the wealthy get healthy, the poor get poorly? lay perceptions of health inequalities

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Social Science & Medicine 62 (2006) 2171–2182

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The wealthy get healthy, the poor get poorly? Lay perceptions ofhealth inequalities

Rosemary Davidsona,�, Jenny Kitzingerb, Kate Huntc

aCentre for Analysis of Social Exclusion, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UKbCardiff School of Journalism, Media and Cultural Studies, Cardiff University, King Edward VII Avenue, Cardiff CF10 3NB, UK

cMRC Social and Public Health Sciences Unit, University of Glasgow, 4 Lilybank Gardens, Glasgow G12 8RZ, UK

Available online 21 November 2005

Abstract

Research repeatedly identifies an association between health and socio-economic status—richer people are healthier than

poorer people. Richard Wilkinson has posited that socio-psychological mechanisms may be part of the explanation for the

fact that socio-economic inequalities run right across the social spectrum in wealthy societies. He argues that polarised

income distributions within countries have a negative impact on stress, self-esteem and social relations which, in turn,

impact on physical well-being. How people experience and perceive inequalities is central to his thesis. However, relatively

little empirical work has explored such lay perceptions. We attempt to address this gap by exploring how people see

inequality, how they theorise its impact on health, and the extent to which they make personal and social comparisons, by

drawing on 14 focus group discussions in Scotland and the north of England. Contrary to other research which suggests

that people from more deprived backgrounds are more reluctant to acknowledge the effects of socio-economic deprivation,

our findings demonstrate that, in some contexts at least, people from less favourable circumstances converse in a way to

suggest that inequalities deeply affect their health and well-being. We discuss these findings in the light of the

methodological challenges presented for pursuing such research.

r 2005 Elsevier Ltd. All rights reserved.

Keywords: Health inequalities; Lay perceptions; Focus groups; Socio-economic inequality; UK

Introduction

Health inequalities are a major public health andpolicy issue within the UK (Davidson, Hunt, &Kitzinger, 2003). Attempts to address such inequal-ities have a long history (e.g. Chadwick, 1842), butin recent times the debate has been defined by thepublication of the Black Report in 1980 (White-head, Townsend, & Davidson, 1992) and the

e front matter r 2005 Elsevier Ltd. All rights reserved

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ing author. Tel.: +4420 7955 6722.

ess: [email protected] (R. Davidson).

subsequent flourishing of related research (Macken-back & Kunst, 1994). In 1997 health inequalitiesrose up the policy agenda with the election of aLabour government which commissioned an inde-pendent inquiry into this issue (Acheson report,1998).

One focus of the inequalities debate in the 1990swas on the importance of absolute versus relativeincome. Richard Wilkinson, a key figure in thisdebate, argues that it is the differences withincountries rather than socio-economic resources perse which might affect health and suggests the impact

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of social hierarchies on socio-psychological factorsmight help explain patterns of health inequality.‘What matters’, he writes, ‘would be not whetheryou have a larger or smaller house or car in itself,but what these and similar differences mean sociallyand what they make you feel about yourself and theworld around you’ (Wilkinson, 1996, p. 75).

Wilkinson’s work has generated considerabledebate and was accompanied by a growing interestin the possible role of psycho-social factors in healthinequalities as well as an interest in the role of‘social capital’ (See, for example, Carroll & DaveySmith, 1997; Davey Smith, Bartley, & Blane, 1990).Yet Wilkinson’s research has not been without itscritics. Illsley, for example, took issue with thecomparison of class death rates over time as suchcomparisons involve ‘ya number of implicit con-ceptual and methodological assumptions’. Socialclasses change in size and composition over timemaking it impossible to compare ‘like with like’’(Illsley, 1986, pp. 151–152). Wilkinson rebuffs thesecriticisms by citing research—specifically threeindexes of inequality—that he claims overcomessuch difficulties (Wilkinson, 1986). Other debatescentred on the data used (Judge, 1995; West, 1997).After re-analysing two sources of data used byWilkinson, Judge claimed that the relationshipbetween income inequality and average life expec-tancy had been exaggerated (Judge, 1995). Inresponse, Wilkinson focused on Judge’s use of onlytwo out of five sources of data to substantiate thelink between income distribution and life expec-tancy (Wilkinson, 1995). Wilkinson conceded lat-terly that his view ‘yof what might lie behind therelation with income inequality has changed sub-stantially over the years’, favouring a more multi-causal, multi-layered explanation than he hadventured previously (Wilkinson, 1999).

More recently, Lynch, Davey Smith, Kaplan, andHouse (2000) have questioned the existence ofpsycho-social mechanisms, instead favouring ‘neo-material’ explanations. For them, a focus onperceptions of inequality ignores the materialconditions that structure everyday experience,leading to an unhelpful political agenda ofvictim blaming (Lynch et al., 2000). Rather thanfocusing on any alternate theory, Marmot andWilkinson respond by reinforcing the importance ofpsycho-social explanations (Marmot & Wilkinson,2001).

