health inequalities essay uk

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• Office for Health Improvement & Disparities

Health disparities and health inequalities: applying All Our Health

Published 11 October 2022

Applies to England

© Crown copyright 2022

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned.

This publication is available at https://www.gov.uk/government/publications/health-disparities-and-health-inequalities-applying-all-our-health/health-disparities-and-health-inequalities-applying-all-our-health

Please note that the Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities on 1 October 2021.

Introduction

This guide is part of All Our Health , a resource that helps health and care professionals and the wider workforce prevent ill health and promote wellbeing as part of their everyday practice. All Our Health content on inclusion health , community-centred practice and improving the wider determinants of health may be of particular interest in connection with this topic. 

Health inequalities are defined as avoidable differences in health outcomes between groups or populations – such as differences in how long we live, or the age at which we get preventable diseases or health conditions. Similarly, health disparities are described by Healthy People 2020 as:

a particular type of health difference that is closely linked with social, economic and/or environmental disadvantage.

Health disparities are said to adversely affect groups of people who have systematically experienced greater obstacles to health. Depending on the workforce, sector or organisation, different language is sometimes used to describe the same problem. The terms ‘health disparities’ and ‘health inequalities’ are sometimes used interchangeably.

The causes of health inequalities or disparities are complex, but are generally associated with variation in a range of factors that positively or negatively influence our ability to be healthy. This includes individual health-related behaviour, such as:

• smoking and diet
• access to services
• social deprivation
• access to work
• education levels
• social networks
• how much control we feel we have over our lives

In recent times, progress has been made in improving key determinants of health for many people including:

• driving down rates of smoking
• introducing measures to address obesity
• improving the quality of health and care services
• increases in educational attainment
• measures to improve housing quality

However, the benefits of this have not been felt equally across the population, resulting in some groups or people living in some areas continuing to spend more of their lives in poor health and dying sooner than others.

This All Our Health: health disparities and health inequalities resource highlights that everyone can contribute to addressing health disparities and health inequalities in the course of their everyday work or role. It has been created to help a wide range of organisations and professionals, including health and care professionals, practitioners, commissioners, senior leaders, managers, and voluntary and community sector workers to:

• gain a broad understanding of what is meant by ‘health disparities’ and ‘health inequalities’
• understand the causes of health disparities and health inequalities
• implement the evidence-based actions and interventions that can be incorporated into everyday practice to address health disparities and health inequalities
• consider who else they may need to work with to address health disparities and health inequalities

What health inequalities and health disparities are, and who is more likely to experience them

In England, there is a 19-year gap in healthy life expectancy (whether we experience health conditions or diseases that impact how long we live in good health) between the most and least affluent areas of the country, with people in the most deprived neighbourhoods , certain ethnic minority and inclusion health groups getting multiple long-term health conditions 10 to 15 years earlier than the least deprived communities, spending more years in ill health and dying sooner. [footnote 1]

The most recent data on how long we live overall ( life expectancy for local areas of the UK: between 2001 to 2003 and 2018 to 2020 ) includes some data from the coronavirus (COVID-19) period. It indicates that life expectancy for men has fallen for England as a whole, but there is significant variation across the regions for both men and women. For example, for men, life expectancy at birth has fallen in all regions other than the south-east and south-west, and, for females, there have been reductions in all regions other than the south-east, south-west and London.

Health inequalities

These differences in health outcomes are known as health inequalities – unfair and avoidable differences in health across the population, and between different groups within society. Health inequalities arise because of the conditions in which we are born, grow, live, work and age. These conditions influence our opportunities for good health, and how we think, feel and act, and this shapes our mental health, physical health and wellbeing. [footnote 2]

Figure 1: domains of health inequality (adapted from Health inequalities: place-based approaches to health inequalities )

Figure 1 above shows the broad range of individual characteristics and societal factors that have been identified as contributing to health inequalities. These are:

• socio-economic status and deprivation – for example, unemployment, low income, living in a deprived area, and factors associated with this such as poor housing and educational attainment
• vulnerable or inclusion health groups – for example, vulnerable migrants, Gypsy, Roma, Irish Traveller and Boater communities, people experiencing homelessness, offenders or former offenders, and sex workers
• protected characteristics under the Equality Act 2010 – the 9 protected characteristics are: age, sex, race, sexual orientation, marriage or civil partnership, pregnancy and maternity, gender reassignment, religion or belief, and disability
• geography – the characteristics of the place where we live, such as population composition, built and natural environment, levels of social connectedness, and features of specific geographies such as urban, rural and coastal

These factors (or domains) are complex and interact with each other to benefit or disadvantage people or groups, leading to differences in health outcomes. Individuals fall into more than one category and, subsequently, may experience multiple drivers of poor health at the same time.

Relevant terms

Figure 2: equality, equity and removal of structural barriers.

Figure 2 above illustrates the characteristics of people or places associated with differences in health outcomes.

Some other key terms in health inequalities and health disparities are:

We want everyone to have equally good health. However, the term ‘equality’ is sometimes used to describe equal treatment or access for everyone regardless of need or outcome.

We want fair outcomes for everyone. What is important is addressing avoidable or remediable differences in health between groups of people.

Figure 2 above demonstrates that, to achieve health equity, some groups may need more or different support or resources in order to achieve the same outcomes.

Ideally, the barriers to good health would be removed for everyone, so adjustments wouldn’t be required – however, this is not always possible.

Ensuring everyone can access services equitably (that is according to need) is a key priority for the NHS.

To achieve this, consideration needs to be given to access to information, services and support. Central to this is enabling people to access the right service at the right time for them, reducing variation in the avoidable use of urgent support such as accident and emergency services through better access to preventative care.

Public Sector Equality Duty

The Public Sector Equality Duty set out in the Equality Act 2010 applies to all public bodies and all those that carry out public functions.

The protected characteristics covered by the duty are:

• gender reassignment
• marriage and civil partnership
• pregnancy and maternity
• religion or belief
• sexual orientation

Public bodies are required to have due regard to the need to:

• eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010
• advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it
• foster good relations between persons who share a relevant protected characteristic and persons who do not share it

Inclusion health

Inclusion health is a ‘catch-all’ term used to describe people who:

• are socially excluded
• typically experience multiple overlapping risk factors for poor health (such as poverty, violence and complex trauma)
• experience stigma and discrimination
• are not consistently accounted for in electronic records (such as healthcare databases)

These experiences frequently lead to barriers in access to healthcare and extremely poor health outcomes.

Deprivation

Deprivation describes a wide range of living conditions that impact on the lives of individuals and communities.  People may be considered to be living in poverty if they lack the financial resources to meet their needs, whereas people can be regarded as deprived if they lack any kind of resources, not just income.

The Index of Multiple Deprivation  is the official measure of relative deprivation in England that measures 7 domains of deprivation when combined and appropriately weighted. These are:

• skills training
• barriers to housing and service
• living environment
• health deprivation

Health disparities and health inequalities are not spread equally across England. There are local variations in the concentration of pre-existing health conditions and chronic disease in certain geographies between different areas. Alongside and contributing to driving these are variations in protective factors, such as:

• living in a strong community
• access to green space
• the impact of living in specific geographies, such as coastal communities

Health disparities and COVID-19

The COVID-19 pandemic has shone a spotlight on health disparities and health inequalities. Disparities or differences in both the risk of getting COVID-19 and of having poorer outcomes have been seen by:

• deprivation
• inclusion health groups

The reasons for these disparities are complex with influencing factors including the impact of existing social and economic inequalities, pre-existing disease and other societal factors. 

Alongside the direct impact of COVID-19, some groups have also been more likely to experience greater impact from measures to control the pandemic .

Why take action on health disparities and inequalities

Health disparities and health inequalities impact on the physical and mental wellbeing, and the life chances of the individuals and groups most affected. Alongside the individual human costs, disparities and inequalities impact on society as a whole.

Prior to COVID-19, health inequalities were estimated to cost the NHS an extra £4.8 billion a year, society around £31 billion in lost productivity, and between £20 and £32 billion a year in lost tax revenue and benefit payments. [footnote 3] Health is therefore a major determinant of economic performance and prosperity.

Consequently, taking action on health inequalities:

• improves the quality of lives of individuals
• reduces cost to the NHS and social care system of treating and caring for people with preventable conditions
• benefits the wider economy

Causes of health inequalities

A wide range of factors influence our ability to be healthy. These factors overlap with one another and are often outside the control of individuals themselves.

Figure 3: system map of the causes of health inequalities (adapted from the Labonte model) [footnote 2]

Figure 3 above demonstrates the complex interplay between the determinants of health (for example, income and housing), psychosocial factors (for example, isolation and social support), health behaviours (for example, smoking and drinking) and physiological impacts (for example, high blood pressure, anxiety and depression) of wider social determinants of health with psychosocial factors, individual health behaviours and the resulting physiological impacts (for example, high blood pressure, anxiety and depression).

Wider determinants of health

The wider determinants of health  include factors such as:

• built and natural environment (including air pollution )
• discrimination

These determinants or influences are not spread equally throughout the population, resulting in some groups experiencing multiple disadvantages throughout their lives, and circumstances compounding to create an un-level playing field .

Health behaviours

The ability of individuals to lead healthy lives is influenced both by the wider determinants of health, and by individual factors ( health behaviours ) associated with people’s opportunities and experiences.

The main behavioural risk factors for poor health – smoking , poor diet or excess weight , physical inactivity and high alcohol consumption – follow the same pattern of uneven distribution as the wider determinants of health, indicating that there is a relationship between an individual’s likelihood of smoking, eating healthily, physical inactivity, and their social and environmental circumstances.

Linked to health behaviours, the concept of ‘health literacy’  refers to people having the appropriate skills, knowledge, understanding and confidence to access, understand, evaluate, use and navigate health and social care information and services. Improving health literacy by supporting patients to engage in shared decision-making can help to reduce health inequalities by empowering and enabling people to navigate individual and societal barriers to improving their health and managing health problems.

The National Institute for Health and Care Excellence ( NICE ) guideline on shared decision-making describes how to make it part of everyday care in all healthcare settings.

Psychosocial factors

Different exposure to social, economic and environmental stressors and adversities, also known as psychosocial factors , work alongside factors related to our ability to cope such as:

• personal resilience
• self-efficacy
• access to social networks

They affect our state of mind from an early age and throughout life, directly affecting resilience, health conditions and health behaviours. Psychosocial factors can help to mitigate or protect against the impact of the social determinants of health.

Core principles

Because the causes of health disparities and health inequalities are complex, overlapping and not equally distributed, it follows that, in order to address them, our actions need to focus on improving the health of those with the poorest health outcomes first, and fastest. Actions should be evidence based, outcomes orientated, systematically applied, scaled up appropriately and appropriately resourced [footnote 4] to ensure that the gap between populations is narrowed.

This means that everyone and every organisation has a role to play . Building on the findings of  Fair Society, Healthy Lives (The Marmot Review) , a further report by the Institute of Health Equity focussing on health inequalities in Greater Manchester sets out a framework for addressing the social determinants of health, identifying the range of sectors and organisations that can contribute to this.

Population intervention triangle

Place-based approaches to reducing health inequalities  provides tools and resources to support sectors and organisations to work together to take whole-system at-scale action on health inequalities.

It uses the population intervention triangle (see Figure 4, below) to describe how local authorities and policy-makers (civic) can work alongside the NHS and other organisations (services), and with communities ( community-centred interventions ) to address health inequalities at a scale that makes a difference, and best meets local needs and circumstances. Actions can be targeted to specific population groups, for example:

• specific life course stages
• barriers to access or good outcomes – such as cultural competence and digital exclusion
• Marmot policy objectives

Interventions should be applied proportionately to need – for example, through a proportionate universalism approach.

Figure 4: population intervention triangle [footnote 2]

Further guidance on community-centred public health  (a core component of the population intervention triangle) identifies 11 elements of an integrated whole-system approach, incorporating a range of actions from neighbourhood work through to strategic leadership. Additional learning on community-centred approaches can also be found in Community-centred practice: applying All Our Health. .

The following sections set out information to inform the actions that different organisations or sectors can take to play a part in addressing health disparities and health inequalities.

You may wish to focus on the sections relevant to your organisation or role, or to review the whole content to gain wider understanding of the role of different sectors and workforces in addition to your own.

The 2019 NHS Long Term Plan set out that action to drive down health inequalities is central to everything that the NHS does.

In addition, the Health and Care Bill 2021 to 2022 promotes integration and partnership-working to improve health and tackle health inequalities. This action takes place through integrated care systems ( ICSs ) and integrated care partnerships , place-based partnerships and through working with people and communities , bringing together health, social care, public health and others to develop strategy and plans to address the needs of the local system.

The NHS operational and planning guidance also builds on previous guidance to prevent ill health and tackle inequalities, particularly in light of the COVID-19 pandemic and its disproportionate impact on certain population groups who were already facing disadvantage and discrimination.

Building on this and contributing to the government’s mission to level up health, NHS England and Improvement (now NHS England) launched the Core20PLUS5 approach to support focused action on improving health inequalities, both at a national and system level. This approach is focused on action in the following areas:

• Core20: the most deprived 20% of the national population as identified by the national Index of Multiple Deprivation
• Plus: ICS -determined population groups experiencing poorer than average health access, experience and/or outcomes – this area should be informed by ICS population health data
• continuity of carer for maternity
• annual health checks for those living with severe mental illness
• chronic respiratory disease management, with a focus on COVID-19, flu and pneumonia vaccination uptake
• early cancer diagnosis
• hypertension case-finding

Driving this action forward is the NHS England Healthcare Inequalities Improvement Programme , which has the vision of delivering exceptional quality healthcare for all, ensuring equitable access, excellent experience and optimal outcomes. For more information on the work of this programme, please access the Equality and Health Inequalities Network NHS future forum space . [footnote 5]

Local government

The Local Government Association highlights the contribution of different determinants of health on health outcomes, setting out the important role of local authorities in prevention including through their specific public health duties and action on the wider determinants of health.

Local authorities duties, functions and interests cover a broad range of activity, from improving health through:

• the application of behavioural and social science
• regulatory functions such as spatial planning , licensing and trading standards
• in respect of the impact of the environment on health (including urban, rural and coastal environments, access to green space, promoting active travel and improving air quality )
• housing , schools and social care provision
• community services such as libraries
• economic development

Local authorities can use their leadership role at place to work alongside partners – for example, through health and wellbeing boards , ICS partnerships and local economic partnerships to enable whole-system action on health inequalities. More information and resources can be found on the LGA website and in the government’s health equity collection .

Voluntary, community and social enterprise ( VCSE ) organisations

The role of VCSE in addressing health inequalities is wide ranging. For example, the  Health Foundation, the Institute of Health Equity and New Philanthropy Capital and the  All Party Parliamentary Committee on Arts and Wellbeing identify the contribution that civil society can make to improving health and addressing health inequalities, including through:

• service delivery
• raising awareness
• influencing

Organisations in these sectors are often trusted by and have good reach into many of the most marginalised communities.

ICS implementation guidance on partnerships with the voluntary, community and social enterprise sector provides further insight on how VCSE partnership should be embedded in how the ICS operates, indicating that VCSE is a key strategic partner with an important contribution to make in shaping, improving and delivering services, and developing and implementing plans to tackle the wider determinants of health. 

View more information on VCSE ’s role in health inequalities from the VCSE Health and Wellbeing Alliance.

Good-quality work is a key contributor to what makes us healthy. Inclusive and sustainable economies: leaving no-one behind identifies the mutually dependent role of the economy and health.

This includes the potential for businesses to act as anchor institutions ,working alongside public and voluntary sector organisations to utilise their spending power and scale social value.

In addition, community businesses can make an important contribution to improving health.

Wider public sector

All public sector organisations have a role to play in addressing health disparities and health inequalities. For many services, the communities they serve are often those that have the poorest health outcomes.

Emergency services such as the police , fire and rescue and ambulance services already recognise their wider role in prevention and contributing to addressing health inequalities. The Royal Society for Public Health’s Emergency Services Hub provides further information and resources to support this role.

