Will COVID-19 be a catalyst for change?
William Pitt, Research Manager and Dr Amy Busby, Senior Director, Kantar Public - UK
Differences in health outcomes, or health inequalities, are driven by structural factors known as the wider determinants of health, such as social, economic, and environmental circumstances. A range of structural factors – including work, income, housing, community and the food that we eat - all affect our health. 1
Life expectancy in the UK is stalling and there is evidence that health inequalities are widening . A difference of ten years in life expectancy exists across the country: a 10-year-old boy today living in the richest part of the UK can expect to live 10 years longer than a 10-year-old boy living in the poorest part. 2
People entered the pandemic with different levels of health and the effects have not been felt equally across the UK.
There have been higher levels of mortality due to COVID-19 in deprived areas, urban areas, and among minority ethnic communities. 3
For example, the proportion of people dying from COVID-19 in the most deprived areas of the UK is more than double that in wealthier areas. 4 Additionally, the COVID-19 mortality rate is higher for people from Black and minority ethnic backgrounds – meaning that they are more likely to die from COVID-19 compared to people of white ethnicity.
Black African men are in fact 2.7 times more likely to die from COVID-19 than white men in the UK. 5 Pre-existing social inequalities have often been exacerbated, both by COVID-19 and by government measures put in place to control the virus.
Kantar Public conducted qualitative research on behalf of the independent charity Health Foundation, as part of their COVID-19 inquiry, to explore public attitudes to health inequalities, by hosting a virtual public dialogue with participants across the UK in early 2021. 6 7
There is a degree of spontaneous awareness of the issue of health inequalities with participants having heard some discussions in the media about the topic. However, generally they are not familiar with the term itself and understanding of the issue is quite low.
When interpreting statistical information about health inequalities, such as the differences in life expectancy and mortality presented above, participants draw on their existing political preferences and their own personal experiences, and quickly default to discussing inequality more broadly rather than health inequality specifically. While the fact that a gap exists is not surprising to most, the scale of the disparity commonly shocks participants, particularly those who were not expecting such a large discrepancy in life expectancy.
Views about health inequalities are complex, nuanced, and driven by wider political views and preferences.
There is some acknowledgement of the role of structural factors in inequalities (particularly among more politically left leaning participants). For example, they mention varying infant mortality rates in countries with different degrees of poverty; and payment at the point of need in the US healthcare system (compared with the UK system of free universal healthcare).
In general, participants move quickly to focus on the role of ‘agency’ and individual action in determining health outcomes rather than ‘structure’, as this is more familiar to them; for example, focusing on behaviours like eating healthily and not smoking, rather than the impact of socioeconomic status.
Structural factors that create disadvantage tend to be seen as barriers, whereas discussions about solutions to health inequalities tend to focus on individual actions for both left and right leaning participants.
For (more politically right leaning) participants, they tend to not perceive structures as barriers. For those (more politically left leaning) participants who tend to recognise the role of structural power, there is a sense of cynicism about the possibility of structural change, meaning they tend to default to individual action as the lever to be influenced.
For example, while some participants recognise that socioeconomic status can play a role in poorer health outcomes, the discussions about solutions to this issue focus on the changes an individual of lower socioeconomic status can make to their life to improve their situation.
There is a general consensus that inequality in the UK is somewhat inevitable due to the UK’s deeply entrenched class system. But there is a shared sense that this is unfair.
When considering how to address this inequality, participants tend to focus on policies and ideas which would create meaningful opportunities for someone to create their own ‘good life’.
Participants paint a broadly consistent picture of what ‘a good life’ in the UK looks like – security, time with family and friends, an absence of stress, and good quality housing. Participants believe everyone in society should have access to the opportunities to achieve this ‘good life’ for themselves.
When discussed as a whole, there is a strong degree of scepticism about the possibilities for narrowing health inequalities in the UK, and participants do not generally see COVID-19 as a catalyst for this change. They do not seem to believe in the willingness or ability of government to achieve big structural change at this moment in time. Indeed, some participants express concern about the potential cost to the taxpayer of attempting this change, when they perceive the health of the UK economy to be poor. 8
However, when specific policy areas and solutions are presented, there is an appetite for ideas to address health inequality related issues. It appears to be easier for the public to view change in this area as feasible when broken down into concrete actions.
Participants discussed and were asked to prioritise six policy areas which are presented in the Build Back Fairer: The COVID-19 Marmot Review:4
Prioritisation is quite challenging for participants who think all these areas have a role to play in reducing health inequality.
However overall, education is seen as the best way to address both structural disadvantage (e.g. by providing access to better jobs) and individual behaviour (e.g. by educating people to make healthier choices). There is a strong general preference for policies which empower individuals by offering them opportunities to achieve their own ‘good life’.
For the UK’s immediate COVID-19 recovery, participants also prioritise policies that they perceive will help enable this; i.e. education catch-up funding, continuing income support (‘furlough’) schemes until work returns to normal, and guaranteeing the minimum wage.
While for some policymakers COVID-19 may feel like a turning point for addressing health inequalities, for the public it is not a topic they have considered deeply before, and they do not strongly link the two issues.
The dominant perspective of participants on the issue, is one of ‘individual agency’ - enabling people to create their own good life. This was common ground for both left- and right- politically leaning participants.
There appears to be a general sense of disempowerment when talking about addressing structures, which can be overcome by explaining how structures can create opportunity, individual agency and aspiration. This highlights the difficulty of engaging the general public on the issue of structural inequalities in general, and health inequalities in particular.
There seems to be an ‘imagination gap’ between what the public desires and what they believe is possible in terms of addressing health inequalities, both during the immediate COVID-19 recovery and in the longer term.
A public conversation which discusses what a ‘good life’ looks like and what individuals need in order to achieve this, may be a more fruitful avenue to inspire public support for this agenda, so that action is taken on the wider determinants of health inequalities in the UK. Any structural reforms presented to the public may gain more credibility and public support if presented as creating opportunities to help individuals improve their own situation.
"This work forms a key strand of the Health Foundation’s COVID-19 impact inquiry, contributing a nuanced picture of public experience and understanding of the pandemic and inequalities. The inquiry as a whole aims to build a bigger picture of the consequences of the pandemic for society and communities across the UK. It explores different dimensions of inequalities and how these are likely to affect people’s health now and in the future.
We believe the findings will provide government with a solid evidence base to inform their recovery policies and tackle these very big issues of inequality to ensure that everyone’s health and wellbeing is protected in the long term."
Martina Kane, Policy and Engagement Manager, The Health Foundation
1 What makes us healthy? An introduction to the social determinants of health, The Health Foundation (2018)
2 Health Equity in England: The Marmot Review 10 Years On, Institute for Health Equity (2020)
3 Deprivation and excess deaths; Reducing inequalities in mortality in England, The Health Foundation (2020)
4 Deaths involving COVID-19 by local area and socioeconomic deprivation: deaths occurring between 1 March and 31 July 2020, Office for National Statistics
5 Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England and Wales: deaths occurring 2 March to 28 July 2020, Office for National Statistics
6 Public dialogues and deliberative approaches by Kantar Public
7 Methodology: Kantar Public conducted a qualitative public dialogue with 72 participants who took part in two waves of virtual workshops across five regions in the UK : Northern Ireland, Scotland, Wales, North England and the Midlands, South and East England. The first wave of workshops was held on 2nd & 4th February 2021, and the second on 9th & 11th March 2021.
8 UK public has a gloomy economic outlook, Kantar Public's Britain Barometer (November 2020)