Despite such reservations about Wilkinson’stheory, his work contributed to the opening of

new debates within the inequalities field and raisednew questions. The issue of how people actuallyexperience and perceive inequalities is one obviousavenue to explore. However, in spite of an extensivebody of work into lay perceptions of various aspectsof health, there has been less work on lay percep-tions of social inequalities and health (Backett-Milburn, Cunningham-Burley, & Davis, 2003;Bolam, Murphy, & Gleeson, 2004).

Work which does touch on these areas wouldinclude studies into differing health discoursesconstructed by working and middle class respon-dents (Pierret, 1993); attempts to link healthbehaviours with psycho-social characteristics(Lynch, Kaplan, & Salonen, 1997) and some ofthe research into the possible role of social capitaland social networks in generating good health(Campbell, Wood, & Kelly, 1999; Sixsmith &Boneham, 2002). Even in this body of work,however, there is little direct attempt to explorehow people see health inequalities and locatethemselves within social hierarchies. One exceptionwould be work by Cattell (1995, 2001), Cattelland Evans (1999), which identifies three factorsinfluencing social networks and social capital:neighbourhood characteristics and perceptions;poverty and social exclusion; and social conscious-ness (Cattell, 2001, p. 1501). Blaxter (1997), Popay,Bennett, et al. (2003) and Popay, Thomas, et al.(2003) provide two further important contributionsto the debate.

Mildred Blaxter used existing quantitative dataand reviewed findings from a number of qualitativestudies of health (though not focused on inequalitiesper se) in order to draw out relevant evidence aboutlay perceptions of health. This suggested that peoplerarely talked in terms of structural determinants ofhealth and illness when asked open-ended questionsabout the causes of ill health. Instead they tended toemphasise the importance of healthy lifestylechoices. In these studies, those who did refer tosocio-economic factors as a possible influence onhealth tended to be in non-manual jobs and havehigher incomes (Blaxter, 1997). Blaxter concludedthat there was ‘a feeling of disbelief or unease [aboutthe association between socio-economic status andhealth inequalities][y] especially among those mostat risk’ and that those ‘most exposed to ‘unequal’health[y] will be least likely to talk readily abouttheir risk status’ (Blaxter, 1997, p. 753, 756).However, such observations need to take intoaccount that this is a sensitive issue for people most

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at risk because ‘To acknowledge ‘inequality’ wouldbe to admit an inferior moral status for oneself orone’s peers’ (Blaxter, 1997, p. 754). Furthermore,the data must be considered in their socio-historicalcontext; for example, some derive from womengiving accounts of their lives in the late 1970s fromthe viewpoint of observing marked improvements insocial conditions (Blaxter & Paterson 1982). Theexperiences of different generations to very differentsocial conditions are likely to be critical to theirviews on health inequalities (Blaxter, 2000).

Research by Popay and colleagues in the 1990spresents some overlapping insights. They exploredlay understandings of social inequalities in healthusing both postal questionnaires and in-depthinterviews. They report that, although people had‘no problem’ offering socio-economic explanationsfor health inequalities in their questionnaires, theywere much more reticent in interviews. The in-depthinterviews revealed that those living in disadvan-taged areas were ‘reluctant to accept the existenceof health inequalities highlighting the moral dilem-mas such questions pose for people living in poormaterial circumstances’ (Popay, Bennett, et al.,2003, p. 1).

Clearly this area of research raises fundamentalmethodological issues because essentially the re-searcher is asking respondents to ‘engage actively inthe constructionyof their own social identity’ in ahighly sensitive area (Blaxter, 1997, p. 755). Never-theless this is precisely what our research attemptedto do. The findings we present here first explore theways in which people discuss their sense of relativedeprivation and their ideas about how it impacts onhealth, and secondly examine if and how peoplecompare themselves with others. To conclude weposition these findings in relation to existing theoryand research and reflect on the implications of ourchosen research method.

Method

The findings presented here originated fromresearch exploring public representations and layperceptions of societal and health inequalities byconducting focus groups, and analysing publichealth policy documents and their subsequent presscoverage (Davidson, 2003; Davidson et al., 2003).Our main concern in this paper is on lay perceptionsand therefore it is this part of the method that willbe outlined here.

Recruitment and group composition

Fourteen focus groups involving 76 researchparticipants were conducted between January 1999and February 2000 in various parts of Scotland andnorthern England. We recruited pre-existing groupsof people within the same social networks (e.g.community centre groups, work colleagues) becausethis study was concerned with observing howindividuals and groups relate to each other, andwe explicitly wanted to access ‘the networks inwhich people might normally discuss (or evade) thesorts of issues likely to be raised in the researchsession’ (Kitzinger & Barbour, 1999, pp. 8–9).

