I’ve set out in previous posts how I've become interested in the role of language, stories, and metaphor, in shaping how we think about complex problems. I'm delighted to share that I've been awarded further funding to continue down this route and take a closer look at the stories told around health* and wider social inequalities.
The research is funded by a Wellcome Trust Research Fellowship in Humanities and Social Science and will run until May 2025. This blog post briefly summarises the initial plan for the research. However, there is still plenty that needs figuring out!
Why look at stories?
Stories are everywhere and we depend on them completely to make sense of the world, and our experiences in it; and also, to articulate these to other people. But, like taking a photograph, it's simply not possible to fit everything in. And so all stories inevitably represent a particular angle on a subject, where decisions have been made about what to include, what to draw attention to, and indeed, what can be left out.
When it comes to describing or framing complex problems (such as social inequalities in health), people use stories to achieve a number of things [1, 2]. Firstly, they advance ideas about what they believe to be the causes of the problem. In doing so, they also point the finger, identifying who is responsible for these causes and ultimately who is to blame. Stories can be more or less explicit about potential solutions, but they almost always provide justifications for taking action that tend to be motivated by ethical and/or financial reasons (e.g. "it's the right thing to do", "we can't afford not to act").
What's interesting is that there are usually multiple competing versions of stories that different people use (e.g. politicians, activists, civil servants, industry, researchers, patients and community groups etc.) to try and influence how we think about problems. At the risk of over-simplifying the situation, it is useful to think about stories in terms of those that seem to be the most readily accepted and influential accounts (i.e. 'dominant' stories), and those that have been designed to challenge popular thinking and promote a different perspective on the problem (i.e. 'counter' stories).
The 'upstream-downstream' story, that I've described in an earlier post, is a classic example. The story is used to redirect attention away from the default focus on 'downstream' behavioural symptoms of health inequalities, to instead tackle the 'upstream' social, economic, and political causes. These 'counter' stories however, often struggle to gain traction in policy and practice settings, and even when they do, can fail to bring about the scale of change needed.
Sticking points with current stories
With the obvious caveat that there has been amazing work done in raising awareness of social inequalities in health, and progressing our understanding of the issue, there is still a way to go in achieving health equity ambitions. Many of the barriers relate to ideological, economic, and political factors. However, it also has been suggested that aspects of the stories themselves may be hampering progress.
Julia Lynch, for example, describes how a focus on health inequalities actually serves to ‘medicalise’ the problem by situating responsibility for action with the health system. This diverts attention away from underlying social and economic inequality, ultimately making the issue more difficult to address [3].
Research has also shown how key ideas that make up public health ‘counter’ stories, such as working ‘upstream’ [4] or tackling the ‘social determinants of health’ [e.g. 5], can be easily interpreted by health system actors in quite narrow ways. Rather than inspiring an ambitious rethink about what is really needed to reduce social inequalities in health, the stories are easily applied to what people are already doing in terms of improving health related behaviour and increasing access to healthcare services. Some people have suggested that this situation shouldn’t come as a surprise, as these are depoliticised stories that tend to promote a focus on individual access to the different determinants of health, rather than challenging the social and political processes that shape their unequal distribution [7-9].
Lastly, our stories have been heavily critiqued for the unhelpful way in which they tend to deny any scope for individual action and resistance to harmful social forces. The result is that our accounts are perceived as, at best, being overly simplistic, and at worst, being both disempowering and stigmatising for the individuals and groups implicated within them [10, 11].
Wellcome Trust Research Fellowship
My fellowship hinges on the simple idea that the health sector is not alone in facing inequalities in outcomes that reflect underlying social and economic inequality. The same trend plays out across all sectors and policy domains, and all front-line workers are effectively picking up the pieces, or dealing with the symptoms, of the same underlying problem.
For my research, I want to look across three different areas (early years education, youth justice, and housing) to identify and compare the stories that people tell around inequalities within these areas, what needs to change, and how to make that happen.
My hope is that by looking at different ways of thinking about and framing inequalities, and by bringing people together to critically discuss and reflect on these, that we might come up with new and impactful accounts. I also wonder whether we might be able to generate more cross-cutting accounts of inequalities that would support cross-sectoral action on the underlying social and economic drivers of inequalities.
I plan to do presentations and webinars throughout the fellowship to keep people updated and help progress my own thinking on things as I go along. If you are interested in the project and would like receive updates on future presentations, please do get in touch: n.mcmahon1@lancaster.ac.uk
This blog post is based on research funded by a Wellcome Trust Research Fellowship in Humanities and Social Science (Grant Ref: 224770/Z/21/Z). Big thank you to my mentors Professor Jennie Popay, Professor Kat Smith, and Professor Elena Semino, for their input in developing the proposal and application!
*I use the expressions 'social inequalities in health' and 'health inequalities' interchangeably in this post to refer to the persistent differences in health outcomes that we see across socioeconomic groups in society. Those who are the most advantaged live longer lives in better health, with life expectancy and years spent in good health reducing as you move through the social scale towards groups who are less advantaged.
Source of 'upstream-downstream' graphic: https://basicmedicalkey.com/introduction-to-public-health-2/
Some refs:
[1] Stone, D. A. (1989). Causal stories and the formation of policy agendas. Polit Sci Q, 104(2), 281-300.
[2] Shön, D., & Rein, M. (1994). Frame reflection: Toward the resolution of intractable policy controversies. New York: Basic Books.
[3] Lynch, J. (2017). Reframing inequality? The health inequalities turn as a dangerous frame shift. J Public Health, 39(4), 653-660.
[4] McMahon, N. (2021). Working ‘upstream’ to reduce social inequalities in health: a qualitative study of how partners in an applied health research collaboration interpret the metaphor. Crit Public Health. doi: 10.1080/09581596.2021.1931663
[5] Brassolotto, J., Raphael, D., & Baldeo, N. (2014). Epistemological barriers to addressing the social determinants of health among public health professionals in Ontario, Canada: a qualitative inquiry. Crit Public Health, 24(3), 321-336.
[6] Dahlgren, G., & Whitehead, M. (2021). The Dahlgren-Whitehead model of health determinants: 30 years on and still chasing rainbows. Public Health, 199, 20-24.
[7] Spiegel, J. M., Breilh, J., & Yassi, A. (2015). Why language matters: insights and challenges in applying a social determination of health approach in a North-South collaborative research program. Global Health, 11(9).
[8] Hankivsky, O., & Christoffersen, A. (2008). Intersectionality and the determinants of health: a Canadian perspective. Crit Public Health, 18(3), 271-283.
[9] Krieger, N., Dorling, D., & McCartney, G. (2012). Mapping injustice, visualizing equity: why theory, metaphors and images matter in tackling inequalities. Public Health, 126(3), 256-258.
[10] Lundberg, O. (2020). Next steps in the development of the social determinants of health approach: the need for a new narrative. Scand J Public Health, 48(5), 473-479.
[11] Smith, K. E., Macintyre, A., Weakley, S., Hill, S. E., Escobar, O., & Fergie, G. (2021). Public understandings of potential policy responses to health inequalities: Evidence from a UK national survey and citizens’ juries in three UK cities. Soc Sci Med, 291, 114458.