Further info

Summary of the literature:

Health inequalities (HI) are differences in health between different groups of people which are unfair and avoidable1. Understanding what HI means as well as their causes have been extensively explored with generation of conceptual models, theories as well as recommendations for action1,2,3. As described by Popay et al4, there is a large body of research on lay concepts of factors that relate to health and illness but less on the public’s understanding of the nature and causes of social inequalities regarding health, illness or HI.

The research findings exploring public understanding of health and HI can be conflicting. For example, some research has shown that often members of the public think of individual behaviours and access to healthcare when asked about health5. Whereas other research has shown a good understanding of how socioeconomic factors links to ill health for people who live with socioeconomic disadvantage6. The conflict is likely to be due to varying methodological approaches including both participant recruitment and data collection (such as framing of the questions). 

Background of this project:

UNderstanding Factors that explain Avoidable hospital admission Inequalities - Research study (UNFAIR) is a 5-year mixed method program of research and a solution-focused piece of work addressing how to reduce HI, particularly for avoidable hospital admissions. Find out more about UNFAIR here.

HI can be complex and difficult to both communicate and understand. Our UNFAIR Patient and Public Involvement and Engagement (PPIE) representatives encouraged us to seek more diverse views, particularly those who are at higher risk of HI. This project is to this end with members of the public front and centre in design. One of our UNFAIR PPIE representatives is a co-applicant and this project is funded by a Tilly Hale Award and National Institute for Health and Care Research (NIHR) funding for the UNFAIR study.

Aims and objectives:

The aims of the project were to explore public understanding and views of health inequalities (HI) with three objectives:

1) Understand what the term HI means to members of the public

2) Explore how people feel about HI

3) Explore their views about what can be changed to address HI

Methods:

We used a hub and spoke model for the workshops, all hosted in 2022:

•   One online workshop open to anyone in England

•   Three local face-to-face workshops with one being peer-led

We invited community groups and participants in under-served areas using known local and national networks such as the Research Design Service (RDS) and FUSE, the Centre for Translational Research in Public Health. Numerous advertising methods were used (e.g. social media, flyers as well as word of mouth). As this was patient and public involvement, no inclusion/exclusion criteria were used. Expression of interest could be through a variety of ways including an online form, email or calling/texting the lead author. Renumeration of time was offered.

The content of the workshops was co-produced with members of the public. This included regular meetings with the UNFAIR PPIE representatives providing invaluable ideas and feedback throughout the project.

Each workshop was either co-led by members of the public and Newcastle University staff or peer-led. Every workshop involved discussing images that depicted health inequalities (HI) as well as factors that relate to our health7-9. The first half of the workshops explored how the participants viewed and felt about HI. The second half explored possible solutions to help reduce HI.

Findings:

1) How are health inequalities (HI) viewed by members of the public?

58 people took part from all walks of life mainly living in the North East but also from other areas such as Yorkshire and Humber, and North West England.

HI consider the differences between how long people live for but also how good their health is. Essentially, some people are dying younger than they should be, as well as, living less healthy lives:

“A lot of my peers didn’t make it. Literally didn’t make it. Aren’t here anymore.”

HI are viewed as unfair and stir up powerful emotions such as anger, frustration, annoyance, hopelessness, worry and alarm:

“It is shocking to see that there is 18 years difference [in healthy life expectancy] between the most and least deprived areas in England.”

The things that contribute to HI and our health are complex and connected. This includes where we are born, the food we eat, the amount of money we have, how connected and accepted we feel and particularly where we live:

“Where you live is important, and you could be just a few miles from a better situation.”

What does good look like?

Respect, accept and value everyone is key, regardless of, for example, their age, how they look, where they live, how much money they have or how they identify:

“All patients are people with feelings; they aren’t numbers, they’re not statistics.”

“Like, we might be in an underprivileged area to where people look, but we're not. Like, we're just us and we're getting by the best we can.”

Recognise the strength and value of individuals and communities by listening to, working with and empowering them to design what works for them from start to finish. Trusted voices within a community are a good place to start.

“It starts with a conversation and listening, not having ideas ready.”

“Local communities know what local communities need.”

Services should be easy to access and simple to use. They should be welcoming for everyone, easy to understand and culturally appropriate. Services and support should provide consistency of care and tailor the support to that person to meet their needs. This includes giving people a choice about how the support or care is provided:

“Should be services centred around the person not the postcode.”

Learning

Diversity and inclusion:

•   Remove barriers for participation as much as possible and language matters.

•   Using networks helped to promote the workshops in under-served areas. 

Time:

•   This type of work takes time to build relationships so vital to keep people informed and adjust according to need where possible.

•   Make sure you are clear about the process for renumeration in your organisation before any workshops to reduce delays.

•   Always include additional project time for unexpected events.

Challenges:

•   Any challenges that come about with co-production are opportunities for growth.

Next steps:

The key messages from the workshops are being used to co-produce a video working in partnership with members of the public and a local animation company.

This animation will be available to members of the public as well as decision makers across the health system to share public views of health inequalities.

References:

1. Marmot M, Goldblatt P, Allen J, et al. Fair Society, Healthy Lives (The Marmot Review). Institute of Health Equity; 2010.

2. Bartley M. Health Inequalities: an introduction to theories, concepts and methods. Cambridge, UK: Blackwell Publishing Ltd; 2004.

3. Dahlgren G, Whitehead M. Policies and Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for Futures Studies; 1991.

4. Popay J, Bennett S, Thomas C, Williams G, Gatrell A, Bostock L. Beyond 'beer, fags, egg and chips'? Exploring lay understandings of social inequalities in health. Sociology of Health & Illness. 2003;25(1):1-23.

5. Kane M, Thornton J, Bibby J. Building public understanding of health and health inequalities. The Health Foundation. 2022. Available from https://www.health.org.uk/publications/long-reads/building-public-understanding-of-health-and-health-inequalities

6. Smith KE, Anderson R. Understanding lay perspectives on socioeconomic health inequalities in Britain: a meta-ethnography. Sociology of Health & Illness. 2018;40(1):146-70.

7. Bambra C, Orton C. A train journey through the English health divide: topological map. Environment and Planning A: Economy and Space. 2016; 48(5).

8. Wiseman A. Inequalities: ‘It never rains but pours’. Gateshead Director of Public Health Annual Report. 2017. Available from: https://www.gateshead.gov.uk/media/4234/Director-of-Public-Health-Annual-Report-2017-18/pdf/1419-PS-DPH_Annual_Report_Final_web_2017-18.pdf?m=636470405507200000.

9. Infographic: What makes us healthy? The Health Foundation. 2019. Available from: https://www.health.org.uk/infographic/infographic-what-makes-us-healthy

Disclaimer: This project is funded by the Tilly Hale Award from Newcastle University and the National Institute for Health and Care Research (NIHR) (ref CA-CL-2018-04-ST2-010).The views expressed are those of the people who took part and not necessarily those of the NIHR, the Department of Health and Social Care or Newcastle University.