widened than narrowed in most European countries.1 While the number of studies has steadily increased, all too little emphasis has been given to factors contributing to health inequalities. Nevertheless, evidence on explanations for health inequalities has accumulated little by little.
Among the explanations discussed since the Black Report artefacts and selection to socio-economic groups are unlikely to be major explanations for health inequalities. It is a paradox that in affluent and even egalitarian societies the origins of health inequalities can be traced back to deeply rooted structural inequalities exemplified by social class, education, and income differences. These distal processes shape inequalities in the more proximal material, behavioural, and other factors.
A body of research confirms that material factors, such as material living conditions, physical working conditions, income, and housing, as well as behavioural factors, such as smoking, drinking, and obesity, explain a large part of the existing health inequalities.2,3 Psychosocial factors also play a role although that is less clear. While some psychosocial stresses and strains partly explain health inequalities, some do not since they are more common among the higher than the lower socio-economic groups.4 There are also examples of unequally distributed medical treatments which may contribute to health inequalities in specific conditions and therefore need further scrutiny. Recently, attention has been devoted to cognitive abilities which also may contribute to the proximal factors explaining health inequalities but these are unlikely to provide a major explanation.
Explanations are needed for scientific progress and they provide the basis for a better understanding of the phenomena under study. However, explanations are equally important to the evidence base needed for efficient policies and interventions to reduce health inequalities, which is the ultimate aim of all socio-economic public health research. While better explanations are searched for, the current evidence on factors contributing to health inequalities can and should already be utilised for tackling the large existing health inequalities. For example, the patterning of smoking and heavy drinking is increasingly unequal and these behaviours may explain even up to half of health inequalities in some countries. We need to understand much better the socio-economic processes leading to unhealthy behaviours to be able to avoid victim blaming and to develop efficient preventive measures. The unequal patterning of material resources and living conditions, another key explanation for health inequalities, highlights that policies should aim at improving the material conditions among those at the bottom of the socio-economic ladder.
The experience from policies and interventions is that there is no simple solution to the large existing health inequalities. Sticking to one or another exclusive explanation of these complex phenomena and overlooking the available evidence is likely to lead to failure and erode the social and political support necessary for implementing measures to reduce health inequalities.5
Health inequalities are not only unjust and therefore unacceptable. They are also a potential obstacle for a positive overall development of health among the population. Even in the affluent countries we have examples of disadvantaged subgroups in which the development of health has stagnated or even reversed. This makes accurate material, behavioural, and other explanations for health inequalities all the more important. Although we as researchers cannot decide upon and implement measures reducing health inequalities, it is our task to provide the research base for interventions and policies as well as assessments for what measures work.
References
1 Mackenbach J, Bos V, Andersen O, et al. Widening inequalities in mortality in Western Europe. Int J Epidemiol 2003;32:830–7.
2 Van Oort F, Van Lenthe F, Mackenbach J. Material, psychosocial, and behavioural factors in the explanation of educational inequalities in mortality in the Netherlands. J Epidemiol Commun Health 2005;59:214–20.
3 Laaksonen M, Roos E, Rahkonen O, et al. Influence of material and behavioural factors on occupational class differences in health. J Epidemiol Commun Health 2005;59:163–9.
4 Rahkonen O, Laaksonen M, Martikainen P, et al. Job control, job demands or social class? The impact of working conditions on the relation between social class and health. J Epidemiol Commun Health 2006;60:50–4.
5 Measuring progress on health inequalities. Editorial. Lancet 2006;367:1876.[Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  S. Friel, M. Chopra, and D. Satcher Unequal weight: equity oriented policy responses to the global obesity epidemic BMJ, December 15, 2007; 335(7632): 1241 - 1243. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||