The wider public sector can work together to address specific determinants and direct causes of health inequalities – for example, to reduce violence or in respect of the impact of the built and natural environment on health .

Taking action

This section sets out some key considerations against priority areas for action identified by national and regional public health teams. It includes prompts for everyone to consider, as well as specific suggestions for different professional and occupation groups.

Ensure you are aware of your organisation or sector’s approach or potential role in addressing health disparities and health inequalities.

You can also keep yourself informed and up to date on the latest information and guidance by joining relevant NHS England Networks or Knowledge Hubs [footnote 5] such as:

• health inequalities
• inclusive and sustainable economies
• healthy communities

In addition, you can review the information above for your organisation or sector, the 6 priority actions for health inequalities below and the suggestions for your occupational group, and consider what you could do in the scope of your role.

Six priority actions

1. have a clear vision and strategy with measurable goals, co-ordinating action at all levels (for example, across organisations or professional boundaries) with a clear focus on priority groups.

Ask yourself:

• what is your vision? What are you trying to achieve?
• what would success look like for you or your organisation?
• do you have a clear strategy and plan for achieving your vision?
• do you have the right resources, and a timeline and plan?
• who else could be involved?
• is there a system, organisational or professional plan or guidance?
• do you know your priority groups?
• have you identified SMART (specific, measurable, achievable, relevant and time-bound) goals and measurable targets?
• are your plans joined up across organisations or with other teams?

2. Put in place effective system leadership and accountability for action on health inequalities

• who leads on action on health inequalities and health disparities?
• what’s your leadership role (whatever your level) – for example in your team, profession, organisation, multi-agency group, sector or network? 
• what do you do to support others to take a leadership role?
• what does your organisation expect of you or others in respect of action on health inequalities? How are people held to account? 
• are you driving changes using quality, service improvement and redesign methodology including Appreciative Inquiry ?
• are you involving and co-producing change with those who are experiencing healthcare inequalities through engaging communities in design, implementation and evaluation?

3. Use data and evidence systematically to identify root causes, effective solutions and assess progress

• what information do you have to identify the problem you’re trying to address?
• what’s the scale of the problem and the root causes?
• how do you know that your planned action is likely to be effective?
• how will you know when you’ve achieved your goal or outcomes?
• how can you contribute to data collection – are you systematically recording health inequalities and equality data in your routine practice?

4. Ensure you or others have the knowledge, skills and capability to embed action on health inequalities as a core part of all roles

• do you, your team or organisation have the knowledge, skills or training to take the required action?
• how could you acquire these?
• who else could help?
• what’s included in job descriptions?
• have you considered health literacy and shared decision-making ? Do clients have the appropriate skills, knowledge, understanding and confidence to access, understand, evaluate, use and navigate health and social care information and services?

5. Use systematic assessment tools

• do you use individual and population needs assessments?
• what tools are available to support you in your work? For example, the Health Equity Assessment Tool ( HEAT )
• do you use a health in all policies ( HiAP ) approach?
• where might you find information on assessment tools? For example, the tools and resources repository on the Health Inequalities Knowledge Hub [footnote 5]
• what do other systems or partners use?
• have you undertaken an equality and health inequality impact assessment?

6. Undertake comprehensive engagement and involvement including magnifying community voice

• are your plans informed by local communities or client groups preferences and needs, including consideration of health literacy ?
• has involvement and engagement been systematic?
• do you use community-centred approaches ?
• have you considered the strengths of individuals themselves and communities, and built these into your conversations or programme?
• do you work with community or community health champions ?
• do you use personalisation approaches such as Making it Real ?
• do you use NICE , and other guidance and tools to support community involvement?
• have you considered how to listen and learn from communities ?

Frontline health and care professionals

Frontline health and care workers have millions of contacts with people at risk of poorer health outcomes every day. As a frontline worker, you can address health inequalities by:

• supporting individuals through their clinical or social care practice
• influencing the design of services
• supporting people to adopt healthier behaviour
• advocating for wider changes

Your work can also contribute to addressing the social conditions of people’s lives such as poverty, disability, damp or overcrowded housing, or a poor diet, making a difference to the communities in which they work. [footnote 6]

My role in tackling health inequalities: a framework for allied health professionals details how allied health professionals can raise awareness, take action and optimise advocacy through 6 lenses:

• clinical team, pathway and service groups
• communities and networks
• nurturing the future

While the framework was developed for and with allied health professionals, many other frontline professionals may find the approach relevant to their area of work.

In addition to reviewing the allied health professional framework, you can:

• Social Care Institute for Excellence ( SCIE ) guidance and information for social workers and social care workers
• resources on the Equality and Health Inequalities Hub and Future NHS platforms for NHS staff
• advice from the Royal colleges for medical staff such as from the Royal College of General Practitioners
• briefings relating to professional groups or service area – for instance, on the role of pharmacy teams in addressing health inequalities [footnote 5]
• on professional websites and the Health Inequalities Knowledge Hub
• other national sources such as the Population Wellbeing Portal
• use strength-based approaches , shared decision-making , personalisation approaches including Making it Real , social prescribing and asking “What matters to you?” to support clients to recognise their own talents and resources, and access other services and community support
• familiarise yourself with the major barriers and enablers that clients face in accessing and having good outcomes from services – for example, health literacy and through supported self-management
• use Making Every Contact Count approaches to support clients to access prevention, behaviour change and community support services
• ensure you look for and systematically use opportunities to contribute to collecting and using data to understand the scale of the problem, and the impact of your work

Team leaders or managers

Team leaders and managers have an important role in actively seeking out and enabling teams to embed evidence-based action targeted at those with the poorest health outcomes.

As a team leader or manager, you can:

• support and enable your teams to take the actions outlined for frontline workers
• undertake a HEAT assessment of team plans and programmes
• embed community-centred and personalisation approaches, and use shared decision-making and strength-based approaches

Commissioners

Commissioners play an important role in addressing health inequalities as resourcing decisions and service models can have an impact on health outcomes.

In particular, you can:

• use needs assessment and design interventions to improve the health of those with the poorest outcomes fastest
• commission at sufficient scale , recognising that priority groups are likely to need more and/or different interventions
• familiarise yourself with the Public Sector Equality Duty and your organisation or sector’s approach to discharging equality and health inequalities duties – for instance, for NHS and social care commissioners, including on embedding strength and asset-based approaches , and personalisation – and NHS resources on personalised care and shared decision-making
• use co-production approaches  to involve people throughout the commissioning process
• monitor and evaluate the effectiveness of services on addressing health inequalities and quality standards
• consider how digital health technologies impact on different groups using the NICE evidence standards framework for digital health technologies
• systematically embed community-centred approaches and use social value to target resources and support to communities with the poorest health outcomes
• the NICE guideline [NG44] on community engagement: improving health and wellbeing and reducing health inequalities covers approaches to engaging with communities to ensure health and wellbeing initiatives deliver better outcomes
• adopt approaches that engage with communities to ensure health and wellbeing initiatives deliver better outcomes
• when monitoring and evaluating the effectiveness of services, ensure that you look at the data with a health inequalities lens – for example, by disaggregating data by ethnicity and deprivation to ensure the service that has been commissioned does not exacerbate health inequalities 

VCSE sector

The VCSE sector plays an important role in enabling people to improve their health and in addressing determinants of health.

As a VCSE worker, you can:

• consider the role and contribution of all your duties to addressing determinants of health
• your sector – for example. from VCSE Health and Wellbeing Alliance members , national bodies , and key organisations such as the NHS Confederation , NHS England and the SCIE
• specific groups – for example, inclusion health: applying All Our Health
• advocate for and enable involvement of people from the most marginalised communities
• consider how you can take a leadership role in, advocate for and embed community-centred public health throughout your work

Senior, strategic or system leaders (including local councillors)

Leaders make an important contribution to prioritising and embedding whole-system action to address health disparities and health inequalities.

As a leader, you can use your role to:

• identify key strategic partnership and collaboration opportunities to support whole-system at scale action – for example, through ICS structures , primary care networks , health and wellbeing boards , local economic partnerships , community safety partnerships , and working with VCSE partners
• demonstrate your personal and organisational commitment to addressing health inequalities
• use your health, care, wider system and place leadership role to prioritise at scale , tackling differences in health outcomes first and fastest
• use the well-led framework for health inequalities leadership in strength-based social care
• review all the resources and content in place-based approaches to reduce health inequalities and complete Tool A with partners for your system or place
• undertake a needs assessment – for example, a joint strategic needs assessment to identify priority need, issues and actions at sufficient scale to make a difference, setting goals and targets to measure impact
• use HEAT and HiAP approaches to take account of health inequalities in all decision-making
• embed community-centred approaches in organisational and system-wide ‘business as usual’
• purchasing more locally and for social benefit
• widening access to quality work
• using buildings and spaces to support communities
• working closely with local partners
• reducing environmental impact
• review the SCIE resources on addressing health inequalities

Understanding need – why take action on health disparities and health inequalities

Facts and figures.

Data tools and resources can help you to understand more about the causes and impact of health disparities and health inequalities at a national level and in your local area.

A guide to using national and local data to address health inequalities  provides an overview of data sources for health inequalities, and their uses. This is updated periodically and can be used alongside local joint strategic needs assessments and other data sources to develop plans to address health inequalities.

The following tools may also be of use:

• Fingertips tools
• Wider Determinants of Health tool
• Inequality tools
• Atlas of Variation
• Public Health Outcomes Framework
• Local Health
• Inclusive and sustainable economies data catalogue
• Wider Impacts of COVID-19 on Health ( WICH ) tool)
• COVID-19 Health Inequalities Monitoring for England ( CHIME ) tool)

Measuring impact

There are a range of reasons why it makes sense to measure your and your organisation’s impact, and demonstrate the value of your contribution. This could be about sharing what has worked well in order to benefit your colleagues and local people, contribute to growing the evidence base for health inequalities, help in prioritising future resource allocation or for individual professional development.

The following resources can help with evaluating individual, organisational or programme impact:

• The everyday interactions measuring impact toolkit
• Place-based approaches to health inequalities
• Well-led framework
• Equality and health inequalities impact assessment template – document available on request from [email protected]

Further reading, resources and information about good or emerging practice

Further information on health inequalities in specific population groups can be found in other All Our Health resources.

Related e-learning

• Population Wellbeing Portal
• All Our Health
• Community-centred approaches to health improvement
• Social prescribing
• Cultural competence
• Personalised care
• Health literacy
• Health Equalities Framework (learning disabilities)
• Embedding Public Health into Clinical Services
• Population health management
• Behaviour change literacy
• Behaviour change development framework

Collaborative working platforms [footnote 5]

• Health Inequalities Knowledge Hub
• Healthy Communities Knowledge Hub
• Inclusive Economies Knowledge Hub
• Future NHS Health Inequalities Network

Professional resources and tools

• Place-based approaches to reducing health inequalities
• Health equity collection
• SCIE resources on tackling inequalities in social care
• Future NHS Collaboration Platform
• NICE ’s evidence standards framework for digital health technologies
• NHS Long Term Plan – chapter 2: prevention and health inequalities
• NHS Long Term Plan – menu of evidence-based interventions and approaches for addressing and reducing health inequalities
• Institute for Health Equity – resources from Professor Michael Marmot and colleagues
• Health Foundation – range of resources from organisation that promotes high-quality healthcare and equitable access
• UK Health Security Agency ( UKHSA ) blog - blog giving regular updates from experts on a range of subjects including health inequalities
• Health matters: public health issues collection – facts and information on public health issues
• King’s Fund – range of resources from national charitable organisation on health inequalities , population health management and other related subjects
• Department for Business, Energy and Industrial Strategy’s Industrial Strategy: the Grand Challenges
• COVID-19: understanding the impact on BAME communities
• DHSC’s Working together to improve health and social care for all white paper
• Health inequalities and the business of place-based working from the Association of Directors of Adult Social Care London and Chris Bentley
• NHS Race and Health Observatory – resources and information on the impact of race and ethnicity on people’s health
• Quality in public health – a framework for England that aims to raise quality in public health services and functions
• NHS Long Term Plan prevention priorities
• Health and Social Care Bill 2021 to 2022
• Chief Medical Officer’s annual report 2021: health in coastal communities
• Inequalities in oral health in England – report describing the current picture of oral health inequalities and oral health services inequalities in England, and ways to reduce them. 

Practice examples

Examples of practice in addressing health inequalities can be found in the UKHSA library, as well as examples on how to use HEAT .

More information on practice in addressing health inequalities can also be found on the Health Inequalities , Healthy Communities and Inclusive and Sustainable Economies Knowledge Hubs.

Barnett K and others. ‘Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study.’ Lancet 2012: volume 380, issue 9,836, pages 36–43.  ↩

Public Health England. ‘Place-based approaches for reducing health inequalities: main report.’ July 2019.  ↩   ↩ 2   ↩ 3

Public Health England. ‘Inclusion and sustainable economies: leaving no one behind (executive summary).’ March 2021.  ↩

Public Health England. ‘Reducing health inequalities: system, scale and sustainability.’ August 2017.  ↩

This forum is open to all but requires users to register or request membership.  ↩   ↩ 2   ↩ 3   ↩ 4   ↩ 5

Social Care Institute for Excellence. ‘Tackling inequalities in social care.’   ↩

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Quantifying health inequalities in England

15 August 2022

• Ann Raymond
• Laurie Rachet-Jacquet
• Inequalities
• Social determinants of health
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• Health inequalities are complex and growing, yet firm evidence on their extent and trajectory is few and far between. There is a vital need to quantify health inequalities in order to better focus policies designed to address them.
• This analysis uses a novel approach to explore the extent of diagnosed health inequalities across different population groups in England. We use the Cambridge Multimorbidity Score, developed by clinicians and academics, to assess the relative impact of different patterns of illness on people and their health care needs. Our access to patient data linking primary care and hospital records allows us to provide a more detailed picture of variations in diagnosed illness by age, socioeconomic status, ethnicity and region in England.
• We know from previous research that, on average, people living in more deprived areas have shorter lives and spend more time living with diagnosed long-term illness. Our analysis shows, on average, a 60-year-old woman in the poorest area of England has diagnosed illness equivalent to that of a 76-year-old woman in the wealthiest area. She will spend more than half (43.6 years) of her life in ill health compared with 46% (41 years) for a woman in the wealthiest areas.
• People living in poorer areas also have greater levels of multiple diagnosed illness (multimorbidity). Large inequalities in the burden of disease are concentrated within a few diagnosed conditions, including chronic pain, diabetes, COPD, anxiety and depression, alcohol problems and cardiovascular disease.
• Inequalities in health start at an early age, with higher rates of diagnosed mental health conditions, chronic pain and alcohol problems starting to develop as early as the late teens and early twenties. These health inequalities then continue to grow and change across the life cycle, through working age and into old age.
• Once we standardise for different age distributions across ethnicities, we find higher levels of diagnosed ill health among people of Pakistani, Bangladeshi and black Caribbean ethnic backgrounds than for people from white ethnic backgrounds.
• We also add to previous research on the north-south health divide: people living in the north of England have the highest health care needs due to diagnosed morbidity once adjusted for age. Four conditions – chronic pain, alcohol problems, COPD and cardiovascular disease – account for 83% of the inequality in diagnosed illness between the North East (region with the highest levels of illness) and the East of England (region with the lowest levels of illness).

Introduction

Non-communicable illness is responsible for 88% of the burden of disease in England , with the majority falling most heavily on the poorest in society. The COVID-19 pandemic has highlighted pervasive socioeconomic, ethnic and geographical health inequalities in our society. But quantifying health inequalities can be difficult due to the complexities of comparing people with multiple different long-term conditions (multimorbidity) and assessing the implications for their health care needs.

In this analysis we use a novel tool known as the Cambridge Multimorbidity Score (see Box 1) to assess the relative impact of different patterns of diagnosed illness on people and their use of the health care system. This score has been developed by doctors, academics and primary care experts, and depends on administrative patient-level data linking primary care and hospital records. Given that our analysis relies on health care data, we are observing diagnosed health inequalities, as opposed to underlying health needs. Inequalities in access to care imply that there may be greater undiagnosed health problems in different population groups – it is not possible to take this into account in this analysis. We briefly outline more about the data and the Cambridge Multimorbidity Score in Box 1 below. More detail on data cleaning and disease definitions can be found in the appendix .