Groups were targeted to encompass as wide arange of socio-economic circumstances across thesample as possible, although individual groupstended to be socially homogenous rather thanheterogeneous. Recruitment of groups was guidedwith the aid of categories of deprivation based onareas of residence available for all Scottish post-codes (and local knowledge for the two groups inGreater Manchester) (McCloone, 1994). Partici-pants were asked to complete a one-page ques-tionnaire in order to collect information on socio-economic status and voting patterns (See Table 1).

In the analysis that follows, groups are describedas ‘affluent’ or ‘deprived’, or ‘high(er)’ or ‘low(er)’socio-economic status, as ascertained from theiraccounts and the information they gave in thequestionnaires. In addition, the table providesinformation about the type of neighbourhood inwhich they were living.

Conduct of the focus group discussions

A schedule for conducting the focus groups wasdeveloped after piloting on four preliminary groups.All groups were facilitated by the first author. Priorto their focus group, respondents were told that theywould be exploring media coverage of health issues,and each session started with a general discussionon this topic. Research participants were thenexplicitly prompted to talk about inequalities inhealth with the introduction of images and head-lines from the reporting of government consultativeand policy documents and the Acheson Report(Department of Health, 1998, 1999; Scottish Office,1998, 1999). Participants were presented with anewspaper picture of a rundown area, anotherjuxtaposing men in suits drinking champagne witha woman walking through an estate, and a close-up

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Table 1

Focus group sample

Group Level of deprivation in area Voted in last election Age range Gender Location

1 MIXED SNP 20–40 6W Greater Glasgow

2 HIGH SNP 25–45 3W 1M Greater Glasgow

3 HIGH LABOUR 50–85 5W 1M Greater Glasgow

4 HIGH LABOUR 65–85 3W 3M Greater Glasgow

5 MIXED LABOUR 25–50 4W 3M Greater Glasgow

6 HIGH SNP 20–60 1W 4M Greater Glasgow

7 LOW LAB/CONS 20–40 4W Aberdeenshire

8 LOW CONSERV. 20–25 4W Lothian Region

9 HIGH LABOUR 20–70 3W 4M Greater Manchester

10 HIGH LABOUR 30–50 6W Greater Glasgow

11 LOW LAB/CONS 30–70 5W 2M Greater Manchester

12 MIXED LAB/SNP/LIB 20–39 4W 2M Greater Glasgow

13 LOW LAB/LIB DEM 40–70 3W 1M Aberdeenshire

14 LOW LABOUR 20–49 2W 2M Greater Glasgow

Total participants ¼ 76 (53W 23M)

R. Davidson et al. / Social Science & Medicine 62 (2006) 2171–21822174

of an infant being held aloft. In each case they wereasked to give their opinions of what the images weredepicting. The groups were then shown newspaperheadlines from the same coverage: ‘Living inGlasgow takes five years off your life’, ‘Gapbetween rich and poor widens again’, and ‘Childrenat risk as health inequality between rich and poorincreases’. Participants were asked to reflect on thetype of story which might have appeared under eachheadline, their own views on this type of story, andwhat they thought was meant by the term ‘healthinequality’.

At all times research participants were encour-aged to exchange opinions with one another ratherthan address themselves to the researcher. Sessionswere thus conducted as genuine ‘focus groups’rather than merely group interviews and interactionbetween people was used both to generate data andas part of the analytical process. The discussionswere recorded, fully transcribed, and coded ontoNUDIST. The analysis focused on both explicit andimplicit references to inequalities, and bothprompted and unprompted responses. As well asnoting the number of references to inequality, theanalysis also involved looking back at the context inwhich comments were made, the tone of theexchange and the specific group dynamics. Quotesrepresenting a spectrum of opinion were flagged askey themes emerged from the data. Less common orunusual viewpoints were also noted, as was anydissent within groups. Confidentiality was protectedby using pseudonyms or respondent identifiers, and

omitting any local place names which could lead tothe identification of participants.

Findings

The following section addresses three questionscentral to Wilkinson’s thesis:

�
Do people accept that health inequalities areassociated with socio-economic status? � How do they explain this association? � Do they consider relative socio-economic status
to be important, and do they compare themselvesto, or feel judged by, others?

Do people accept that health inequalities are

associated with socio-economic status?

Among all the lower socio-economic groups inour research there was widespread acceptance of theidea that sharp inequalities exist within contempor-ary society. For example, a charity officer stated, ‘Itend to think there’s two types of people now: thehaves and the have-nots’ [R4, FG5:6, lower SES]and, in another group, a lone parent said ‘the richget richer, the poor get poorer’ [R1, FG1:39, lowerSES]. Such comments were met by murmurs ofassent and nods from other group members. Similarideas were expressed in two of the six more affluentgroups. However, participants in the other fourgroups of relatively affluent participants did notdiscuss society in these terms.


