Two high profile reports on health inequalities in Scotland were launched last month. The first, Leave No One Behind(a Health Foundation report), aimed to provide a multi-dimensional, up-to-date analysis of health inequalities in Scotland. The second, Closing the Gap (from Our Scottish Future, a campaigning organisation set up by Gordon Brown), focused on setting out the consequences of Scotland’s health inequalities for the NHS and put forward a series of recommendations to reduce these inequalities. These reports came hot on the heels of the 2022 Scottish Parliament Health and Sport Committee Inquiry, which culminated in its own report. In short, policy interest in Scotland’s entrenched and internationally-renowned health inequalities shows no sign of abating.
Within these reports, evidence of health inequalities is often grounded in quantitative depictions – such as the startling headline that infant mortality is increasing for the most deprived quintile of Scotland’s population. This may reflect enduring media interest in the ‘killer graph’ or ‘killer number’ as a call to action. Yet, such coverage of quantitative depictions can also depersonalise issues that are, at base, intensely and painfully human. All too often, what is left largely untapped in debates based on such reports is a wealth of qualitative research exploring inequalities and the social determinants of health (e.g. poverty, housing and public services) from the perspective of Scotland’s communities. These studies, we suggest, offer foundations for developing more rounded and comprehensive accounts of health inequalities.
For example, a preoccupation with health gaps between population quintiles means both new reports inadvertently focus our attention on poverty and deprivation (rather than societal inequalities). This approach of clustering people into groups also potentially obscures the range of experiences within each quintile. So, while it is important to note that the most disadvantaged quintile seems to be ‘falling behind’ the rest of Scotland’s population, such analysis provides little sense of why this might be – what is happening within these communities, the variety of experiences within this group or the depth and persistence of poverty for some. We believe future assessments of health inequalities have much to gain from better utilising qualitative research that captures the lived realities and complex injustices behind statistical analysis.
What’s in these new reports on health inequalities in Scotland?
Both Closing the Gap and Leave No One Behind present a multi-dimensional overview of health inequalities in Scotland, using a series of bar charts and line graphs to demonstrate that multiple measures suggest Scotland’s population health is getting worse and that health inequalities are core to understanding why this is. Scotland has long held a reputation for being ‘the sick man of Europe but the unequal patterning of poor health and early death remains shocking and deeply unjust. As such, any work to help create political and public pressure for action to reduce health inequalities, and to tackle the underlying social and economic inequalities, is welcome. Yet, there have been many reports on health inequalities in Scotland before, most of which have a similar look and feel – they are heavily populated by visualisations of quantified data, interspersed with explanatory text that is statistics heavy. Most – and these recent two reports are no exception – then draw on expert reflections to propose ways forward. Frustratingly – again, the latest two reports are no exception – these proposals often seem dwarfed by the sheer magnitude of the challenge.
For the most part (and Closing the Gap’s somewhat patronising emphasis on health literacy is one exception) these proposals are hard to disagree with. Yet, we contend, they are also far from enough. Indeed, the Scottish Parliament’s Health and Sport Committee Inquiry report was more specific and more ambitious about the kinds of policy changes required to tackle Scotland’s health inequalities, calling for action from both Scottish and UK Governments.
An optimistic view might be that these new reports maintain the pressure on the Scottish Government and others to take action. A pessimistic view, however, is that they risk shifting the focus away from the more specific proposals within the Committee’s Inquiry on to other issues (health literacy and health services, in the case of Closing the Gap; policy processes in the case of Leave No One Behind).
The people behind the statistics – qualitative and participatory data
Behind all of the graphs, statistics and policy suggestions lie the people who live in Scotland. This is where stories unfold about what Scotland is and what we believe our future looks like (or could look like). Yet, even though the Health Foundation commissioned research using deliberative methods to explore public views, mixed methods research examining the views of stakeholders, plus a review of lay accounts in qualitative research (which we produced and aim to publish soon), the stories and experiences behind the statistics barely feature in the final report. Here, we draw on our review to outline five key ways in which insights from qualitative research might help move analysis of Scotland’s health inequalities beyond reportage.
- Understanding variable experiences via intersectional and historical lenses: The University of Glasgow-led Health Foundation report on health inequalities in Scotland places a useful spotlight on intersectionality, stressing that the experiences within population quintiles are not homogenous and that, for example, different ethnic groups experience contrasting social gradients of health for some outcomes. Yet, while quantitative research can disaggregate some of this variability, it cannot adequately capture the multiple ways in which individuals experience these intersecting inequalities, or the extent to which context shapes these experiences, in the way qualitativeaccounts can. For example, a qualitative study of people living in the Leith Walk area of Edinburgh found that multiple disadvantages interacted to shape people’s knowledge of local health-enabling resources and their capacity to benefit from these resources. Likewise, while quantitative data can depict trends over time, qualitative data offers deeper insights into the long shadow that historical experiences cast over places and people, and to examples of community of resilience.