Box 1: Data and approach

Data description.

This research draws on detailed patient-level administrative data linked for primary (CPRD Aurum) and secondary care (Hospital Episode Statistics) from a large patient sample (2 million before sample exclusions). We use this to measure prevalence and incidence rates over time in England for a list of 20 major conditions. Using this sample, we can identify each patient’s (multiple) diagnosed conditions and calculate the Cambridge Multimorbidity Score. We are also able to define the Index of Multiple Deprivation (IMD) score for each patient’s local area, age, gender, ethnicity and region. In this analysis, we present a summary of diagnosed health inequalities for different population groups in England in 2019/20.

Diagnosed versus true prevalence

Using administrative data to identify disease has several advantages, such as large patient samples and being less subjective than self-reported measures. However, it can be impacted by patients’ access to care and changes in diagnosis policy and practices over time. For instance, particular patient groups might be under-diagnosed with certain conditions due to factors such as health literacy, financial barriers to accessing services or under-resourcing of health services that disproportionately serve those groups .  Diagnosis rates can also be affected by policy changes such as the introduction of a new diagnostic test for certain conditions. Due to these limitations, all our analysis in this research pertains to diagnosed prevalence rather than true prevalence.

Cambridge Multimorbidity Score

The Cambridge Multimorbidity Score (CMS) assigns a ‘score’ to 20 conditions, to indicate the impact of a patient being diagnosed with a condition on their health care use. For instance, cancer and heart failure are given higher scores than hypertension (high blood pressure) or hearing loss, because they are more likely to lead to death, or unplanned hospital admissions, and are more likely to result in greater primary care needs. A multimorbidity score is useful because it provides a single medically validated measure of comorbidity that allows us to compare trends in disease prevalence over time and by population subgroups. The CMS is also a more relevant measure for planning health care resources, due to the presence of a weighting system that incorporates health care utilisation. The full list of conditions and their weighted scores can be found in the appendix . 

Diagnosed health inequalities by deprivation of local area

We analyse socioeconomic health inequalities by dividing local areas in England into 10 groups, or deciles, according to the Index of Multiple Deprivation (IMD). We then calculate the average Cambridge Multimorbidity Score (CMS) for people living in local areas within each decile. Decile 1 is those living in the most deprived 10% of local areas, while decile 10 is those living in the least deprived 10% of local areas.

Figure 1 shows the average comorbidity score (CMS-weighted prevalence) for diagnosed illness in each decile, broken down by contributing condition. Higher levels of local area deprivation are associated with a higher average comorbidity score. The gradient is steepest for the most deprived deciles, with greater disparities in diagnosed illness for those living in more deprived areas than for people living in the wealthiest half of the country.

*Alcohol problems include conditions associated with harmful levels of alcohol consumption including alcoholic liver cirrhosis, alcoholic hepatitis and mental and behavioural disorders associated with alcoholism. † Cardiovascular diseases include coronary heart disease, heart failure, stroke and transient ischaemic attack (TIA). In this figure we group several conditions into 'Other'. Age standardised averages for the 20 conditions contained in the Cambridge Multimorbidity score, by IMD decile, ethnicity and region can be found here: https://www.health.org.uk/sites/default/files/2022-08/age-standardised_cambridge_morbidity_score_.xlsx

Chronic pain, COPD, alcohol problems, anxiety and depression, cardiovascular disease and diabetes contribute to 64% of the burden of disease in the most deprived decile, compared with 49% in the least deprived decile. All of these conditions are at least 50% more prevalent in the most deprived areas of England than the least, and COPD is over three times more common once we standardise for age.

In contrast, cancer is one condition for which the diagnosed prevalence is higher in richer areas. This is a surprising result, as we know from other research that there are higher levels of diagnosed incidence of cancer in more deprived areas . Inequalities in cancer are complex and multifaceted: we see higher levels of cancer incidence by age in poorer areas, but there are further differences in terms of tumour locations, stage at diagnosis and survival rates. People in less deprived areas are more likely to live for longer with a cancer diagnosis, therefore the share of people living with the disease is greater.

People in poorer areas become ill earlier in life

Looking at diagnosed long-term conditions by age, gender and deprivation we can see how much earlier the people living in poorer areas reach a given level of ill health.

Figure 2a plots the average comorbidity score by age group and local area IMD decile. Inequalities in diagnosed long-term conditions are widest in absolute terms for people in their 70s, although in relative terms people living in the poorest areas have an average CMS of more than double those in the least deprived areas in their 50s and 60s.

We can compare how the diagnosed illness (average CMS) of those in the most deprived decile stand in relation to the older people living in wealthier areas. The analysis shows how the inequalities observed in Figure 1 are the result of diagnosed disease emerging earlier in more deprived areas. For example, people aged 30–49 living in the most deprived 10% of local areas have the same average comorbidity score as those aged 50–59 living in the least deprived local areas.

If we compare the extremes, those in the most and least deprived areas, we can see just how different lived experience of health is across the country. Figure 2b shows the levels of diagnosed illness (average CMS) by age and gender for the most and least deprived deciles: on average 60-year-old women in the most deprived decile have around the same level of diagnosed morbidity as 76-year-old women in the least deprived areas. Men have lower levels of socioeconomic inequality in diagnosed ill health at the same age, with a 10-year disparity in diagnosed illness compared with 16 years for women.

For diagnosed illness, there is a clear transition across the life cycle

Figure 3 disaggregates the gap in diagnosed long-term illness between the most and the least deprived areas, showing which conditions contribute to the inequalities in each age group. It is striking that over 50% of inequality in diagnosed illness for all age groups older than 30 years is caused by only three conditions: chronic pain, COPD and diabetes. These conditions, along with alcohol problems, heart failure and dementia, account for at least three-quarters of the absolute inequality and most of the burden of disease that exists within the population aged 50 years and older.

In Figure 3, we show the contribution of each condition to health disparities by age group. Absolute levels of inequality are very small for younger people, but this analysis shows that there is a clear transition of inequality across the life cycle. Children in more deprived areas are much more likely to be living with asthma, epilepsy and to experience alcohol problems and are less likely to be diagnosed with anxiety or depression. From the age of 20 we see greater differences in chronic pain, alcohol problems and anxiety and depression. From the age of 30 we begin to see health inequalities manifesting in different kinds of health conditions. Disparities in diabetes, COPD and cardiovascular disease rates grow and overtake anxiety and depression, although we still observe growing inequality in chronic pain and alcohol problems. Among people aged 50 and older, inequality in morbidity is dominated by chronic pain, COPD, diabetes and dementia. Contrary to other diseases, we see a higher prevalence of diagnosed cancer in the least deprived areas among older patients.

These findings suggest that health inequalities start at an early age and accumulate over time. Chronic stress and adverse conditions have been shown to contribute directly and indirectly to poorer health outcomes through their cumulative impact. This phenomenon, known as allostatic load , is linked to earlier death and is greater for those from poorer backgrounds . The stages of inequality in ill health shown here strengthens the case for a life course approach to public health policy.

The disparity in diagnosed ill health then reduces for people aged 80 or older. People living to this age have time to develop long-term illness even if they live in the least deprived areas. This is a study of people living with diagnosed illness and so does not reflect the stark inequalities in mortality rates . It is therefore worth thinking about the amount of time spent in ill health in the context of life expectancy.

Life expectancy and living with illness

Differences in the prevalence of diagnosed long-term conditions can be explained by inequalities in the wider determinants of health. Here, we explore the age at which we see disparities in health starting to develop.

We have produced alternate estimates of life expectancy to national statistics using our primary care data linked to mortality records, along with an additional measure of disease-free life expectancy (see Table 1). Disease-free life expectancy provides an estimate of the average number of years a person would live without being diagnosed with any of the illnesses included in the CMS.

Table 1: Life expectancy and disease-free life expectancy estimates, most and least deprived deciles, 2019/20

Note : Life expectancy estimates drawn from CPRD data are higher than those produced by ONS . This reflects that our data are a sample of 2 million people registered at a primary care practice and therefore do not include deaths among people not registered at a practice, who may have higher mortality rates. Our life expectancy estimates may also be higher for the following reasons: CPRD does not always observe when patients emigrate and do not de-register themselves; our data sample may not pick up infants and infant mortality as our dataset does not make use of the CPRD Mother Baby Link; the national statistics also include a 3-year average, covering a slightly different time period.

Inequalities in life expectancy are wider for men, but women spend longer in ill health

Our estimates reinforce the large inequalities in life expectancy indicated by official national estimates (Table 1). Both sets of estimates show that inequalities in life expectancy are greater for men than for women. They also both estimate that on average men living in the poorest areas live 9 fewer years  than their counterparts in the wealthiest areas of England. The socioeconomic inequality in life expectancy for men is such that, despite spending a greater share of their lives with diagnosed illness (46% compared with 44%, Table 1), men in the most deprived areas spend less time living with diagnosed illness (35.7 years compared with 37.9 years in the least deprived areas).

But women overall face more time spent living with illness. Women in the poorest areas are expected to be diagnosed with a long-term illness at 40 years of age and are expected to spend over half their lives in ill health (52%). Women in the least deprived areas, on the other hand, on average develop their first illness 8 years later. They are expected to live an additional 5 years than those in the most deprived areas according to our estimates (the equivalent figure is an additional 8 years from official national estimates).

There are inequalities by region and by ethnic background

This novel method of analysis clearly shows inequalities in diagnosed illness both by the patient’s ethnicity and where in England they live. We observe more diagnosed ill health in some people from minority ethnic backgrounds (Figure 4) and in the north of England (Figure 5). As evidenced in previous research , health inequalities are heavily linked to ethnic and geographic socioeconomic inequalities. For example, a recent study showed that once you consider the differences in socioeconomics and other important factors between ethnic groups, the differences in rates of obesity between ethnic groups are either severely diminished or removed entirely. There is much we still do not know about the interactions between ethnicity, region, the wider determinants of health, and how these impact access and need for health care.

To directly compare average rates of illness for people across ethnicities is to ignore their demographic differences. The average age of the white population is higher than those from other ethnic backgrounds. The white population in this analysis includes those from minority white backgrounds. As shown in Figure 4, once we standardise for different age distributions across ethnicities, we find higher levels of diagnosed ill health in Pakistani, Bangladeshi, and black Caribbean people than among the white population in England.

In this figure we group several conditions into 'Other'. Age standardised averages for the 20 conditions contained in the Cambridge Multimorbidity score, by IMD decile, ethnicity and region can be found here: https://www.health.org.uk/sites/default/files/2022-08/age-standardised_cambridge_morbidity_score_.xlsx

People from Pakistani and Bangladeshi ethnic backgrounds in England have the highest age-standardised rates of chronic pain, diabetes, dementia and cardiovascular disease. Despite not having the highest prevalence in other cardiovascular disease, the white population has the highest rate of diagnosed atrial fibrillation, an important risk factor for cardiovascular disease that can lead to preventive intervention in primary care. The white population also have the lowest rate of diabetes but are more likely to be living with diagnosed anxiety or depression, alcohol problems and cancer .

As previously discussed, these data reflect disparities in diagnosed health conditions and therefore they only show inequalities in needs that are identified by the health system. Evidence suggests that access and engagement with care is limited for some population groups, often on the basis of ethnicity. For instance this year, a review from NHS Race and Health Observatory and the Race Evidence Review found evidence to suggest that there are ‘clear barriers’ for people from minority ethnic backgrounds to seeking help for mental health problems. Other research has also found lower access to cancer screening and lower levels of patient satisfaction . The results presented here should therefore be considered in this context and further research is required to accurately represent underlying health inequalities.

Figure 5 shows the age-standardised average morbidity score by region, adding to the evidence of a north-south health divide . People living in the North East and North West regions of England have the highest health care needs, in part due to higher levels of chronic pain, alcohol problems, COPD and cardiovascular disease. These four conditions account for 83% of the inequality in diagnosed illness between the North East (highest) and the East of England (lowest). The north-south divide seen here is reflected in regional disparities in average incomes , wealth , economic opportunity and educational attainment , and speaks to the strong relationship between inequalities in the wider determinants of health and inequalities in diagnosed ill health.

Conclusions

There is a vital need to quantify health inequalities to better focus health and wider policy to address them. Equality is at the centre of NHS England’s strategy , but insights on the extent of health inequalities like those presented here are few and far between. Our analysis adds to a growing body of evidence that health outcomes for disadvantaged groups are dramatically worse across a number of measures, with poorer people living shorter lives in greater discomfort due to ill health. These socioeconomic inequalities are borne out in greater levels of diagnosed ill health among minority ethnic populations and in different regions of England.

Our results show health inequalities starting at a very early age and continuing to develop through adulthood. The early ages and changing structure of health inequalities reinforces the notion that nothing short of a joined-up policy approach can address the wide and complex health inequalities we see in England. We believe this new presentation of health inequalities shows powerfully that investing in the circumstances in which people live will help people stay healthier for longer.

These are some of the first results from analysis conducted by the Health Foundation’s REAL Centre in the development of a health and care funding projections model, in partnership with the University of Liverpool’s Institute of Population Health . The analysis was conducted using the Clinical Practice Research Datalink (CPRD). The data are provided by patients and collected by the NHS as part of their care and support. Regulatory approvals to use CPRD data for this analysis were granted by the CPRD Independent Scientific Advisory Committee (ISAC protocol number 20-000096 ).

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Why a health inequalities white paper is still so vital and should not be scrapped

Linked news.

Health inequalities: Government must not abandon white paper, health leaders urge

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• Peer review
• Layla McCay , director of policy
• NHS Confederation

Health inequalities across the country have been widening for many years, and if they had ever not been obvious before, the covid-19 pandemic served to shine a spotlight on the health inequalities which are so keenly apparent in so many communities across the UK.

A significant and growing gap in life expectancy for people living in areas with the highest and lowest levels of deprivation means there is now an urgent need to create opportunities for health and care systems to drive improvements in population health outcomes at pace. So, if the rumours are to be believed and the new secretary of state for health and social care has decided to shelve the work of her predecessor and abandon the long-awaited health inequalities white paper this will deal a huge blow to the health and life chances of millions of people across the country.

The newly created Integrated Care Systems (ICSs) provide a fresh opportunity for central government and local leaders to share power locally in a flexible and dynamic way which, over time, should really help reduce inequalities in health outcomes. Through integrated care partnerships (ICPs), local leaders can embrace community power and they will have a mechanism to develop services according to the priorities of their local communities.

To improve population health, NHS, local government and social care leaders alike are urging the government not to perform such a significant and damaging volte-face, but to build on existing knowledge of what works and to consider holistically the social, economic, and commercial determinants of health when addressing inequalities. Their view is that a system-wide approach is fundamental and breaking down siloed ways of working within local systems will be crucial.

They say that the government must commit to this white paper which should consider action in four key areas to really shift the dial and reduce health inequalities once and for all.

First, leaders want to see health equity in all policies. Up to 80 per cent of what affects health—both physical and mental—is from outside of the health system, so the impact of a white paper that fails to outline a cross-government approach that looks beyond the remit of the Department of Health and Social Care (DHSC), will be drastically constrained.

The need to adopt a cross-Whitehall approach to reduce health inequalities is widely accepted. The NHS Confederation, as a member of the Inequalities in Health Alliance, a coalition of over 150 healthcare organisations, is calling for a cross-government strategy to reduce inequalities. They have written to the new Secretary of State urging her to keep the commitment to publish it before the end of this year. A health equity in all policies approach recommends action beyond the health sector, taking into account all the drivers of ill health and promoting actions that contribute to good health and wellbeing.

Secondly, leaders want prevention to be incentivised so that local systems can allocate resources according to health need and deprivation. This will require the government to make use of the structural and regulatory levers at its disposal, such as taxes and levies, to create a society where the healthy choice is the easy choice for everyone.

Last year’s Government Spending Review which failed to commit to a real-terms increase in the public health grant and soaring inflation rates which currently stand at 9 per cent, mean the Spending Review’s commitments represent a significant real-terms cut in funding. The white paper must reinstate real-terms funding increases at the level seen before 2015.