Research participants from the lower socio-economic groups were also quick to link thesesocio-economic inequalities to differences in healthand often talked vividly about the impact of theirenvironment on their own illnesses and life expec-tancy. By contrast, although some respondents whowere living in better socio-economic circumstancesaccepted such data, others questioned whether poorliving conditions really did reduce life expectancy.Take, for example, the following comments from agroup of Conservative-voting graduates in theirtwenties where all four participants resist thesuggestion that life expectancy was related to class:

R4: Depends on the individual.R2: I don’t think that’s necessarily true ‘causeyR3: [y] Just because you live in a well-off areadoesn’t mean to sayyR1: You can have a hereditary disease, or youcan have alcohol problems. [y]R3: y so I don’t think you can separate it intoclass problems that way. I mean, things likecancer you just don’t know who’s going to carryit [y.] [FG8:30, higher SES]

Thus, in contrast to Blaxter’s findings that thepeople most at risk from health inequalities arethose least likely to talk about this issue (Blaxter,1997, p. 751), we found the opposite to be true. Inour research it was the groups from deprived areaswho most readily volunteered socio-economic ex-planations of ill health and who most readilyaccepted the notion that where you live impacts onhow long you live. The next section takes a closerlook at how such associations were explained.

How do people explain the association between socio-

economic status and health?

The research participants in the lower socio-economic groups had ready explanations for whyhealth is associated with living conditions. A loneparent living in a deprived area of Glasgow appearsto speak for herself, and for other participants,when describing her financial circumstances:

R5: The poor get poorer, or poorly, it’s becausewe don’t have—you’re fighting to get yourbenefits. You get yourself into a state, you getdepressed, stress sets in, because of the circum-stances you’re in. [FG1:48, lower SES]

People often identified mental stress as a mediatorbetween poor socio-economic circumstances and

poor health (see also Popay, Bennett, et al., 2003).They also highlighted the direct health implicationsof poor housing and talked about the ways in whichricher people can buy peace of mind, as is the casewith the following group of Glaswegian womenworking as cleaners where three of the six partici-pants engage in the following discussion:

R4: they’re [wealthier people] no living in damphouses that’s overrun with rats and dampness.R2: And they’re no stressed out ‘cause they’vegot alarms in their houses and everything.R4: And plus if they can afford to live there,they’ve got a better standard of living than whatsomebody has, say maybe in Drumchapel, PossilPark [two more deprived areas of GreaterGlasgow]. [y]R3: And they wouldnae have gangs hangingabout the cornersyR2: So they’re okay in their own houses, stayingtheirself whereas an old person in a tenement,they are getting battered [y]R3: They’ve got the money to buy the best offood, their clothing, best of houses, whilst we areliving in slums. [FG10:28-31, lower SES]

In discussing ‘health issues’, participants from arange of groups spontaneously referred to inequal-ities in healthcare provision and/or resources, aswell as the duality of a public/private system. Theseappeared to be already common topics for discus-sion that mobilised established viewpoints. How-ever, the lower socio-economic groups tended todiscuss concerns about issues such as hospitalwaiting lists (and being unable to receive fastertreatment by going private) and the general cost ofstaying healthy with more passion and anger. Inaddition, richer people, they pointed out, had easieraccess to fresh fruit and vegetables, nice relaxingholidays and had the money and time to use ahealth club. Within the lower socio-economicgroups, research participants often supplementedtheir responses by offering vivid personal accountsdescribing how living in difficult circumstancesimpacted on both mental and thus physical wellbeing in the course of discussion and exchangingexperiences with their peers. They discussed issuessuch as not being able to afford the price of schooldinners for their children—as one mother statedsimply ‘I’m too poor to pay that’ [FG9:4, lowerSES]. They discussed how cramped conditions athome led to arguments or social difficulties such aschildren lacking space to do homework. They


recounted vivid stories about the problems of socialbreakdown. Fear of street violence was prevalentand intense anger was expressed against neighbourswho made life difficult for others through anti-socialor criminal behaviour. All of this was seen to impactdirectly on health. One research participant, forexample, explained how she was no longer going toa local shop to avoid having to pass a gang of youngpeople: ‘[y] the impact on your health is quitetremendous because you feel threatened [y] So youget depressed, you get anxious’ [R5, FG9: 23-24,lower SES]. (For detailed discussion of how peopletalk about the impact of place on health seeDavidson & Hunt, submitted.)