- Understanding how policies are experienced: Leave No One Behind places a strong emphasis on a perceived ‘implementation gap’ in Scotland, drawing on the underpinning NESTA report which explored the views of a range of stakeholders. What this doesn’t tell is how the people targeted by many of these policy changes view the situation – do they agree that the main issue is an ‘implementation gap’? While it would take a specifically conceived research project to directly address this question, existing qualitative research in Scotland already provides many in-depth accounts of how policies are experienced. Here, we see that people’s accounts frequently suggest that Scotland’s social ‘safety nets’ are bewildering and that the increasing conditionality of welfare support can be experienced as highly stressful, punitive and degrading. From research exploring public experiences of policy decisions to defund large industrial employers (in the 1980s), to increasing welfare conditionality (1997-2010) to more recent austerity policies (2010+), the emphasis in these accounts is not on implementation gaps but on policies that are understood to be deliberately designed to reduce support in the communities that need it most.
- Capturing what can’t (easily) be measured: One unintentional function of a preoccupation with quantified data is that factors and experiences that are not already being measured are almost always obscured. In contrast, qualitative research can help identify factors that appear to be shaping health experiences in important ways, which are not well captured by quantitative data. This includes experiences of stigma and discrimination, which several studies suggested help explain why some groups are less likely to pro-actively engage with health services (e.g. here) or undertake exercise (e.g. here), underlining our sense that Closing the Gap’s focus on health literacy is misplaced. Other studies highlight the significant difference that front-line providers can play in shaping how policies are experienced, meaning the same policies can have very different consequences for people’s sense of being (un)cared for (see, for example, this research highlighting the impacts that responsive housing providers can make).
- Identifying fresh insights: As research fields mature, common conceptual frameworks and ideas take root, framing the way phenomena are understood and, frequently, what is measured and analysed. For health inequalities, several widely used frameworks depict the social determinants of health, nearly all of which emphasise the role of employment, education, income, housing and access to services in health inequalities. The quantified data that populate the pages of Leave No One Behind and Closing the Gap reflect these common understandings and are mirrored in many lay accounts. However, qualitative research also probes beyond the established. For example, multiple studies of communities in Scotland emphasise the role that violence and crime play in shaping lives (see, for example, here, here & here). Yet, these experiences are not well captured by statistics and do not (yet) regularly form part of quantified analysis of the social determinants of health inequalities. Qualitative research, here, can point to new explanatory avenues to explore.
- Capturing shared stories and creating collective dialogue: A final qualitative contribution to highlight is the potential of more participatory, deliberative and dialogue-based methods, to build shared stories and craft future visions. Indeed, the Health Foundation’s report emphasizes the central role of public engagement and action in moving forward. Qualitative research in Scotland has long functioned to capture popular narratives of health and ill-health (e.g. Blaxter, 1983). More recently, there has been a turn towards more deliberative and creative methods, in which participants are engaged in conversations about health inequalities and about potential policy responses (e.g. a citizens’ jury study in which mini-publics deliberated over potential policy responses to health inequalities) or in which they work collaboratively with researchers to co-produce research insights (e.g. a study with young-peer researchersexploring the ways in which places shape their health). Some of the most impressive examples of such innovation take place within ‘grey literature’, led by charities and campaigning organisations with strong roots in the communities whose life chances they seek to improve. These methods have the potential not only to provide new insights into public understandings of health inequalities, and of potential responses, but also to affirm people’s right to be seen as experts of their own lives. Especially in the context of claims that a sense of ‘political attack’ helps explain Scotland’s excess mortality, offering affected communities control over collective narratives seems not only worthwhile, but imperative.
This blog is certainly no clarion call to reignite social science’s paradigm wars. But as Scotland faces yet another ‘and now what’ conversation about health inequalities, driven forward, but somehow not collectively energised, by slide decks of distressing graphs, our sense is that more narrative and participatory approaches have to be worth a try. The potential prize is a richer and rounder picture of health inequalities, in which more of the population might feel seen, and hopefully heard.
Acknowledgements: The University of Strathclyde School of Social Work received £7,951 from The Health Foundation for the authors (KS & ES) to undertake a review of qualitative literature on health inequalities and the social determinants in Scotland, plus a further £5,040 for KS to support the deliberative research led by The Diffley Partnership (February-October 2022). They hope to publish the full literature review shortly.
Kat Smith is a Professor of Public Health Policy at the University of Strathclyde. Her research interests include understanding who and what shape the policies impacting on people’s health (especially in the UK), improving the use of evidence in policy (with a view to achieving better health outcomes), and analysing efforts to improve public health and reduce health inequalities. Kat is currently leading a policy-focused workstream in the SIPHER Consortium which is using complex systems modelling to try to achieve a preventative shift towards healthy public policy. Her most recent book, co-authored with Clare Bambra and Julia Lynch, was The Unequal Pandemic: COVID-19 and Health Inequalities (open access).
Ellen Stewart is a Senior Lecturer in Health Policy at the University of Strathclyde. Her current research includes a Wellcome Trust Collaborative Award on the role of charity in the NHS, and leading public engagement for the SIPHER Consortium. In July 2023 her latest book How Britain Loves the NHS: practices of care and contestation will be published by Policy Press.