Thirdly inclusive innovation, integration, and access will be key to driving down national and local inequalities in health. The covid-19 pandemic showed that innovation in health and care services could be delivered including remote consultation. However, while very positive, there is a real risk that without concerted action to ensure these new approaches reach the country’s most deprived areas and communities, they will exacerbate inequalities.

The white paper is needed and must set out funding proposals to close the digital gap, and a strategy for the provision of health services on the high street. A plan is also needed for a population health management approach to general practice data to enable primary prevention to begin in primary care.

Equitable innovation will mean that communities are involved and engaged in defining what it looks like and that results are monitored and evaluated over the long term. Deep partnership working with the voluntary, community, and social enterprise sector will also provide valuable links into those communities.

Finally, there needs to be real concerted action on the cost-of-living crisis for communities.

A record number of working families now find themselves living in poverty. Government support must be targeted towards those who need it most in our communities. For health and care staff, this means a fully funded, generous pay rise for healthcare staff on the lowest pay, and a national care workers’ minimum wage of £10.50. The white paper must also encourage a flexible approach to the Apprenticeship Levy, using widening participation principles to enable more people from disadvantaged or excluded communities to get into work.

With concerted action it is possible to make real inroads in tackling the increasingly disparate health outcomes experienced across the country to create the conditions for a healthier population, with no-one left behind.

Moving from silo to system in our approach to population health outcome improvement will not just allow local health and care leaders to mind the health inequity gap but will engage and empower them to mend and reduce it.

Competing interests: none declared.

Provenance and peer review: not commissioned, not peer reviewed.

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Tackling Health Inequalities in the United Kingdom: The Progress and Pitfalls of Policy

Assess the progress and pitfalls of current United Kingdom (U.K.) policies to reduce health inequalities.

(1) Describe the context enabling health inequalities to get onto the policy agenda in the United Kingdom. (2) Categorize and assess selected current U.K. policies that may affect health inequalities. (3) Apply the “policy windows” model to understand the issues faced in formulating and implementing such policies. (4) Examine the emerging policy challenges in the U.K. and elsewhere.

Data Sources

Official documents, secondary analyses, and interviews with policymakers.

Study Design

Qualitative, policy analysis.

Data Collection

2001–2002. The methods were divided into two stages. The first identified policies which were connected with individual inquiry recommendations. The second involved case-studies of three policies areas which were thought to be crucial in tackling health inequalities. Both stages involved interviews with policy-makers and documentary analysis.

Principal Findings

(1) The current U.K. government stated a commitment to reducing health inequalities. (2) The government has begun to implement policies that address the wider determinants. (3) Some progress is evident but many indicators remain stubborn. (4) Difficulties remain in terms of coordinating policies across government and measuring progress. (5) The “policy windows” model explains the limited extent of progress and highlights current and possible future pitfalls. (6) The U.K.'s experience has lessons for other governments involved in tackling health inequalities.

Conclusions

Health inequalities are on the agenda of U.K. government policy and steps have been made to address them. There are some signs of progress but much remains to be done including overcoming some of the perverse incentives at the national level, improving joint working, ensuring appropriate measures of performance/progress, and improving monitoring arrangements. A conceptual policy model aids understanding and points to ways of sustaining and extending the recent progress and overcoming pitfalls.

This article is based on the premise that many of the causes and manifestations of health inequalities in the United Kingdom and the United States have been described and are largely understood ( Marmot and Wilkinson 1999 ; Berkman and Kawachi 2000 ). While further understandings are still required, much less is understood about the formulation and implementation of policies to tackle such identified inequalities in health status between and within population groups, areas, and other divisions ( Exworthy, Berney, and Powell 2002 ; Lurie 2002 ). In the United Kingdom and elsewhere, general improvements in health have not benefited all social groups equally and it is less clear how policies can reduce these health inequalities.

Health inequalities are the systematic, structural differences in health status between and within social groups within the population. The term “health inequalities” is closely linked to “social determinants of health” ( Marmot and Wilkinson 1999 ) as it refers to the multiple influences upon health status, including socioeconomic status, diet, education, employment, housing, and income. It is thus concerned with the “causes of the causes” of disease. Inequalities in health care do exist (notably in access to care) but these are not considered the principal cause of inequalities in health status ( Marmot 1999 ).

The social determinants of health and health inequalities pose particular problems for policymakers. The causes are multifaceted and the solutions must be too. Policies may need to be long-term, require the collaboration of multiple agencies, and generate few outcomes measures initially. Unless policy processes are understood, current and future policies may not achieve their goals. Indeed, some policies such as those that have reduced overall levels of smoking have unwittingly increased socioeconomic inequalities in smoking ( Jarvis 1997 ; Evans 2002 ). Also, the lack of evidence about effective policies is significant given the policies to tackle health inequalities that have been recently proposed by the U.K. government. Other countries have also begun to develop similar public health programs ( Lurie 2002 ); for example:

• Australia: “Better health outcomes for Australians: national goals, targets and strategies for better health outcomes into the next century.” (1994)
• New Zealand: “The New Zealand Health Strategy.” (2000)
• United States: “Healthy People 2010” (2000) is a set of national health objectives. It aims “to improve quality and years of healthy life, and to eliminate health disparities.”

This article describes and explains the ways in which the U.K. government has sought to tackle health inequalities, and examines the effect of these policies. The article is divided into four sections. A brief description of methods precedes the second section, which examines the origins and impact of two scientific inquiries concerning health inequalities. Third, a purposive sample of policies is examined to illustrate the dimensions of a typology of approaches to tackling health inequalities. Fourth, the conceptual “policy windows” model is used to appraise the extent to which the U.K. government has been able to tackle health inequalities.

This article reports the findings from a study that aimed (a) to assess the progress of the U.K. government in implementing the recommendations of the Acheson Report, and (b) to examine the ways in which the U.K. government has sought to formulate and implement policies to tackle health inequalities. Conducted in 2001 and 2002, the study comprised two phases. The first “mapped” the policies associated with each recommendation. Civil servants in central government reviewed this analysis; their responses were appraised and integrated. The second phase involved three case studies of policymaking relevant to health inequalities: tax and welfare benefit policies, and performance management of policies and transport. The study used three sources of evidence: documentary analysis from government departments (e.g., official reports and performance indicators), secondary data sources (e.g., published literature and commentaries), and 32 key informant interviews with civil servants. Triangulation was strengthened by an advisory group of experts from academia, research agencies, and health care organizations. Analyses applied the findings to a conceptual policy model that helped to explain progress and pitfalls in policy formulation and implementation.

The Role of Inquiries in Shaping U.K. Policy toward Health Inequalities

The U.K.'s approach to tackling health inequalities is characterized by two inquiries: the Black Report and the Acheson Report (named after their respective chairs). As their impact upon policy is markedly different, they are crucial in understanding the relationship between evidence and policy ( Oliver and Exworthy 2003 ).

a. The Black Report

The Black Report (1980) on health inequalities was commissioned by the Labour government in 1977. It identified four possible explanations of health inequalities: artifact, natural selection, cultural, and structural, but saw no role for health care in reducing health inequalities ( Mackenbach Stronks, and Kunst 1989 ). The report was published just before a public holiday and only 260 copies were made available ( Townsend, Davidson, and Whitehead 1988 ). The report was rejected by the Conservative government (then in power) because the proposals were too costly and because of their political antipathy to the issue. Thus, the Black Report had little or no impact on policy for more than a decade ( Berridge and Blume 2003 ; Davey-Smith, Bartley, and Blane 1990 ).

b. Independent Inquiry into Inequalities in Health.

The newly elected government commissioned an independent inquiry in 1997—the “second Black Report” ( Exworthy 2003 ). The inquiry was asked to “moderate a review of the latest available information on inequalities in health” and “to identify priority areas for future policy development.” The Acheson Report ( Acheson 1998a ) concluded that the “weight of scientific evidence supports a socio-economic explanation of health inequalities.” It supported a model that was composed of different layers including individual lifestyles and the socioeconomic environment ( Dahlgreen and Whitehead 1991 ). Addressing social determinants, the report considered poverty, education, employment, housing, transport, nutrition, the life-course, ethnicity, gender, and health care. The report made 39 recommendations, three of which were claimed to be “crucial,” namely:

• “All policies likely to have an impact on health should be evaluated in terms of their impact on health inequalities,”
• “A high priority should be given to the health of families with children,” and
• “Further steps should be taken to reduce income inequalities and improve the living standards of poor households” (p.xi).

The report made only three recommendations on health care, denoting its perceived contribution to tackling health inequalities.

The Acheson Report was “welcomed” by the government, noting that it was already implementing some of the report's recommendations ( Department of Health [DOH] 1998a ). Academics and practitioners generally welcomed the report though this was not universal. Critiques of the Acheson Report fall into five areas ( Exworthy 2003 ).

• No Priorities. The recommendations apparently carried equal weight ( Illsley 1999 ), implying that the recommendations were a “shopping-list.” Acheson (1998b) argued that the first three recommendations were “crucial” but remaining recommendations were not ranked in priority order.
• No Mechanisms. The means by which aid policymakers would translate recommendations into action were absent. Illsley (1999) described the recommendations as “politically naïve.” However, the inquiry's terms of reference sought “areas for policy development” and not to advocate specific targets, to the criticism of some practitioners (see Macintyre 1999 ).
• Evidence–Policy Mismatch. The disconnection between evidence and some recommendations apparently undermined the report ( Klein 2000 ). Strong evidence tended to generate specific recommendations; for example, regarding water fluoridation ( Davey-Smith 2001 ). By contrast, Birch (1999) cites the example of income inequality. Evidence from “well controlled studies designed to assess the effects of interventions on health inequalities” was often lacking but these lacunae were not seen as a reason for inaction ( Macintyre et al. 2001 ).
• Specificity of Recommendations. Some recommendations (such as giving a high priority to the health of families with children) were considered too vague for policymakers to implement ( Davey-Smith, Morris, and Shaw 1998 ; Evans 2002 ). Others (such as the further promotion of the concept of “health promoting schools”) were considered too specific, especially when no implementation mechanisms were proposed.
• Cost-effectiveness. The lack of evidence concerning cost-effectiveness of policies to tackle health inequalities was concerning ( Williams 1999 ; Oliver 2001 ). The terms of reference required recommendations to be “affordable” and yet, no economist sat on the inquiry. This is significant since the Black Report was (in part) rejected on the grounds that recommendations were too costly.

Most recommendations are associated with new or adapted policies ( Exworthy et al. 2003 ). The study (upon which this article is based) appraised the influence of the report upon policy in four ways ( Exworthy et al. 2003 ):

• It prompted new policies to tackle health inequalities,
• It introduced a health inequality dimension to existing policies,
• It encouraged or contributed to a climate of opinion in favor of tackling health inequalities, and
• It acted as a source-book or reference against which policies are examined and tested.

It is difficult to determine how far the policies would have been implemented anyway, without the report ( Macintyre 1999 ).

An Assessment of Current U.K. Policies to Tackle Health Inequalities

Typology of policies.

A typology disaggregates policy interventions into distinct domains (such as policy means and ends, mechanisms, or population). This aids analysis of the combinations of political and organizational resources required for the effective implementation. Analysis for this study generated a six-fold typology of U.K. policies.

However, caution is needed in examining policies to tackle health inequalities. First, policies that might affect health inequalities may not have been specifically designed with them in mind. Second, the time-lags between policy inception, formulation, and implementation can be several years, which means that intermediate measures or (health) outcomes will not be evident in the short to medium term. Third, intermediate markers (such as process indicators) are appropriate only if the cause and effect of policies upon health inequalities are clearly understood. Fourth, policy processes are not linear; policies to tackle health inequalities may be confounded by countervailing socioeconomic factors. Evaluation of policy developments is thus provisional.

Recent U.K. Policy Developments

While the examples ( Table 1 and below) are not a comprehensive assessment of all examples, they are a purposive sample to illustrate the nature and scope of current policies and provide the evidence for the conceptual model (below). (For a fuller description of relevant policies, see Exworthy et al. 2003 .)

A Typology of U.K. Policy Addressing Health Inequalities

Adapted from Exworthy (2003, p. 19) .

Life-course—Early Years and Children

The “health inequalities” literature has increasingly focused on the life-course as a key explanatory approach ( Blane 1999 ). A policy emphasis on early years development is consistent with the life-course thesis.

• Sure Start . With antecedents in the U.S. Head Start program, the U.K.'s Sure Start policy initiative aims to improve the life-chances for young children and their families, especially those living in poverty, by changing the pattern of existing services. The 500 programs by 2004 will reach only about one-third of children living in poverty and are available only to those children who live in the Sure Start areas ( Sure Start, nd ). It is unclear how children living in poverty elsewhere will benefit unless policies can be successfully transferred to non-Sure Start areas.
• Child Poverty . The government aims to reduce the number of children in poverty by a quarter by 2004. The U.K. has one of the highest rates of child poverty (measured as households with income below 60 percent of the median income) of Organization for Economic Cooperation and Development (OECD) countries; it stands at about 20 percent ( Brewer and Gregg 2001, p. 4 ). The policies include targeting disadvantaged communities, raising welfare benefit levels and introducing new benefits (that aim to support low-paid workers and subsidize child care). Progress is inconclusive but some positive signs are evident. From 1996–1997 to 2000–2001, “there was a fall of 1.3M in the number of children below 60 percent of the 1996/7 median income” ( Office of National Statistics 2002 ). Yet, it is difficult to attribute these changes to the policies per se. Yet, many of the children who have been “lifted out” of poverty were closest to the poverty line, thereby creating a residual group which existing policies do not or cannot reach.

Area-Based Initiatives

The current U.K. government has targeted policies on specific geographical communities to tackle poverty and disadvantage ( Office of the Deputy Prime Minister 2003 ).

• Health Action Zones (HAZ) . These interagency partnerships were established in 26 areas of deprivation and poor health in England, covering 13 million people. Each HAZ aims to devise and implement a strategy that reduces health inequalities. However, the HAZs have suffered from continual organizational change since they were formed in 1997 and have increasingly been used by central government as the vehicle for reform in other sectors. For example, HAZ resources have been given to the new Primary Care Trusts ( Office of the Deputy Prime Minister 2003 ). The HAZs have often created short-term projects that have proved difficult to integrate within “mainstream” organizations ( Lawson et al. 2002 ).

Redistribution—Welfare-to-Work

Overall, there has been modest redistribution to poorer groups across the social gradient (Institute for Fiscal Studies [IFS] 2002) ( Figure 1 ).

Income Redistribution: 1997–2001 and 1997–2002

However, traditional forms of redistribution (mainly taxation) have been rejected by the government. It considers paid employment to be the best way out of poverty and has thus linked benefit payments to employment, a policy termed “welfare-to-work.” Policies like this incorporate minimum levels but do not necessarily address inequality per se since they do not seek to redistribute incomes progressively.

• Tax Credits . Several “Tax Credits” (e.g., Working Families Tax Credit [WFTC] and Children's Tax Credit, akin to the U.S. Earned Income Tax Credit and Child Tax Credit) ( Dolowitz 2003 ) have been introduced that provide employment-based benefits for adults. These tax credits are linked to “New Deal” programs (for lone parents and disabled persons) that offer incentives (e.g., child care costs or employer subsidies) to enable certain groups into employment. Their impact is expected to be modest on employment; for example, the WFTC is predicted to raise “the employment rate of single mother by 3 percent points” ( Paull, Taylor, and Duncan 2002 ).

Health Care

Though health care generally contributes little to reducing health inequalities, it is often a primary mechanism for policy implementation. However, the National Health Service (NHS) remains the center of gravity in U.K. health policy. National attention is invariably directed toward NHS, often stifling public health issues. For example, there has been debate as to whether the ministerial responsibility for public health should remain within the DOH, overshadowed by the NHS. The Health Select Committee ( House of Commons 2001 ) recommended that the responsibility should rest with DOH but that its external profile should be raised. Also, despite continual NHS reform, targets have been set to reduce morbidity and mortality from the “big killers”:

• Cancer: “To reduce the death rate in people under 75 by at least a fifth.”
• Coronary Heart Disease and Stroke: “To reduce the death rate in people under 75 by at least two fifths.”
• Accidents: “To reduce the death rate by at least a fifth and serious injury by at least a tenth.”
• Mental Illness: “To reduce the death rate from suicide and undetermined injury by at least a fifth” ( Department of Health 1999 ).