By contrast, in seeking explanations as to whyhealth inequalities exist, higher socio-economicstatus participants tended to explore a narrowerrange of causes. Although some more affluentresearch participants produced explanations whichoverlapped with the type of explanation offeredabove, others blamed health inequalities on life stylechoices rather than social conditions. If theyaccepted that poorer people had poorer health(and, as noted previously, some were reluctant to doso) then the explanations they offered for this weremore often associated with poorer people’s lack ofeducation, criminal behaviour (‘they’re all shootingeach other’), self-abuse (especially illegal drugs) orpoor consumer choices and misguided priorities. Agroup of employees at a firm of accountants, forexample, saw the existence of health inequalities asthe result of a lack of education and failure toattend to health information. One commented that:

R1: [y] you’ll still find that these poor peoplecan afford their cigarettes. [FG7:11, higher SES]

Other members of the group agree and go on toexpand on this:

R3: Diet, cigarettes, alcohol, stress, drugs,prostitution [laughter], they’ve all got to be real.

R4: I think, really, more affluent people through-out the country tend to take more notice of [y]what people tell us we need [to do] to live ahealthy life em, than those that are poorer.[FG7:12, higher SES]

Similarly, within a group of neighbours in anaffluent part of Greater Manchester, one participantquestions the consumption patterns of lower socio-economic groups:

R3: They want this wonderful life that’s put tothem on the television. [y] Instead of havingenough money to pay your bills and a roof overyour head, warm food in your stomach and acomfy bed. That is the lowest priority on theirlist. They want designer this, designer that, and afast car and if they haven’t got that then they feelthey’ve underachieved in life, and they therefore,they feel depressed. [FG11:25, 56, higher SES]

Others in the group interject with comments suchas ‘[They want] all the gadgets’ [R4], ‘They’ve gottheir priorities totally wrong’ [R1].

The implications of such consumer choices werediscussed in some of the lower socio-economicgroups too. But, in these groups, such choices weremore likely to be placed in context by linkingbehaviour to the social conditions in which peoplelived. For example, a group of unemployedparticipants discussed their ‘need’ to smoke, despiteknowing the health consequences, as a response to astressful environment:

R5: [y] Well, me as well Jake [R3], I’m wellaware that this is knocking seconds off me lifeevery time I take a puff [indicating her cigarette],it’s doing my head in.

R6: But it calms you down, it keeps you, don’t it.It does. [FG9:42, lower SES]

Contrasting perspectives on the consumption ofdesigner goods were displayed in groups of varyingsocio-economic status. Thus while the more affluentindividuals cited above tended to attribute people’s‘inappropriate spending’ to ignorance, susceptibilityto media influence, bad judgment and moral failing,different accounts were offered by other researchparticipants, particularly in the groups of peoplefrom lower socio-economic backgrounds. Poorerresearch participants talked, for example, abouthow the ‘dream’ of a better life was a necessaryfantasy for people living in deprived conditions—hence the popularity of buying lottery tickets: ‘thequick fix [y] into nae worriesyeverybody’s look-ing to escape from that’ [FG6:33-34, lower SES]. Ina group consisting of four unemployed members ofa community centre, the discussion turns to howjoblessness might make people turn to drugs:

R3: They’re [people from poorer areas] drinkingand taking drugs and that’s [y] taking more offtheir life than what it is for the rich ones, isn’t it,‘cause they’re at work.[y] Whereas the poor


have no got any work so, all they do is take drinkand drugs isn’t it?

R1: That’s right.

R2: To pass the time possibly.

R1: Aye, to forget all their worries, just take thedrugs and take the drink. [FG2:22-23, lower SES]

Similarly, some of the less affluent groupsacknowledged the ‘problem’ of poor people spend-ing on designer goods, but they offered complexaccounts of this. In the following extract, forexample, two people from a community group in adeprived area discuss how someone with no moneymight feel to see more affluent people enjoyingexpensive products. They reflect on how this mightimpact on the person’s confidence and self-esteem,as well as how they would be judged by others.

R3: [They’ll think]y ‘Why have I no got that?’And that’ll put them down as well, they’ll think ‘Imust be an inferior type person’ [y]

R1: Yeah, their self confidence.

R3: [y] ‘Why am I like that, is it because of me?’[y] a lot of people look down on that person andall that sort of thing, ‘look at the state of her,why’s she like that, it’s her fault’. [FG6:32-34,lower SES]

In this context some research participants fromthe lower socio-economic groups saw the purchaseof designer goods as a reasonable, if double edged,way of trying to create, or project, a sense of self-worth within an unequal society which made poorerpeople feel worthless. Some talked about feelinglured into trying to buy over-priced products thatmade them, or their children, feel better in the shortterm, even when this was at the expense of buyinggood quality food. Being unable to buy particulargoods, and hence being unable to buy into thevalues associated with them, prompted feelings offailure and inferiority.

