Listening to the wisdom of people

01 July 2014

What is to be done about Health inequalities – the importance of listening to the wisdom of people with direct experience of inequalities

The phrase ‘Health Inequalities’ refers to the unfair differences in the health experience of different groups in the population. These inequalities are shocking – seven years difference in the length of time people can expect to live between the most and least disadvantaged and 18 years difference in healthy years of life.

One of the most important problems with current action to reduce these health inequalities by national and local government and public health specialists is the neglect of the viewpoints of people bearing the brunt of these inequalities.  Instead of listening to and acting on the wisdom people gain from living their lives in difficult social circumstances, most attempts to reduce these inequalities see people as risks, vulnerable and/or freely choosing health-damaging behaviours such as smoking.

If health inequalities are to be reduced, the expertise of people most severely affected – including those experiencing low income, poor housing, unemployment and other social and economic problems – needs to be used to identify what the most important problems are that they face and to help shape the solutions to be adopted – locally and nationally. For example, people living in low-income neighbourhoods can have very sophisticated ‘theories’ about the cause of health inequalities. The two quotes below, taken from research I conducted with colleagues in the North West of England, illustrate that many people in this low income neighbourhood identify chronic stress arising from living in poor material circumstances as a significant pathway to ill health, and emphasised that the key to managing this stress is strength of character:

“It’s obvious that we would not feel, health-wise, as someone would who has all the comforts and luxuries. They go on holidays three times a year…. we can’t afford one holiday.  Their outlook on life is more relaxed, comfortable. We are struggling day to day with pressures and to keep up with things."

"The first thing you do when you get up is see the graffiti, the vandalism and it doesn’t help. But at the end of the day it’s how the individual deals with it all. If you let it get you down, you are going to have the health problems.”

Despite their focus on indirect pathways to health inequalities (e.g. their stress) and the importance of individual responses to protect their health (e.g. their strength of character), these residents were also very well aware of what one woman called ‘the outside worries, like not having a job and [having] no money’. They understood that these had the major impact on health but that they had no control over these things. Inevitably, people develop ways to cope with these ‘bigger worries’, which ironically may have negative consequences for individuals and communities. These include older people afraid to go out because of anti-social behaviour, but instead experience social isolation and loneliness as a result; or people not mixing with other groups in a neighbourhood because they are perceived to be problematic – whilst protecting themselves this can undermine the potential of social cohesion and collective action for change; young women who see motherhood as one of the new socially-valued identities available to them and the development and/or maintenance of health-damaging behaviours as dramatically illustrated in this young mother’s comment:

“The doctor put me on Prozac for living here because it’s depressing. You look around and all you see is junkies. I started drinking a hell of a lot more since I’ve been here. I drink every night just to get to sleep. I smoke more as well. There’s a lot of things."

The issue is not whether these ‘theories’ are right or wrong – the key point is that they serve an important purpose in the lives of people living in difficult social circumstances.  Most importantly, people’s practical wisdom about health inequalities allows those bearing the brunt of our unequal society to reclaim socially valued identities in a context in which their moral worth is being undermined by the stigmatising individualistic approaches that currently dominates action to address health inequalities.

If we are to truly begin to address health inequalities we need to pay great attention to people’s practical wisdom. We need to reframe the ‘issues’ to make sure that health inequalities are represented in a non-stigmatising way. We need to understand the context in which people make decisions and to see the wisdom in those decisions. And we need to ensure that organisations and professionals don’t contribute to barriers to genuine engagement because it’s complex or doesn’t fit our models. 

Instead of narrow consultation approaches to engaging with communities, we need to support enduring conversations with people living with social inequalities that shorten their lives and give them fewer healthy years of life. We need to ensure that engaging people means that they are in control; that they set the agendas, help to reframe the problem and co-produce solutions. We need to ensure that this is well-resourced and that the power imbalances between ordinary people and professional groups and organisations are acknowledged and challenged.

We need a revolution in how those with power and resources think about and act on approaches to addressing health inequalities.

 

Professor Jennie Popay is Chair of People’s Health Trust and Professor of Sociology and Public Health at Lancaster University.  

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