These targets are not expressed in terms of inequality, though they sometimes include minima targets. (By contrast, U.S. “Healthy People 2010” targets cover 28 areas). Attention on public health has previously been distracted by organizational restructuring and the dominance of specialist services ( Exworthy, Berney, and Powell 2002 ). Newly formed organizations—Primary Care Trusts (PCTs)—are responsible for commissioning hospital services, developing primary care, and tackling health inequalities. Similar pressures persist but PCTs are apparently giving more attention to health improvement ( Wilkin et al. 2002 ).

Targets and Performance Culture

The government has extensively employed targets to secure its policy objectives; they operate at all organizational levels.

• Public Service Agreements (PSAs). Public service agreements are a form of “contract” between the finance ministry and spending departments. Most departments have PSAs that could contribute to significant reductions in health inequalities, but most were not devised with that in mind. Analysis of PSAs highlights the need for greater linkage between policy (spending) and outcomes, and clearer accountability. The PSAs denote the expanding role of the finance ministry in social policy ( Deakin and Parry 2000 ).
• Health Inequality Targets. The Acheson Report did not recommend targets for reducing health inequalities. In its draft public health strategy, the government did not propose “at this stage to set national targets… because the causation is complex and many factors interact” ( Department of Health 1998b ). Two national targets were introduced in 2001:
• “Starting with children under one year, by 2010, to reduce by at least 10 percent the gap in mortality between manual groups and the population as a whole.”
• “Starting with health authorities, by 2010, to reduce by at least 10 percent the gap between the fifth of areas with the lowest life expectancy at birth and the population as a whole.”

Intermediate indicator have been developed to support these two long-term objectives. This contrasts with 10 leading health indicators and 28 focus areas associated with “Healthy People 2010” in the United States.

Structures and Processes

• Joined-up Government (JUG). Complex problems are invariably multicausal and so policy interventions require governments to work laterally across departments—issues faced by other countries that have sought strategies similar to the United Kingdom ( Ling 2002 ). Though a “systems-wide” approach to health inequalities is beneficial ( Lurie 2002 ), JUG may sometimes be inappropriate. For example, policy formulation may involve multiple departments but responsibility for implementation may rest with one. Alternatively, fiscal redistribution policies may be less prone to the dilemmas of fragmented government.

Since the 1970s, organizational and policy reform has fragmented public services between different service providers, thereby confounding coordination ( Osbourne and Gaebler 1992 ; Rhodes 1997 ). Departments have traditionally ensured reasonably effective service delivery but these “vertical” policy silos have hindered “horizontal” coordination ( Cabinet Office 2000 ). Issues that fall outside vertical silos are neglected because no effective central coordination exists ( Flinders 2002 ). Thus, “wicked” or intractable issues such as health inequalities pose particular problems ( Richards 2001 ). Departmental culture has also hampered collaboration because personal and institutional incentives discourage JUG. Policymakers and Ministers are generally not promoted for pursuing cross-departmental initiatives. As departments compete for resources, cross-departmental activities represent an opportunity to defend departmental “territory” ( Flinders 2002 ). These inhibiting factors apply strongly to health inequalities. Though many departments' policies affect health inequalities, few mechanisms exist to exert leverage over their activities.

• Cross-cutting Review . The finance ministry established “cross-cutting reviews” to inform government spending in areas that fall outside the portfolios of spending departments. Health inequalities were the subject of a cross-cutting review in 2001. A committee of civil servants from all departments reviewed research evidence and official data sources. They identified the need for a long-term government-wide strategy to tackle health inequalities and the importance of influencing mainstream policy in all areas of government ( Her Majesty's Treasury 2002 ). They advocated a stronger focus on deprived areas, better preventative health care, programs to improve nutrition and physical exercise, and improved housing conditions. Published in late 2002, it is too early to judge the review's outcomes.

A Conceptual Assessment of Policy Progress and Pitfalls

Various policy models can explain the ways in which policies are formulated and implemented (e.g., Wolman 1981 ; Challis et al. 1988 ). The “policy windows” model by Kingdon (1995) is especially useful because it explains how and why issues get onto the policy agenda, as the prelude to implementation. Kingdon argues that policy windows open (and close) by the coupling (or decoupling) of three streams: problem, policy, and politics.

The accumulation of evidence about health inequalities is a necessary, but not a sufficient condition for policy change. Issues need to be seen or defined as “problems” that are amenable to policy interventions. This is not straightforward because “public policies in seemingly unrelated areas may have population health affects” ( Lurie 2002, p. 96 ). The policy stream comprises initiatives and strategies advanced by stakeholders inside and outside government. Initiatives float in a “primeval soup” and are only selected when they satisfy three criteria: technically feasibility, congruence with the dominant values, and anticipation of future constraints. The politics stream consists of bargaining, negotiation, and compromise between interest groups and power bases. When all three streams are coupled, often with the aid of natural cycles (e.g., elections) or a “policy entrepreneur,” opportunities for change occur. Equally, when separated, change is less likely. This section uses the model to assess the coupling of these streams.

Problem Stream

The accumulation of evidence, and specifically the Acheson Report, have helped established health inequalities as a “policy problem.” (Similar “inquiries” elsewhere have also shaped the “problem”) (e.g., Smedley, Stith, and Nelson 2002 ; Guy 1997 ). This has been a necessary but not sufficient condition. The Acheson Report and the cross-cutting review on health inequalities are part of a new approach to policymaking that increasingly relies on research and other evidence. While the government stresses that “what counts is what works” ( Davies, Nutley, and Smith 2000 ), evidence-based policymaking will falter with limited or contradictory evidence ( Evans 2002 ). Ongoing measurement will thus need to ensure the “problem” remains clearly ( Evans 2002 ).

Policy Stream

Criteria for the policy stream have not been met. First, evidence about the “technical feasibility” of policies (notably their effectiveness) remains limited. Despite this, there has been a flurry of policy activity, sometimes seemingly unrelated to health inequalities. It is debatable whether policies are sufficiently comprehensive to overcome the countervailing forces that generate and sustain health inequalities. For example, redistribution has occurred but is this sufficient to counteract widening income inequality (as measured by Gini coefficient) since the Labour government was elected? Also, the appropriate combination of policies (say, between universal and targeted programs) required to achieve policy aims related to health inequalities is unknown.

Second, values congruence appears moderate. Reduction of health inequalities is seen as a desirable policy objective, though it barely registers as a public issue. It is uncertain whether the government is willing to address inequality (rather than poverty, per se) by making stronger efforts at redistribution, for example.

Third, several future constraints have yet to be confronted. Sustaining policy ownership by departments will require measures of improvement. However, isolating the impact of policies to tackle health inequalities is problematic ( Macintyre 1999 ). This is exacerbated by the long timescale of some policies; for example, the health inequality targets have a timetable of 2010 by which time Ministers and policymakers may no longer be in post. Similar issues are faced by the U.S. “Healthy People 2010” policy. Most initiatives to tackle health inequalities have been one-off, short-term projects; projects remain marginal to mainstream policy and provision. In the longer-term, mainstream activities must be adapted to address health inequalities but bending the mainstream is difficult when other pressures (such as health care reform) are prevalent.

Politics Stream

It is unclear whether there is a critical mass of civil servants and Ministers across government who are committed to tackling health inequalities. These policy entrepreneurs do not yet constitute a policy community with networks of information and experience. This is partly because their careers do not rely on such cross-departmental collaboration. The Minister for Public Health is a relatively junior position, the occupants of which have not lasted long in post. (In the United States, despite Joint Congressional Hearings on health disparities in 2002 and legislative proposals by Senator Bill Frist [for example], policy communities [concerning health inequalities] are probably more nascent than in the United Kingdom). With emphasis on reforming public services, initiatives such as the cross-cutting review and health inequality targets may carry little weight in political negotiations. Thus, the government's approach to health inequalities may be “rhetorically powerful but politically very cautious” ( Evans 2002, p. 79 ).

Each stream shows some progress and there has been some “coupling” of the streams; thus opening the U.K. “policy window” ajar. (By comparison, the U.S. policy window may be less open as each stream still faces numerous obstacles.) It may be open now, but many factors may force its closure, including Ministerial changes, departure of policy entrepreneurs, declining tax revenues (funding social programs), and competing priorities (e.g., NHS reform). The formation of structures and processes, evidence about effective interventions, and intermediate measures of progress will help wedge it open. Thus, the policy window cannot be guaranteed to remain ajar. Understanding the reasons for such opening/closing will explain the progress and pitfalls of policy.

After many years in the “wilderness,” social determinants and health inequalities are on the U.K. policy agenda; the issue has been defined as policy “problems.” The Acheson Report and other research helped raise the profile of health inequalities across government and provided the basis for policy development. As this was essential, policy has made some progress but has also encountered some pitfalls. Getting the problem onto the policy agenda is significant progress in itself. Additionally, progress has been evident in the structures and processes of policymaking and in recognizing the potential impact of all policies upon health (inequalities). Pitfalls are manifest in the scant evidence about effective interventions, limited evidence of change in intermediate markers and outcomes, weak incentives to sustain JUG, and poor integration of “health inequality” policy within mainstream systems. These ways in which progress has been made and the pitfalls addressed provide lessons for other countries engaged in such policy endeavors. Moreover, accounting for progress or pitfalls elsewhere is aided by the application of the “policy windows” model as it overcomes contextual explanations, facilitates international comparisons, and aids policy transfer. The three streams have largely been coupled and the policy window opened ajar. While this augurs well for future policy development, the confluence needs to be continually maintained in the long-term to make significant reductions in health inequalities. In doing so, the nature and scope of health policy shifts, from concerns about just health care (cost, quality, and access) to encompass the social determinants of health.

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Our approach to reducing healthcare inequalities

The NHS Long Term Plan placed tackling health inequalities at the heart of NHS goals for this decade. The big population health improvement goals can only be met through far better engagement with those least likely to present at NHS services now.

Furthermore, COVID-19 has shone a harsh light on some of the health and wider inequalities that persist in our society.  Guidance issued by NHS England in response to the COVID-19 pandemic, set out eight urgent actions for tackling health inequalities. This was later refined to five key priority areas which underpin the work of the National Healthcare Inequalities Improvement Programme ( HiQiP) .  These include:

• restoring NHS services inclusively
• mitigating against digital exclusion
• ensuring datasets are complete and timely
• accelerating preventative programmes
• strengthening leadership and accountability.

Our approach is to work as a super-matrix across all NHS England programmes and policy areas, and the NHS more broadly, to hardwire healthcare inequalities improvement into our strategies, policies, initiatives and programmes.

The programme’s vision is exceptional quality healthcare for all ensuring equitable access, excellent experience and optimal outcomes .

Our most intensive work to date has been working with COVID-19 Vaccine Equalities team to drive equitable uptake of the COVID-19 vaccines and with the Elective Recovery team to create the conditions for an inclusive restoration of our elective waiting list.

From a clinical perspective, we are driving forward the evidence based Core20PLUS5 framework which defines key population groups and clinical focus areas for accelerated improvement in healthcare inequalities.

A number of initiatives are in development to support a social movement ethos including the introduction of Core20PLUS ambassadors and Core20PLUSConnectors .

We have also developed the Health Inequalities Improvement Dashboard  which brings together key strategic indicators in one place, enabling NHS services to take targeted action to reduce inequalities.

Most of the fundamental factors driving inequalities in health are beyond the responsibility of the health care system, for example our education system; economic and community development in our most deprived neighbourhoods; employment levels; pay and conditions; and availability and quality of housing.

The NHS contributes to tackling inequalities in health in three distinct ways.

• Influencing multi-agency action to address social determinants of health The role of integrated care systems (ICSs) working with local authorities and local communities is particularly critical here. Nationally NHS England will continue to work alongside the Government and the Office for Health Improvement and Disparities. We can also forge new international partnerships such as that between the NHS Race and Health Observatory and the US Centre for Disease Control.
• The NHS is a significant economic actor in its own right The choices we make as an employer, a purchaser and a local ‘anchor institution’ can help moderate inequalities.
• Tackling inequalities in healthcare provision This is our direct responsibility and must be the prime focus of our action. The enduring mission of the NHS is high quality care for all. That means tackling the relative disparities in access to services, patient experience and healthcare outcomes.

Great work is happening across a number of organisations to address healthcare inequalities and we are committed to working with our partners to further enhance and accelerate this.

Understanding Health Inequalities Essay

• To find inspiration for your paper and overcome writer’s block
• As a source of information (ensure proper referencing)
• As a template for you assignment

Introduction

Understanding what is meant by health inequalities is the first step in addressing the issue. Two central and separate UK health inquiries; one from Acheson and the other from the black report, helped to develop extensive debate regarding health inequalities. Subsequently, they triggered the need for policy and action in addressing the issue.

Different conceptual models have been used to explain and demonstrate how various factors influence individual and community health. Some of these factors such as age and sex are beyond d human intervention.

On the other hand, there are other wider factors which affect an individual’s health, and which can be controlled. There are various numerous debates related to the causes of these inequalities as well as on the most plausible action that should be taken to address these inequalities.

Health equity, also known as healthcare inequality or healthcare disparities refers to the differences that prevail with regard to the quality of health and related activities transversely different populations. The concept of health inequalities was not been a priority for the UK government in the 1980s and early 1990s.

In the 21 st century, evidence for escalated inequalities in the social pattern of health is beyond reasonable doubt and there is vast literature to support this. More than 800 empirical and conceptual papers have dedicated their time and effort to this topic since the late 1990s.

The area of research in health inequalities has been greatly politicized, right from the ideological context through explanatory frameworks to the various discourses that propose remedies to the problem. Reducing inequalities in health has become an integral part in as far as the UK Government policy is concerned.

The key debates related to inequalities and health in the UK, are on the causes on these inequalities and how they can be resolved.

Public health in Britain today is more or less of a paradox where despite the fact that Britain now experiences greater health than it has ever experienced in history, health inequalities had remained to be stubbornly ubiquitous. Several authors have come forth to present the setbacks of health inequalities in the United Kingdom.

This paper aims at identifying and critically reviewing what different authors have got say about this issue in their different works. It has analyzed different conceptual and policy debates which are paramount in as far as inequalities in health are concerned. It has pointed out the respective material and psychosocial influences on health inequalities.

The paper is quizzical on the direction ought to be taken by public health professionals in influencing policies, as well as their implementation in relation to health inequalities. This is of concern in a world where much emphasis is on wealth creation as opposed to addressing poverty.

The years 1980-2005 were a period marked by huge growth in international research and vast literature aimed at demonstrating the inequalities in health, and the governance of poverty as a potential cause of these inequalities. Davey Smith and colleagues at the University of Bristol have made great contributions to this concept by generating evidence to support it.

Davey Smith, et al (1999) responded to Acheson’s report (1998) on health inequalities evident in the UK. The Acheson’s report shows the existence of health disparities and their correlation with social class. The findings showed a general decline in mortality between 1970 and 1990, but that of the upper social classes was characterized by a more rapid decline.

Acheson mentions 39 policies that are applicable in ameliorating health inequalities in various sectors of the economy that range from taxation to agriculture. This report had a great influence on “Out Healthier Nation: A Contract for Health”, the 1998 government green paper and the 1999 “Saving Lives: Our Healthier Nation”, white paper.

Davey Smith, et al not only reviewed Acheson’s data indicating the escalation in health inequalities but also argued that the solution to this escalation could be easily solved.

He states, “Any child can tell you how this can be achieved: the poor have too little money so the solution to ending their poverty is to give them more money. Poverty reduction therefore can be really attained by throwing money at the problem”, (Davey Smith, et al., 1999, 378).

Labonte, 1999 has also placed an argument based on Acheson’s report. Labonte says that there is need to go beyond just analyzing health inequalities to grappling with policy options. Labonte notes that Acheson’s and related reports did not bring about change, instead they became legitimizing tools for those who were committed to change.