Before continuing, however, it is important todisrupt the simple generalised contrast between thetalk in the more and less affluent groups by drawingattention to the variable of age. Some of theresearch participants of pensionable age, regardless

of their socio-economic status, were sceptical of theidea that the sort of socio-economic inequalities thatexisted today might impact on health. In their viewliving standards had improved immeasurably dur-ing their lifetime and everyone was better off. ‘Real’poverty no longer existed. They were also at a loss

to explain the spending choices and higher expecta-tions taken for granted by ‘the younger generation’:

R3: Look at the price they pay for training shoesnow, I mean, we never had that, we were lucky ifwe had a pair of sand shoes on our feet. [FG3:29-30, lower SES]R6: And how about holidays, they’re off onforeign holidays. [y] Years ago we were lucky ifwe got to Dunoon [a local seaside town].[FG4:61, lower SES]

Some of these older research participants there-fore found the statistics about health inequalitieshard to believe or, at the very least, felt the statisticsshould be understood in context of an extended lifeexpectancy for everyone.

Do people think relative socio-economic status is

important? Do they compare themselves to, or feel

judged by, others?

A language of division permeated all groups inthe study with research participants talking in ‘us’and ‘them’ terms about different ‘classes’ of people.People routinely compared themselves to othergroups or ‘types’ of people in constructing theiridentities. There was also a widespread conscious-ness across all the groups about how they wereplaced in social hierarchies and how they might beseen by others.

For participants of higher socio-economic status,however, this was not usually a very emotivesubject. They might joke about being seen as snobs,but comparing themselves to others was not apainful process. So for a group of female graduates,for example, it seemed unproblematic to openlydiscuss signifiers of social status, revealing theirexpectations of the actions of people at differentlevels of the social strata:

R3: I think it’d be worse for somebody from[affluent area] going in to buy ‘Value’ bread—you’d look more down on that than you wouldsomebody from [deprived area] who was buyingit, [y]. You’d think, why are they really buyingthat when they can afford Kingsmill Gold orwhatever.R4: They’ve been sacked [laughter] [FG8:25-26,higher SES]

Some had personally witnessed the effects ofpoverty and inequality (e.g. through their work) anddisplayed awareness, or even a little guilt, about


their relative privilege. Other members of the moreaffluent groups, however, were either unaware ofthe conditions under which poorer people lived, orexpressed a strong sense of distance from ‘suchpeople’. In the extract below, for example, aparticipant from a higher income group does tryto speculate on the feelings of others ‘less fortunate’than herself. However, she confesses that she isunable to identify with them or understand what shedescribes as their apathy, inability to help them-selves or ‘lack of pride’. The subsequent commentfrom another member of the group, about herdifficulty in obtaining someone to clean herwindows, underlies this distanced viewpoint:

R5: People don’t have a sense of pride, or theythink nobody cares about them [y] I can’t makea kind of connection with them mentally becauseI don’t know where they’re coming from and Idon’t know why they’re there. Um, and there area lot of people like that in fact. [y] I tend tothink ‘well why are they there, you know, whathappens to actually get like that?’

R4: Yes, yes. I wonder why, you know, sinceChristmas we’ve been unable to get a windowcleaner in this area [y]

[FG11:6, higher SES]

Beyond the problem of finding a window cleaner,few higher socio-economic status groups spoke withany passion on the subject of class divisions andhow these might impact on people. However, forthose from lower socio-economic groups, the issueof their position in the hierarchy generated verystrong feelings indeed. They could readily identifywith people who don’t have ‘a sense of pride’because they sometimes struggled to maintain theirown and they were acutely aware of how they werejudged by others. Several research participantsfeared ‘postcode prejudice’—whereby, for example,putting your local postcode on a job applicationmight prevent you from getting a job interview. Afew defiantly claimed that the ‘rough’ image of theirlocal area did not bother them, and some said it wasimportant simply to ignore such stigma. As anunemployed man commented: ‘you just don’t be toosensitive [y] I think you just live with it’ [R5,FG6:14, lower SES]. Many, however, expressed adirect sense of shame or embarrassment (Davidson& Hunt, submitted).

Thus, socio-economic deprivation brought notonly material disadvantage but was seen to impact

on people’s sense of themselves and their aspira-tions. As two unemployed men comment:

R5: You go to up here [local area] and you’rehammered and looked down on and you’re just apest. And it’s like so you grow up with that kindof attitude, knowing your place, and if you don’t,then you’re a trouble-maker or you’re ay[y]

R3: Or you’re marked, as soon as you’re bornyou’re marked. That’s your station in life, don’tmove out of it. [FG6:43, lower SES]

Research participants from lower socio-economicgroups also talked eloquently about feeling thattheir communities were unheard and ignored.Although some were reserving judgment on the(then new) Labour administration, others were notoptimistic and described feeling victimised by anobstructive or uncaring government at both na-tional and local level. The theme of ‘knowing yourplace’ ran through many of these discussions. Asone woman commented: ‘when you try to betteryourself they slap you back into place’ [FG1:49,lower SES]. Some research participants also ex-pressed a strong sense of alienation. One mandescribed his belief that whole sections of societywere now seen as disposable ‘fling away people’ [R4,FG5:27, lower SES], and another research partici-pant declared:

R5: [T]he government’s made us feel, as if we’re acarpet for [them] to wipe their feet on, and to bebrushed aside [y]. I’m talking about mepersonally, I feel rejected by the government,like I’ve been told, we don’t need you, I mean,who cares about yous up there, right, we’ll justdeal with people that’s in our category, with thesuits.

[FG1:49, lower SES]

Discussion and methodological reflection

This study has attempted to make a specificcontribution to the debate about the potential roleof psycho-social factors in health inequalitiesthrough exploring how people see inequality, howthey theorise its impact on health, and the extent towhich they compare themselves to others and feelthis impacts on them. Our research suggests thatmany of Wilkinson’s ideas about lay perceptionsmay have some foundation. In particular it demon-strates that, in some contexts, those ‘at the bottomof the heap’ converse in a way that suggests


inequalities deeply affect their health and well-being. Accounts of community breakdown wereplentiful and people powerfully expressed theirfeelings of being ‘marked’, of feeling shame, anger,frustration, rejection, injustice and alienation. Theseemotional states were perceived to lead to sleepless-ness, fear, anxiety, and stress. The notion that livingin a ‘divided society’ would take ‘time off your life’was met with little surprise. Whilst Cattell’s (2001)study also finds perceptions of inequality adverselyaffecting health, she observes that residents ‘activein local initiatives and groups were motivated bytheir perceptions of inequality (Cattell, 2001, pp.1511–1512). However our study yielded very few ifany accounts of this nature.

Polarised income distribution was also recognisedby research participants from lower socio-economicgroups as impacting on their self-esteem. It affectedtheir psychological well being (the inability to ‘keepup’ with others fed into feelings of failure,inferiority and depression) and also impacted onsome of their decisions about how to use scarcefinancial resources. Those on low incomes talked ofhow pressures to compete materially can affecthealth, for example by diverting resources fromgood food to designer goods for children. Thisaccords with Wilkinson’s assertion that economicinequalities might impact on people, not so much(or only) because of what they had, or lacked, butbecause of the social symbolism of ownership.These research participants’ accounts also expandon Wilkinson’s assertion by explaining some of thepractical consequences of responding to the sym-bolic economy around designer goods. In light ofthe alternative ‘neo-materialist’ explanations putforward by Lynch et al. (2000), our focus groupdata illustrate people’s accounts of their experienceof poverty as well as relative deprivation. However,the lay perceptions gathered in this study do conveymore than the experience of living in impoverishedcircumstances, exploring the impact of status,hierarchies, and personal comparisons.

The focus group discussion with more affluentgroups proved less supportive of Wilkinson’s thesis.These research participants were less likely tosuggest that their (or other people’s) health wasaffected by socio-economic status and they gave lesscredence to the idea that social comparisons wereimportant to them. The more affluent groups spokelittle of the negative (or positive) effects of living inan unequal society. This suggests that those furtherup the social scale are less ‘affected’, in so far as

such effects may relate to people’s consciousexperience of, or willingness to talk about, suchinequalities. Therefore Wilkinson’s assertions thatpeople across the entire social spectrum are affectedby a skewed income distribution remains unsup-ported, at least by the voices of those more towardsthe ‘middle’ of that spectrum.

In order to contextualise the findings outlinedabove it is important to consider how they relate toother research and to reflect on the methodologicalimplications of different ways of accessing people’sviews, experiences and voices. In particular it isinteresting to note that our findings in some waysseem to challenge results from other studies. Manyresearch findings and reviews suggest that ‘structur-al risk factors’ may not hold great meaning at theindividual level (Bolam et al., 2004, p. 1363) andthat few people think in economic or environmentalterms about the aetiology of ill health—and thosewho do so tend to be the more affluent respondents(Blaxter, 1990; Macintyre, McKay, & Ellaway,2005). In contrast, our study shows that a sizeableproportion of our research participants were notsurprised in the slightest at the existence of largesocio-economic differences in mortality rates andthat this was especially true of the researchparticipants living in more deprived circumstances.

Such variations in findings are most probablyattributable to methodological differences. Widevariation in the type of response collected bydifferent methods of data collection in this areahas been noted by others (see Blaxter, 2000; Popay,Thomas, et al., 2003) and it seems likely that severalaspects of our focus group research design impactedon the type of talk generated. Our recruitmentmethod may be the first important site of difference.Our emphasis on recruiting groups rather thanindividuals privileged people who were sociallynetworked within their communities and wereperhaps, therefore, more likely to have a sense ofcollectivity and have developed shared accounts.