They are basically ideological tools which are more essential than evidence base in creation and development of policies. However, Acheson did not provide a basis for continued debate on inequalities within the government.

Acheson has been criticized by Labonte as not relating economic practices with social inequalities as he has done with social aspects and health inequalities. Acheson also failed to probe into the existence of poverty hence has left some crucial components related to health and inequalities unturned.

O’Keefe (2000) has argued out the causes of health inequalities based on globalization, which is considered to have an increasing influence on social policy in all countries.

She explains that decisions related to health inequalities are made by “undemocratic trans-national regulatory organizations that include the World Trade Organization”.

O’Keefe suggests that deliberative democracy placed at the heart of such trans-national bodies could be an ideal solution for the health inequalities experienced in the different countries. However, this was dependant on the world-wide strength to question the unjust social structures that operate on a global level.

In her work, Stewart-Brown 2000 probes into the causes of social inequality. Stewart-Brown is puzzled by the impression derived from this question. It has become more or less like a taboo in literature. Stewart-Brown has used a contrary analytical approach different from that of Davey Smith, et al., and Labonte as discussed earlier on. She has borrowed from conflict management and psychotherapeutic theory.

She implies that the problem of social inequalities in health can be resolved by a development in the direction of emotional literacy involving all income groups and especially those with most wealth by so doing (Stewart-Brown, 2000).

Davey Smith, et al., (2000) have demonstrated that ethnic differences in health status in their review on the UK epidemiological evidence on ethnic health inequalities. Various types of explanations have been explored in this review that entail migration, culture, artefact, behaviour, biology, socioeconomic factors and racism.

They conclude by suggesting that influences falling under the different explanations would largely contribute to the production of ethnic differentials in health. However, production of more sensitive socioeconomic indicators is required if clarity and definitiveness is to be achieved.

Bolam, et al., (2003) have focused on an important and current issue of debate on inequalities in health based on the contribution of psychological factors while looking at structural, material and economic factors related to health.

Bolam and others have advanced this debate by coming up with a more complex and entirely socialized theory that examines the key component in psychological explanations known as the “the sense of control over health”. In their article, Bolam and others explore these determinants by analysing interviews where 30 lower socioeconomic status participants engaged in the interviews.

The participants were obtained from two qualitative studies on health inequalities. The major findings were bent on the correlation of two contrasting factors on control over health, that is, “fatalism and positive thought”.

The debate on material and psychosocial explanations for health inequalities has imperative policy implications and especially macro-economic policy and appropriate interventions with regard to health services. There is one important health service intervention in the UK aimed at reducing health inequalities, and this is the nation-wide programme on smoking cessation.

Woods et al (2003) have noted the implementation of this programme during early implementing health action zones. Woods and others are not at all enthusiastic about this programme because it is only a rhetoric act by the government but, despite this, smoking cessation has been categorically and centrally steered.

They argue that despite the fact that smoking cessation may lead to an overall population-level minimization in smoking, it have the potential of causing a wider gap than the current one in as far as health inequality is concerned.

A similar theoretical debate by Muntaner, et al., (2000) in their thought provoking article have brought focus on the worth of the concept of ‘social capital’ with regard to comprehending and identifying an appropriate action on health inequalities. Muntaner and others have challenged the theoretical value as well as the evidence base that shows social capital to be a determinant of health inequalities.

They show the use of social capital as an alternative to party politics and economic redistribution within the state and it is because of this that they are sceptical about its practical benefit in addressing health inequalities.

Morrow (2000) explores the accounts of young people with regard to the community and neighbourhood while using the concept of social capital, and the effect on health inequalities. In his work, it is evident that Morrow realises the limitations of the social capital concept but Morrow has argued out that it is valuable in helping the young people explicitly understand their social environment.

Ostry, et al., (2000) studied the “relationship between unemployment, technological change and psychological work conditions in restructured work places in British Columbian sawmills”. In this study there was a downsizing of the employees where reduction took place in terms of number and job title.

It was evident that psychosocial conditions of work were ameliorated after the downsizing but, only few workers experienced these better work conditions. Even though this was the case there was a need for future improvements based on the lessons learnt.

To start with, a population based approach is very important while assessing the implication of downsizing because a long-term follow-up of the downsized workers is important. Secondly, there is great need to pay attention to the long-term implications associated with employment and their effects on health with regard to the downsized workers and especially those who are less than 35 years.

Also, the downsizing resulted in escalated levels of control, which was more steepened across the different job categories in 1997 as compared with 1965. This was considered to have health implications and mainly so for the unskilled workers where downsizing had taken place. Lastly, the method used for assessing the working conditions needed improvement. Self-reports ought to be used in such future studies.

Methodological challenges are evident in relation to evaluating the policy interventions aimed at reducing health inequalities. Evans Shito and Keskimaki (2000) have placed great attention on the description of the long term Finnish policy goal addressing health inequalities. They have outlined the barriers to successful policy programmes with regard to addressing these inequalities.

In a similar light of debate, Evans and Killoran (2000) have made a report on “realistic evaluation”. In this report they have realistically evaluated five UK projects put in place so as to test the effect of five partnership models in addressing health inequalities.

They identify six key themes, which are “shared strategic vision, leadership and management; relations and local ownership; accountability; organizational readiness and responsiveness to a changing environment”.

The need to understand how the mechanisms used in the project were executed in the light of local and national policy change has been greatly emphasized. Lessons for programmes on health improvement in the UK, primary care groups and health action zones have been identified.

Asthana and Halliday (2006) have argued about health inequalities with regard to how they should be objectively tackled in the UK. This is in accordance with the prevailing scepticisms on the best approach to take while translating broad policy recommendations into practical actions. The value of local level initiatives has remained to be a great concern due to its implicit nature.

In this book, key targets for intervention have been identified via a comprehensive exploration of the directive and procedures that lead to health inequalities across populations. The authors have examined both national policy content and local practice in determining what is applicable in addressing health inequalities, why and how it works.

This book is authoritative but, very much accessible in providing a detailed account of “theory, policy and practice” hence, creating a good debate ground for what works and what does not work in as far as addressing health inequalities in the UK is concerned.

An article by Buch, 2010 on “Health Inequalities in the UK-Our most Pressing Problem” has presented a debate that was held by the British Medical Association on health inequalities. The debate was centred on the most pressing problem at hand: why there was such a great gap between the different sections of the British population in relation to health and what the most ideal solution to the problem was.

Evidence by Professor Marmot showed that there was a seven year gap with regard to life expectancy. There was also a 19 year gap with regard to healthy life expectancy between the lowest and the highest socioeconomic groups. Ameliorating health inequalities via trying to equalize the socioeconomic status of each and every person would be faced by major challenges. Health agenda was considered to rhyme the environmental agenda where walking, moderate consumption of meat and cycling were encouraged (Buch, 2010).

The question therefore was on how health inequalities could be effectively addressed. Lack of commitment and will are some of the suggested reasons for the persistent escalating health inequalities. There is weighted evidence that the gap related to health inequalities can be filled through policies already developed.

However, the politicians are still struggling with the direction in which they would take in implementing the changes. The government continuously comes up with various ideologies on how to address the health inequalities. Unfortunately, they never get to seriously work on them as they are always debating on how these inequalities could be addressed without doing anything.

“The Impact of Inequality: How to make Sick Societies Healthier” by Wilkinson (2005) is a continuation of his book, “Unhealthy Societies: The Afflictions of Inequality”. The current book reviews the present status of knowledge and offers an explanation as to what causes the health inequalities as well as providing potential solutions to the problem.

This book consists of highly assembled and valuable evidence with an articulate and convincing argument suitable for use by epidemiologists, policy makers, social scientists, public health officials and students.

It is Wilkinson’s ideologies that provoke thought like when he wonders of the difference in government’s response to health inequalities if income gradient in relation to health were to be different. An illustration of this is what the response would be if the higher income groups were the ones experiencing worst health.

Wilkinson has written the book from a particular point of view, that which focuses on social justice and reform. He does not criticize capitalism as per se and does not posit extreme ideologies. Wilkinson’s view of social progress is very much in existence in the contemporary UK society, where market is part and parcel of the existing societal structure.

According to Wilkinson, inequalities in health can be reduced, better stress management mechanism developed to reduce social stress and the quality of social relations made to be better. All these efforts would play a very vital role in improving the health and well-being across populations in the society.

His conclusion is on an optimistic stand-point as he acknowledges the health inequalities across populations but then again, he says that change is very much possible and that the health inequalities can be reduced.

The universe is still in the process of expansion in as far as moral democratic values are concerned, this coupled with growing sensitivity to the suffering of others, Wilkinson points out that a decrease in inequality and improvement of well-being across the social classes was very imperative in strengthening political goals.

Carlisle (2001) has presented the debates related to inequalities and health based on three different explanatory discourses as presented by Macintyre (1997). The first, hereditarianism explanations, on class variations in relation to disease have been presented based on the argument that people’s social position is dependent on natural capacity that is biologically determined.

Based on this perception, variations in health are considered to be inevitable and nothing much can be done about them. Behavioural explanations have been used to justify the high mortality rate amongst labouring classes and ill health of the economically poor sections of the population as a subsequent result of working-class maternal ignorance alongside living conditions that are not up to standard.

In this case, education would have been a preferable measure in improving health. The environmental aspect attributed causes of inequalities in health considered to widespread poverty and material components of urban industrial life. Based on the latter, social reforms were considered to be of great value in addressing the environmental aspect in as far as health and inequalities were concerned.

Popay, et al., (1998) in their review of modern research, have presented a debate based on two main constructions that continue to govern research pertaining to health inequalities. The first construction is individual behaviours and lifestyle while the second one is social inequalities and injustice.

There are some elements of continuity with regard to historical environmental explanations on poverty and deprivation, and behavioural/ hereditarianism explanations on lifestyle and culture the causes of health inequalities.

Nonetheless, differences exist in relation to social values and political ideology in the different explanatory discourses and all are directed at identification of appropriate and applicable policies.

Carlisle concludes by suggesting that lack of clarity revolving around competing explanations fosters political skilful moves at the policy level where the UK government seeks leadership in grappling with the issue, while delegating responsibility to community members and individual figures.

Carlisle presents an overview of three but highly contested explanations that are linked to inequalities in health in the contemporary world. These are poverty/deprivation, psychological stress and individual deficit. The deprivation facet is a strong evidence for the inequalities but it is not complete.

Various critics focus on the barrier of the gradient since health inequalities are not only found within the poorer segments of the society but are a sequel of social class gradients (Marmot et al., 1991). Material differences therefore are not adequate in explaining this. The psychosocial stress model was developed to fill in the gaps from the poverty model.

It views the problem as a generative mechanism for inequalities in health based on the relationship between the individual person and social structure. The individual deficit model has similarly acknowledged social inequality but does not focus much on restructuring the society as compared with addressing the problem and at individual level, examining their culture as well.

Heller, et al., (2002) has argued out the widening and large gap in mortality rate between those at the extreme ends of social distribution despite the amelioration in overall mortality rate. It is this gap between the extremes that has been indicated to be the relative mortality variation between those who experience greatest and least deprivation.

Heller and others have shown that the changes in social distribution that transverse the population has been a major contributor to the reduced mortality rate. Heller and others have argued out that based on their findings, there is no widening gap in overall health inequality when redistribution within the social classes is factored in.

According to the review of both Mackenbach and Kunst (1997) on the different methods of overall health inequality assessment in any population, none of them can be pointed out to be the very best.

Heller and others have used a method that does not directly address the issue despite the fact that it is flexible to changes in social class distribution and allows description of mortality within social classes. Unfortunately, Heller and others have used a method that presumes that every member within a certain social class has the same predisposing risk of mortality.

In addition, when one moves from one social class to another, he or she adopts that mortality profile of that new social class. This is not usually the case and especially in the short-term. The method used to sasses the degree of health inequality in relation to the widening gap of mortality between the extremes of social distribution may be inaccurate as the change may be partly attributed to artefact of health selection.

Inequality is a term that has been used in relation to the distribution of health or ill-health across populations. This ideology or concept is not just an expression of existing differences in relation to race, sex, age and species which exist.

It is neither a mere expression of the natural physiological constitution or procedures involved that have been socially and economically developed. The vast literature and attention on “health inequalities” show that this issue is very much complex. This literature has demonstrated that recognizable and discernable factors related to health inequalities are not easy to isolate from one other as they are very much entangled with one another.

The differences that prevail between people are considered to be eternal and not capable of being modified. The society is made up of various institutions. These institutions can influence health inequalities indirectly and subtly, or directly and evidently.

Some individuals think that this concept of health inequalities is associated with moral reinforcement while others consider it to be non-existent or not yielding into any consequences. The latter consider health inequalities to be inevitable and are as a result of man’s desire to build society. They consider the scope for change to be limited and of miniscule importance.

The concept of social class has been evident in the various literatures. Populations are not alike in terms of literacy, wealth, income and housing. The population is thus divided into strata and societies differ based on these strata. However, it is difficult to identify the borders between the different the different strata but, this does not mean that the strata are less real.

On the contrary, the social strata are sections of the population that share the same types of resources and have similar lifestyles. Controversy continues to prevail with regard to the origin and importance of social class in as far as health inequalities and change are concerned.

Despite the fact that some literatures show that there no significant correlation between health inequalities and poverty/deprivation, one cannot ignore the need to improve the health of those with the highest degree of deprivation. The approach to addressing health inequalities in the UK should be comprehensive in that it focuses on various possible causes of these inequalities.

This will aid in developing the comprehensive approach required to address these causes. Therefore, there is need to include determination of relevant polices that should be put to work so as to improve the overall socioeconomic status of the population.

A reduction in mortality rate between the extremes in social distribution is the not the only way through which health inequalities can be addressed. Rather it is one facet of social inequality on health inequalities. Irrespective of the rhetorical commitment in addressing issues related to health inequalities, it is a great issue that continues to persist in the UK society.

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Link Between Social Class and Health Inequalities

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The Relationship Between Social Class and Health Inequalities

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Young people’s views and experience of diet-related inequalities in England (UK): a qualitative study

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Vanessa Er, Mary Crowder, Eleanor Holding, Nicholas Woodrow, Naomi Griffin, Carolyn Summerbell, Matt Egan, Hannah Fairbrother, Young people’s views and experience of diet-related inequalities in England (UK): a qualitative study, Health Promotion International , Volume 39, Issue 4, August 2024, daae107, https://doi.org/10.1093/heapro/daae107

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Inequalities in diets contribute to overall inequalities in health. Economic inequality and inequalities in access to healthy food are key drivers of poor diet and ill health among young people (YP). Despite mounting evidence of structural barriers to healthy eating, less is known about how YP view and experience these inequalities where they live, and how to address them. To explore YP’s perspectives on the drivers of diet-related health inequalities, we conducted three interlinked focus groups with YP aged 13–21 years from six youth groups across three geographical areas in England. We analysed the data inductively and deductively using reflexive thematic analysis and generated themes by examining how social structure, context and agency interact and impact YP’s diet. YP were aware of how inequalities in employment conditions impact their families’ income and ability to eat a healthy diet. They cited the high availability of hot food takeaways in their local areas as a significant barrier to healthy eating but did not support closing or restricting these outlets. They held strong views on policies to tackle diet inequality and showed a nuanced understanding of the strengths and limitations of universal and targeted approaches. Our study showed that YP have an awareness and understanding of food as important in relation to health, and of diet-related inequalities. However, further efforts are needed to shape and promote policies that resonate with YP and address both their health and wider social concerns.

Our study recognizes that young people have an awareness and understanding of food as important in relation to health, and of diet-related inequalities.

Young people have a nuanced appreciation of bounded agency: that is, the way social, cultural and economic factors shape individual food choices and practices.

Young people are potential sources of support for health equity strategies that include social determinist approaches.

Further efforts are needed to shape and promote policies that resonate with young people and reflect and address both their health and wider social concerns.

Inequalities in diets contribute to overall inequalities in health ( The Parliamentary Office of Science and Technology, 2022 ). Improvements in diets can improve population-wide health and reduce wider health inequalities. Poor diet in childhood and adolescence tracks into adulthood ( Hovdenak et al. , 2019 ; Appannah et al. , 2021 ) and is associated with lower health-related quality of life ( Wu et al. , 2019 ) and higher risk of chronic diseases, such as cardiovascular disease ( Daniels et al. , 2011 ), diabetes ( Lascar et al. , 2018 ) and some cancers ( World Cancer Research Fund and American Institute for Cancer Research, 2018 ). According to the Global Burden of Disease dashboard, poor diet was the cause of 7.9 million deaths worldwide in 2019, accounting for 14% of all deaths ( Global Burden of Disease Collaborative Network, 2020 ).

One of the main drivers for poor dietary quality is economic inequality and the relatively high cost of eating a healthy diet. According to the Food and Agriculture Organization’s (FAO) report on ‘The State of Food Security and Nutrition in the World’, more than 3.1 billion people across the world could not afford a healthy diet in 2021 ( Food and Agriculture Organization et al. , 2023 ). In the UK, The Food Foundation reported an increase in the proportion of food insecure households with children, from 12.2% in 2022 to 24.4% in 2023 ( The Food Foundation, 2023 ). Additionally, healthy nutritious food was two times more expensive than unhealthy products. Young people (YP) from disadvantaged backgrounds are more likely to experience food insecurity ( O’Connell et al. , 2019 ), which has worsened since the COVID-19 pandemic and the cost-of-living crisis. Studies conducted in England have shown that YP from socioeconomically disadvantaged backgrounds are more likely to have poor diets ( Johnson et al. , 2018 ; Public Health England and Food Standards Agency, 2021 ). The 2020–21 UK National Diet and Nutrition Survey revealed higher consumption of sugar-sweetened beverages and energy-dense food, and lower consumption of fruits and vegetables among the most socioeconomically deprived YP ( Public Health England and Food Standards Agency, 2021 ). Furthermore, the latest statistics from the UK National Child Measurement Programme revealed that children aged 10–11 years living in the most deprived areas were more than twice as likely to be categorized as obese, based on body mass index, compared to those living in the least deprived areas (31.3% vs. 13.5%) ( Office for National Statistics, 2022 ).

Another driver of YP’s diet is the neighbourhood food environment. There is consistent evidence showing a high density of fast-food and takeaway outlets in socioeconomically deprived areas and areas with a high concentration of ethnic minority population ( Fleischhacker et al. , 2011 ; Molaodi et al. , 2012 ; Thornton et al. , 2016 ; Public Health England, 2018 ; Sanchez-Vaznaugh et al. , 2019 ). This means greater availability of, and access to unhealthy food, as these outlets tend to sell relatively cheap, energy-dense and nutrient-poor food ( Jaworowska et al. , 2014 ; Huang et al. , 2022 ; Rinaldi et al. , 2022 ). The inequalities also extend to unhealthy food advertising where YP from ethnic minority and socioeconomically disadvantaged backgrounds are disproportionately targeted where they live, as well as online ( Backholer et al. , 2021 ). In the UK, children living in low-income households are more likely to eat takeaway meals at home, and those who consume takeaways more frequently have poorer diets ( Adams et al. , 2015 ; Taher et al. , 2019 ). The density of takeaway outlets across England increases each year ( MRC Epidemiology Unit, University of Cambridge, 2019 ). A study of takeaway outlets in Norfolk, UK revealed that the density of takeaway outlets grew between 1990 and 2008, and the increase in the number of outlets was higher in the most deprived areas compared to the least deprived, with this widening over time (3.5 times higher in 2008 vs. 2.8 times higher in 1990) ( Maguire et al. , 2015 ). There is emerging evidence of socioeconomic patterning in online access to takeaway outlets too. A recent study by Keeble et al. (2021) found that the percentage of registered food outlets on an online food delivery service in the most deprived areas was approximately two times greater than in the least deprived areas in the UK.

Despite mounting evidence of the structural barriers to eating a healthy diet, such as economic inequalities and the food environment, less is known about how YP view and experience these inequalities where they live, or how to address them. There have been two previous systematic reviews and a scoping review of YP’s views on healthy eating, all focusing on body size (e.g. obesity, body shape and weight) rather than health or health inequalities per se . One review included 11- to 16-year-olds ( Shepherd et al. , 2006 ); another 12- to 18-year-olds ( Rees et al. , 2014 ) and the third 18- to 24-year-olds ( Munt et al. , 2017 ). None of these reviews presented detailed analysis focused on health inequalities, as the reviewers noted that included studies typically reported few details on equity dimensions. The reviews by Shepherd et al. (2006) and Rees et al. (2014) found that YP tended not to frame food as a health issue. Rather they tended to view food in terms of what they liked and disliked.

The case has been made that low agency population interventions, such as free school meals (FSMs), advertising restrictions of foods high in fat, salt and sugar (HFSS) and restrictions of takeaway outlets, are effective and equitable ways to reduce poor diet in the population ( Adams et al. , 2016 ). However, research literature is sparse on YP’s views of such interventions, or their views on alternative (high agency) education interventions or the relative merits of targeted and population-level approaches. In England, the FSM ( Department for Education, 2018 ) and holiday activities and food programmes ( Department for Education, 2022 ) provide healthy food to school-aged children from low-income backgrounds, but there is no provision for older YP (e.g. aged 18–24) from similar backgrounds. Currently, there is a restriction on broadcast advertising for HFSS foods, but only for those aimed at children ( UK Advertising Standards Authority, 2024 ). The existing planning policy only restricts the opening of new takeaway outlets ( Keeble et al. , 2019 ), which has been perceived as less useful in areas that already have a high density of takeaway outlets.

To address the gap in the literature, our study was guided by the following questions:

What is YP’s understanding and experience of diet-related health inequalities?

What are the drivers of diet-related health inequalities where YP live?

What are YP’s views on addressing diet-related health inequalities where they live?

The research in this article drew on data from a wider study exploring YP’s perceptions of what influences their opportunities to be healthy within their local area and their understanding of health inequalities ( Fairbrother et al. , 2022 ). The philosophical underpinning of our approach is critical realism. We view health inequalities as real (they exist independently of human practices and awareness) while acknowledging the role of human practices, perspectives and social context in shaping how we know about health inequalities. In other words, our knowledge of health inequalities is subjective and incomplete. Our approach was critical in orientation ( Braun and Clarke, 2024 ) in that, we sought to unpack and interrogate participants’ accounts to provide causal explanations of health inequalities and make recommendations that are relevant and beneficial to YP. We conducted a qualitative study to understand YP’s perceptions and experiences of health inequalities, with a focus on explaining the causal mechanisms of health inequalities.

Positionality

As a team of public health researchers, our work is rooted in explaining and addressing health inequalities. Based on our knowledge of the literature, we assumed that YP have a more individualistic explanation of the causes of, and solutions to health inequalities. We believe that YP have a right to good health and they should be supported to live to their fullest potential. We made a conscious effort to include disadvantaged and marginalized voices. However, we recognized the power imbalance as we are older, well-educated and ‘relatively advantaged’ (though this term masks some variation in the research team, such as variation in social backgrounds, job security, housing security and other intersecting equity dimensions). Therefore, we took a participatory approach to research in our attempt to balance power dynamics and meaningfully include YP of disadvantaged backgrounds in discussions on health inequalities. Engaging in a process of reflexivity, we acknowledge that our analysis is informed by our prior understandings of health equity, including pre-held assumptions that social determinants, as described by Marmot et al. (2020) , are particularly important for both explaining and tackling health inequalities. We acknowledge that our research findings extend from our subjective experience of the research, influenced by our social and professional backgrounds, and our particular interactions with the YP who participated.

Sampling and recruitment

We recruited YP aged 13–21 years through six youth groups across three geographical areas in England; London, South Yorkshire and North East. Our original sampling frame targeted YP living in areas with contrasting levels of deprivation and geography (e.g. rural and urban). This was hampered by the COVID-19 pandemic, so we recruited YP from youth groups with whom we had established relationships, all of which were located in areas in the most deprived quintile based on the 2019 English indices of multiple deprivation. Furthermore, while we initially aimed to work with YP aged 13–17 years, we took an inclusive approach as some of our youth groups also included YP over 18.

Data collection

We conducted a series of three interlinked focus groups with YP from each of the six youth groups between February 2021 and June 2021, resulting in a total of 18 focus group sessions. The focus groups were planned to be in-person, but we switched to an online format for all but three sessions with one youth group in the North East due to the UK’s lockdown and social distancing restrictions during the COVID-19 pandemic.

Session 1 used a participatory concept mapping activity ( Jessiman et al. , 2021 ) to explore perceptions of what influences YP’s opportunities to be healthy in their local area. Session 2 examined YP’s understanding of health inequalities through prompted discussion of selected health-related news headlines, including FSMs, fast food and advertising of less healthy food. Session 3 focused on YP’s priorities for change to improve health in their area.

Facilitators used a topic guide (see Supplementary Material ) that had been piloted with youth organizations to aid discussions. At least two researchers facilitated each focus group, accompanied by a youth worker for safeguarding purposes and to support YP if required ( Woodrow et al. , 2022 ). Focus groups lasted between 90 and 100 minutes and were audio-recorded with consent. Participants also provided information on ethnicity, age and residential postcode (used to determine area deprivation level). We gave participants £20 vouchers at the end of each focus group as a token of appreciation for their time.

The study has ethics approval from the School of Health and Related Research (SCHARR) Ethics Committee at the University of Sheffield (ref: 037145). All participants provided written consent. For participants under the age of 16 years, opt-in consent was also obtained from parents/guardians.

Data analysis

Prior to analysis, audio recordings were transcribed verbatim and anonymized by approved transcription services. The research in this article drew on data from a wider study exploring YP’s perceptions of what influences their opportunities to be healthy within their local area and their understanding of health inequalities ( Fairbrother et al. , 2022 ). Here, we only include discussions about food as data. We analysed the data using reflective thematic analysis ( Braun and Clarke, 2022 ) as it is theoretically flexible and fits with a critical realist approach. Using this approach, we examined the mechanisms and structures that give rise to diet-related inequalities by focusing on participants’ accounts and situating them within the contexts (realities) that participants live in. This requires continual reflexivity and critical engagement with the data and the analytical process.

V.E. and M.C. read the transcripts and applied a mix of semantic (surface meaning) and latent coding (underlying meaning), aided by a qualitative analysis software, NVivo 12. During the coding process, V.E. and M.C. met regularly to discuss the meaning of the data to ensure reflexivity and expand the interpretation of the data. We analysed the data deductively by using two frameworks as a lens to make sense of the data: Smith and Anderson’s (2018) framework for lay perspectives of socioeconomic health inequalities, and Pearce et al.’s (2019) conceptual model of pathways to inequalities in child health. We combined it with inductive analysis as we were open to the possibility that the data may not fit these frameworks.

Upon reflection, we decided that Giddens’s (1989) structuration theory which posits social practices as an interplay between agency and social structure, was a better fit for the data and used it to inform the conceptualization of themes. We focused on how diet-related inequalities were produced, by contextualizing YP’s eating practices and interactions with their local food environment, and connecting it with the social history and structure of the area where they live. The themes were further developed by V.E. and M.C. alongside discussions with C.S. and H.F. to ensure the themes capture the central meanings and patterns identified from the data and answer the research questions. V.E. wrote a narrative for each theme, with the scope of each theme being iteratively defined and refined with inputs from M.C., C.S., M.E. and H.F.

Our final sample consisted of 42 YP aged 13–21 living in urban and rural areas, and of different genders and ethnicity (see Table 1 ).

Participant characteristics

The YP in this study perceived eating a healthy diet as unattainable due to intersecting inequalities that manifested in their daily food practices and environment. YP’s agency to eat healthily was constrained by structural inequalities, mainly economic inequality and low availability and access to healthy food in deprived areas. We identified three key themes: (i) impact of economic inequality on family food practices, (ii) availability and access to hot food takeaways in areas of high deprivation and (iii) making healthy food more accessible to families.

(i) Perceived impacts of economic inequality on family food practices

This theme captures YP’s understanding of economic inequality. They viewed economic inequality through a ‘place’ lens, whereby some regions or neighbouring local areas in the UK were viewed as more economically disadvantaged than others. A recurring view suggested a mechanism whereby places with economic problems had poorer employment opportunities for YP and their parents. This in turn led to two types of barriers to healthy eating. Firstly, low incomes—YP believed that healthy foods tend to be more expensive than unhealthy food and that low-income families may have to choose between healthy diets and other essentials such as heating and school uniforms. Secondly, YP perceived that for many low-income families, there is less opportunity to prepare healthy meals at home due to a lack of time as a result of working long hours and/or multiple jobs.

Though YP acknowledged the importance of nutrition knowledge and cooking skills for healthy eating, they were acutely aware of how family income (or lack of it) restricted their ability to have an adequate and healthy diet.

I see it sort of like if you have a run down job, you don’t have as much pay to pay for the food. Meanwhile, if you have a high job and you have the high society, you have more pay, therefore you’re able to take on more food. Which brings in the inequality with food discussed tonight. (North East Group 2, Session 2)

There was a common perception among YP that unhealthy food is cheap while healthy food (described mainly as fresh fruits and vegetables) is expensive and thus unattainable on a low income.

things like salads they’re expensive man, like five, six quid then the opposite of that, like portion of chips is like a quid…Even the prices of fruit and veg, I don’t know why they price up a bit too much. (London Group 1, Session 1) I’d say so because like there’s a lot of income inequality where we are especially, so a lot of like poorer households find it hard to buy the more healthy stuff. They tend to be more expensive, especially in supermarkets… (South Yorkshire Group 2, Session 1)

YP also knew of low-income families having to prioritize household bills and expenses over food. A few spoke from experience about their parents having to spend less on food to pay for essentials such as school uniforms. The need to make trade-offs came to the fore while discussing the impact of the COVID-19 pandemic. YP noted that some in their community could hardly afford to pay utility bills and were thus unable to store and/or cook fresh food, resorting to the convenience of fast-food or hot food takeaways.

I think, with fast food, it doesn’t need to be maintained in a sense, so like, let’s say you can’t afford electricity bills, you can’t afford to keep your fridge running, or something. Buying healthy stuff isn’t, it’s not going to last, so just buying fast food, might be cheese and everything, is like OK, I’ve bought it, I can eat it, through it in a day, like it’s finished. (London Group 1, Session 2) …that goes back to the budgeting thing. Some people, especially people who don’t necessarily have a lot of money might want to spend less on food and more on making sure that their child has the right stuff for school. (South Yorkshire Group 1, Session 1)

While YP made direct reference to low income as a barrier to healthy eating, they also demonstrated an in-depth understanding of inequalities in employment conditions faced by those working in low-paid jobs, and how that negatively impacts one’s ability to eat a healthy diet. They pointed out that those in low-paid jobs often lack time to prepare and cook meals as they tend to work long hours or multiple jobs. The North-South (England) divide in economic opportunities was regularly brought up by YPs from the North East. According to one YP, movement restrictions during the COVID-19 pandemic further highlighted the inequalities experienced by those in low-paid jobs (e.g. bus drivers and delivery drivers) as they were less able to work from home.

We did talk a bit about how people in the North, the sort of jobs that we have, it’s less likely that you’ll be able to work from home. So if you are working from home – which predominantly, especially if you’re in the South because a lot of the economies, they’re very knowledge-based – you can afford to do that sort of thing from home…So they have certainly got more time and more time that they can dedicate to something like cooking. (North East Group 1, Session 2)

(ii) Availability and access to hot food takeaways in areas of high deprivation

This theme describes how YP felt physically surrounded by hot food takeaways in their local neighbourhood, and digitally surrounded via food delivery apps. They showed an understanding of how different elements of underserved communities intersect to encourage negative health practices.

YP cited the high density of hot food takeaways in their local area and a lack of food retail shops selling affordable and healthy options as barriers to healthy eating. As a YP related:

I wanted to talk about like fast food joints, like in [Name of location] like there’s a lot of like fried chicken shops, a lot of like and they’ve renamed themselves to grills…like to get like more consumer support. And basically like, what I was saying was like it makes it harder for me. (London Group 2, Session 1).