Secondly, facilitator/research participant interac-tion is very different in a focus group than in a one-to-one interview or a questionnaire. Individualstalking with an interviewer (perhaps perceived to befrom a more privileged background) might feelinhibited in talking about their experience ofrelative deprivation. By contrast, group discussionwith one’s peers might have the opposite effect,diluting the significance of the interviewer’s persona,promoting the discussion of ‘lay expertise’ ratherthan the ‘right’ answers and encouraging people to


share stories about how their socio-economiccontext impacts on their health.

The location of our focus groups may also havebeen a significant factor. The fact that the sessionswere conducted on ‘home territory’ (e.g. in com-munity centres) may have increased the potential fordiscussion about local concerns, particularly forthose in deprived areas. It may well be that althoughpeople do not often think in abstract structuralterms about class and health inequalities—they do

experience and express such ideas through thenotion of their own locality and place.

Finally there are elements in group discussionwhich may provide different responses to thosegenerated by individuals in isolation. It has beenwell documented that the nature of the groupprocess itself facilitates the expression of collectiveaccounts and that it is a method which ‘can helpindividuals to develop a perspective which trans-cends their individual context and thus may trans-form ‘personal troubles’ into ‘public issues’’(Kitzinger & Barbour, 1999, p. 19; Mills, 1959,p. 9). Certainly the trajectory of the group discus-sions in this study suggested a progression towardfurther acknowledgement of inequalities impactingon health as the discussion evolved, and from moreindividualistic explanations to increasingly focus onshared experiences of socio-economic deprivationand how this impacted on health.

In some ways our focus group research might beseen as less ‘representative’ of the ‘true’ pattern ofopinion than that accessed by other methods. Inother ways, however, it might be that our researchapproach offers one way of overcoming the problemthat Blaxter highlights, namely that those most atrisk from health inequalities may be least likely toacknowledge them because ‘[t]o acknowledge ‘in-equality’ would be to admit an inferior moral statusfor oneself or one’s peers’ (Blaxter, 1997, p. 754).

The potential stigma of talking about inequalitieswas certainly evident in the groups. Researchparticipants engaged in careful linguistic ‘work’ inorder to manage the implications of the discussionfor their own identities. However, in the context ofthe focus group discussions, people were still able toaddress the issue of inequality explicitly and locatethemselves within the hierarchies and own theconsequences for their own lives. People weresometimes prepared to compare incomes and talkabout what they could, or could not, afford (‘I’mtoo poor to pay that [school dinners]’). Theyacknowledged the impact of inequalities on their

own life expectancy (‘Aye, we’ve lost five years offour life, well, I have’) and eloquently expressfeelings of rejection (‘I’m talking about me person-ally, I feel rejected by the government’). In additionto owning the issues personally, they also oftentalked collectively about ‘us’ and ‘we’ (e.g. ‘we areliving in slums’). The research design used in thisstudy thus seemed to allow some groups to vividlygive voice to their views on inequalities and thisgave us access to a key area of their experiencewhich might be more muted in other contexts.

Conclusion

From the mid eighties Richard Wilkinson hasformulated a theory based on the health effects ofsubjective experience of inequality, yet there havebeen only a few studies conducted on lay perceptionsof inequalities in health. The various criticisms ofWilkinson’s thesis deserve careful consideration (e.g.Judge, 1995; West, 1997). However, the accountswhich we present here lend some support to thepsycho-social theory he has put forward. This is not

of course to suggest that material disparities are notresponsible for inequalities in health. Rather itsuggests that people at the bottom of the socialhierarchy have to bear the direct consequences oftheir poverty alongside living in a society which alsomakes them acutely aware of the goods andprivileges they lack. The present study is limited insize and in who it accessed. Future research could,we would suggest, pursue the question of agedifferences, seek to access views from people atmore extreme ends of the scale of affluence anddeprivation, and attend to rural and urban diversityand the experiences of ethnic minorities. Only byobtaining personal accounts from right across thesocial spectrum on a large scale, using multipleresearch methods, will a more comprehensive pictureemerge. However, we think the study presented hereprovides some compelling evidence of lay awarenessof social hierarchies and the impact of socio-economic factors on health. In the light of ourfindings, the conclusions drawn from other studies,which have suggested that those from poorercircumstances are least likely to discuss the impactof structural factors on health, may be premature.

Acknowledgements

We would like to thank the study respondents,We are also grateful to two anonymous referees,


Mildred Blaxter and Sally Macintyre for commentson previous drafts. The research was funded by theMedical Research Council in the form of a Ph.D.studentship. The views expressed are those of theauthors and not necessarily those of the MRC.

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the wealthy get healthy, the poor get poorly? lay perceptions of health inequalities

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