In terms of family food practices, the constant exposure to hot food takeaway was perceived as offering easy access to food for those whose home situations made it challenging to prepare home-cooked meals. For example, YP described how parents in low-income families worked long hours, leading YP and their families to take the ‘easier option’ of purchasing and consuming readily available hot food takeaways. Even though they were aware that hot food takeaways are unhealthy, they felt that they had to choose convenience over the nutritional quality of their meals.

Because it could be quite a busy job that involves travel where they’d be an air hostess or a conductor for a train. It just might take a lot of time away from their family, so that has to force them to do – in a way – irrational things. Such as constantly sending a fast food order instead of healthy objects. (North East Group 2, Session 2) Like if you come from a lower, like a poor area, maybe – like I knew someone who his mum would give him a quid and he’d go to the shop and just buy something and have it for his tea and he’d be out all night until like 10. His upbringings, obviously it’s not going to be the same as someone who has home-cooked meals every night that are prepared with nutritional value in mind. (South Yorkshire Group 2, Session 3)

YP also talked about how the high availability of cheap and ‘tasty’ hot food takeaways, particularly around the school vicinity, made it convenient for YP to purchase and consume them. It was clear during the discussions that hot food takeaway outlets had become part of the social fabric of local life even though YP were critical of the ubiquitousness of these outlets where they live. They were considered by some YP as the ‘place to go’ after school as there was not much to do for YP in their local area, which also highlighted the lack of services and facilities that cater to youths in areas of high deprivation. Inadvertently, YPs socialized at hot food takeaway outlets and ended up consuming food deemed to be less healthy despite their intentions.

When probed about the high density of hot food takeaways, a YP highlighted the complex interdependency of individual and structural factors that affect one’s ability to eat healthily. Specifically, they explained that demand for cheap and quick meals resulted in the opening of hot food takeaway outlets, which in turn created high visibility and high consumption. This then reinforced the need for more outlets. In contrast, the cycle could be broken or disrupted by the lower demand for ‘cheap’ hot food takeaways in more affluent neighbourhoods.

And then I guess because I think, like, yeah, if you’re in an area where demand is higher you’re going to have more takeaway so then if you’ve got more takeaway then that’s, kind of, what you see most of the time then you’re going to end up going to those takeaways more maybe. And seeing that, like, seeing it as more of an option compared to in a wealthier area where if at first you’re not, like, if there isn’t too much demand for fast food in wealthier areas then the takeaways aren’t really going to go there and then, because, like, and it is then, it is also easier to just go to the supermarket and, like, get stuff. (London Group 2, Session 3)

YP’s narratives also suggested that hot food takeaways have a prominent online presence in their everyday lives. They related their experience of being inundated with advertising of HFSS sold by hot food takeaways in their local area when using food delivery applications, and though healthier options were available, they were more expensive and deemed unaffordable.

…there’s about, I think it’s about 20 on my app just around me, because I live near a load of take aways. (South Yorkshire Group 1, Session 2) …and like delivery companies, some of them actually offer the, the opportunity to like buy healthier options. Some of them do salads and all sort of meals that are meant to be healthier. But it’s like those options are very expensive, compared to the junk food, so called junk food options. So it still leaves you with no choice than to go for the junk food rather than the healthier option. (London Group 1, Session 2)

(iii) Making healthy food more accessible to families

This theme presents YP’s views on public policies or interventions to address inequalities in accessing healthy food. YP had strong views on policies to tackle food inequality and showed a nuanced understanding of the strengths and limitations of universal and targeted approaches. Discussions about interventions, especially those targeted at low-income families were strongly tied to the stigma of poverty. YP in general were not in favour of a targeted FSM approach as they perceived it to be stigmatizing. As recounted by a participant: ‘ There’s an element of shame to it as to whether or not you will accept for yourself that you need that help, feeding your kids and feeding your family’ (North East Group 1, Session 2) .

Although YP from low-income families who were eligible for FSM appreciated the assistance from the government, their accounts of receiving FSM referred to shame and centred on who was ‘poor enough’ to receive government assistance. One YP felt guilty for receiving FSM because their parents held ‘decent’ jobs (i.e. perceived to be well-paid) with full-time employment, and did not consider themselves to be impoverished.

My mum’s a teacher and my dad works at the NHS, but a couple of years ago we were eligible for free school meals because it was something like me mum wasn’t earning enough so we therefore qualified. We felt kind of guilty, like we were robbing it from someone… because there are literally people on it who are choosing between feeding the kids at lunch or clothes for school uniform. (South Yorkshire Group 1, Session 2)

One focus group referred to food voucher schemes, of the kind administered by some schools during the COVID-19 epidemic. Vouchers were seen as a way of giving families a way to decide how best to meet dietary needs and food preferences. This came up while discussing FSM provision during the COVID-19 pandemic, whereby most schools provided food parcels to students. There were strong criticisms of the quality of food parcels as the items were not nutritious and were overpriced. In contrast, another YP who received food vouchers shared how that gave her family the freedom to purchase food according to their needs, and thus they were able to maximize the value of the vouchers:

So for instance, I get them (food vouchers) and we go shopping every month so we just save up all the vouchers and spend it on different places…We get tinned vegetables, like peas and carrots and that, but we don’t really like fresh veg or owt like that because it runs out of date really quickly. There’s no point really getting it. (South Yorkshire Group 1, Session 2)

Most YP demonstrated empathy for those who were perceived to be worst off, for example, those who had to use food banks. Alongside feelings of shame and guilt for receiving FSM, YP shared concerns about the proliferation of food banks in their area and the stigma associated with going to one, particularly the fear of parents being blamed for their inability to provide food for their children. YP’s empathy also extended to local business owners. Although they recognized the adverse impact of hot food takeaways, YP did not want these outlets to be closed or restricted by local authorities—a planning policy that can be introduced by local authorities to limit the number of hot food takeaways, especially within the school vicinity. They expressed concern about the potential loss of income for the businesses and more importantly, loss of employment for workers at the outlets. In terms of supporting customer choice, YP often framed this as wishing to see healthier food options at local outlets as this is where they felt the choice was limited. Incentivizing customers to purchase healthier meals through a loyalty scheme was one of the examples given by YP.

And, I don’t know, I was thinking incentives so, like, in a fast food chain, because you can’t shut them and you don’t really want to disturb their business, but if there was something, like, if you buy a certain number of the healthier meals and you get one of the less healthy meals for free or something, kind of, like a loyalty card…because I don’t think awareness alone necessarily helps because I think people are generally aware but it’s a case of actually, like, putting that into action and I think that can be quite tricky. (London Group 2, Session 3)

This article examines YP’s views on and experiences of inequalities in relation to their access to healthy food and diets. While previous studies have explored YP’s views of healthy eating ( Shepherd et al. , 2006 ; Rees et al. , 2014 ; Munt et al. , 2017 ), there is little evidence on YP’s views of how inequalities in healthy eating occur and how to address them.

The YP we spoke to viewed inequalities in food and health partly in terms of how different people were more or less likely to consume healthy food (with fast food often used by participants as an archetypal ‘unhealthy’ food type). YP discussed inequalities in more explicit food poverty terms: showing awareness that some individuals and families struggle to afford sufficient food. Low income, coupled with the high cost of healthier food products, was singled out as a significant barrier to eating a healthy diet by YP. This is supported by analyses of food costs in the USA, UK and Europe ( Kern et al. , 2017 ; Penne and Goedemé, 2021 ; The Food Foundation, 2023 ), which demonstrated that the cost of healthier food products was higher than less healthy products (two times more in the UK). Furthermore, one in five households in the UK would have to spend almost half of their disposable income to achieve a healthy diet, leaving little for other expenditures ( The Food Foundation, 2023 ). YP also linked low income to inequality in employment opportunities, specifically low access to, and availability of higher paying jobs where they live, and its impact on their diet. This was raised by participants in all three study sites, but more prominently in the North East of England, which has one of the highest rates of unemployment and proportion of benefit claimants ( Office for National Statistics, 2023b ), and the lowest average weekly salary in England ( Office for National Statistics, 2023a ).

We found that YP in our study had a less individualistic understanding of inequality than was suggested in the literature ( Backett-Milburn et al. , 2003 ; Vromen et al. , 2015 ; L’Hôte et al. , 2018 ; Smith and Anderson, 2018 ). While acknowledging the importance of dietary knowledge and cooking skills, our study participants showed an understanding of how structural inequalities impact their ability to acquire and consume a healthy diet. For example, YP were able to articulate the reinforcing connection between availability (supply) and purchase (demand) of hot food takeaways in their local area, which in turn made it easier for them to consume energy-dense and nutrient-poor food. The literature supports YP’s view that disparities in both physical and online food availability reinforce area inequalities. The high density of affordable but less healthy hot food takeaway outlets in deprived areas, both physically and online, has been well-documented ( Fleischhacker et al. , 2011 ; Maguire et al. , 2015 ; Keeble et al. , 2021 ). There is also evidence that it is often the same communities who experience both low income and high exposure to fast-food takeaway in the UK. Burgoine et al. (2018) , for example, demonstrating the double burden of low income and exposure to fast-food takeaway and its impact, found that the lowest income combined with the highest fast-food outlet proportion was associated with greater odds of obesity (odds ratio = 2.43, 95% confidence intervals: 2.09, 2.84). Another study in the UK found that within 4 years of Gateshead Council’s ban on planning permission for fast-food outlets, there was a 13.88% reduction in the proportion of fast-food outlets compared to five other local authorities in the North East of England which did not implement the ban ( Brown et al. , 2022 ). The ban was associated with a decrease in the prevalence of overweight and obesity among children in year 6, living in areas that have a high density of fast-food outlets ( Xiang et al. , 2022 ). This further demonstrates that obesity (as measured by body mass index) is a manifestation of social inequalities in health.

Previous reviews have found that health tends to be deprioritized in YP’s accounts of food, body shape and weight. The previous evidence suggests that YP focus instead on what they like and dislike, particularly on social factors such as social norms and peer expectations relating to body shape, and the social isolation that may result from not living up to those norms ( Shepherd et al. , 2006 ; Rees et al. , 2014 ; Munt et al. , 2017 ). The previous reviews have little to say on health inequalities, perhaps reflecting YP’s apparent lack of interest in health per se . However, some reviewers pointed out that many authors of included studies neglected to provide data on health equity dimensions. In contrast, many of the YP we spoke to were willing to discuss food in relation to health and health inequalities. Possibly, this is because we (the researchers) made our interest in health inequalities known to participants, in contrast to some previously published studies where the researcher's interest in health inequalities may not have been apparent. However, we think it reasonable to hypothesize that health and inequalities may have been more present in YP’s minds at the time of our data collection, given that it occurred during the COVID-19 pandemic. The study also took place in an era where food poverty and food charity (such as food banks) have become more prominent in UK discourse ( The Food Foundation, 2023 ).

Whilst we present YP’s interest in health inequality as a finding from our study, we are careful not to exaggerate the point. The YP we spoke to were also capable of discussing food availability and access in more social terms. For example, participants viewed fast-food chains as places where YP can socialize with friends. This is consistent with findings from a qualitative study of local (adults) perceptions and experiences of chicken shops in a deprived area in East London, which found the shops described as a part of everyday life and valued community spaces ( Thompson et al. , 2018 ). Some participants of our study even felt protective towards local businesses, not wishing to see them shut down. YP’s attitudes towards measures intended to address food poverty were also shaped by more than food considerations. The thought of using welfare or charity was associated by some YP with stigma—and also guilt that seeking help to obtain food could prevent assistance from going to someone with a greater need. These attitudes present insights into what YP regard as social responsibility: supporting local businesses (even unhealthy ones), and assuming that charity and welfare are finite resources best targeted at those in greatest need.

YP’s attitude to universalism was complex. Some appeared to support universal approaches, for example, universal FSMs as a means of reducing stigma. Some wanted further intervention from the government to extend the FSM funding to include after-school and holiday meals. This is in line with the findings of two studies with YP in the UK ( Fairbrother et al. , 2012 ; Knight et al. , 2018 ) which emphasized government and corporate responsibility for ensuring adequate nutrition and a healthy diet is affordable for families. However, other studies on the public’s attitudes towards inequalities have revealed a reticence towards government intervention and a preference for educational (information) and individual behavioural change interventions instead ( Backett-Milburn et al. , 2003 ; Vromen et al. , 2015 ; Smith and Anderson, 2018 ). A comparison study of YP’s view on inequality in the USA, UK and Australia, also found most participants focused on individualized (agency) explanations of, and solutions for inequalities, with little critical engagement of the structural causes of inequalities ( Vromen et al. , 2015 ).

Implications

Our findings show YP have a nuanced appreciation of bounded agency: that is, the way social, cultural and economic factors shape individual choice and practices. However, public health policymakers might view some of the YP’s views with mixed feelings. On the one hand, there is evidence of YP’s understanding of health inequalities, and social determinants, and a clear desire for improvement. On the other hand, this section of the public holds views on social responsibility that do not all fit neatly within the kind of universalist and regulatory approaches to health equity that many UK public health practitioners have long espoused ( Bambra et al. , 2011 ; L’Hôte et al. , 2018 ; Marmot et al. , 2020 ). We found evidence of common ground between YP and public health viewpoints, but further bridging work between the public health community and the public is still required.

We believe that our study can contribute to a re-imagining and updating of the evidence base about YP’s views about food and inequalities. In contrast with previous evidence, this re-imagining recognizes that YP have an awareness and understanding of food as important in relation to health, and of diet-related inequalities—including considerations of both individual behaviour and social determinants. While different findings between studies may reflect methodological differences, there are also plausible reasons for hypothesizing that times have changed, and that YP’s views have changed with them. This hypothesis should be explored further in future research.

Strengths and limitations

We recruited YP living in areas of high deprivation. Using a place lens coupled with participatory concept mapping was an accessible way of eliciting YP’s views on diet-related health inequalities. It made tangible the structural inequalities that manifest in everyday life and impact YP’s ability to eat a healthy diet. It also allowed us to explore YP’s diet in multiple aspects of their life and a range of settings, including school, home and community.

Though our study showed that YP’s agency of purchasing and consuming a healthy diet was constrained by individual and area-level economic inequalities, we were unable to explore how that differs by levels of autonomy and agency. A Lancet series on dietary intake among adolescents (aged 10–24 years) emphasized the need to view adolescents as unique; each with different development trajectories within diverse sociocultural contexts ( Neufeld et al. , 2022 ), rather than being defined by age only. Most of our participants still lived at home and thus conversations about food centred around school meals and hot food takeaways. However, a few participants who had more independence and agency felt that they were being forgotten and not supported by existing policies to obtain and consume a healthy diet. In two of the three study sites, all participants were white British. Although these areas have a high proportion of White population, we may have obtained more diverse views if we had included YP of different ethnicity. There were mentions of value for money as a key factor influencing food purchases in our study. A deeper exploration would enhance our understanding of what value for money means to YP, and its implications.

Individual and area-level economic inequalities constrain YP’s ability to eat a healthy diet. The YP we spoke to appeared to be aware of this. We hypothesize that this awareness may reflect changing contextual factors such as the experience of the COVID-19 pandemic and widely discussed concerns about food poverty. YP are potential sources of support for health equity strategies that include social determinist approaches. However, it would be a mistake to assume this support can be relied on without further efforts to shape and promote policies that resonate with YP and address both their health and wider social concerns.

H.F., C.S. and M.E. conceived the study. V.E., M.C., E.H., N.W. and N.G. collected and analysed the data. V.E. wrote the first draft. All interpreted the data, edited and reviewed drafts and approved the final version of the manuscript.

We would like to thank the young people and the youth organizations who took part in the study. Thanks also to Phillippa Kyle and Nicky Knights for their contribution to data collection and analysis.

This study was funded by the National Institute for Health and Care Research (NIHR) School for Public Health Research (SPHR) (Grant Reference Number PD-SPH-2015). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

We do not have any conflict of interest. The funders had no role in the design of the study; in the collection, analyses or interpretation of data; in the writing of the manuscript or in the decision to publish the results.

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