Why and how has the United Kingdom become a high producer of health inequalities research over the past 50 years? A realist explanatory case study

Abstract

Background Evidence on health inequalities has been growing over the past few decades, yet the capacity to produce research on health inequalities varies between countries worldwide and needs to be strengthened. More in-depth understanding of the sociohistorical, political and institutional processes that enable this type of research and related research capacity to be generated in different contexts is needed. A recent bibliometric analysis of the health inequalities research field found inequalities in the global production of this type of research. It also found the United Kingdom to be the second-highest global contributor to this research field after the United States. This study aims to understand why and how the United Kingdom, as an example of a “high producer” of health inequalities research, has been able to generate so much health inequalities research over the past five decades, and which main mechanisms might have been involved in generating this specific research capacity over time. Methods We conducted a realist explanatory case study, which included 12 semi-structured interviews, to test six theoretical mechanisms that we proposed might have been involved in this process. Data from the interviews and grey and scientific literature were triangulated to inform our findings. Results We found evidence to suggest that at least four of our proposed mechanisms have been activated by certain conditions and have contributed to the health inequalities research production process in the United Kingdom over the past 50 years. Limited evidence suggests that two new mechanisms might have potentially also been at play. Conclusions Valuable learning can be established from this case study, which explores the United Kingdom’s experience in developing a strong national health inequalities research tradition, and the potential mechanisms involved in this process. More research is needed to explore additional facilitating and inhibiting mechanisms and other factors involved in this process in this context, as well as in other settings where less health inequalities research has been produced. This type of in-depth knowledge could be used to guide the development of new health inequalities research capacity-strengthening strategies and support the development of novel approaches and solutions aiming to tackle health inequalities.

Understanding Health Inequalities Research Capacities: Insights and Recommendations From Comparing Two High Income Settings

“…First, both studies identified that the United Kingdom and Barcelona have strong traditions of public health and recognition of social justice (contextual factors), which date back to the nineteenth century. 30,32,40 In addition, evidence suggests that under certain conditions, this recognition of HI accumulated over time (contextual factor), and when potentially combined with heightened concern (mechanism), it triggered a change in certain agents' behaviors and actions, initiating a chain of events which likely led to the production of a high volume of HI research in both settings (outcome of interest).…”

“…In addition, dedicated resources must also be allocated (mechanism) to ensure a minimum level of investment in HI-related human resources via creating dedicated training programs and enabling career structures, and to create a critical mass of trained professionals who are able to work on HI (contextual factor). 24,27,30,32 During the COVID-19 pandemic, for example, several public institutions in Barcelona were able to rapidly identify inequalities in COVID-19 incidence and mortality within and between neighborhoods, partly due to the preexisting HI research infrastructure in the city. 8 Third, the strong political nature of the HI research production process emerges from both case studies, particularly the influential role of politics, and institutional and individual values (contextual factors) in activating certain mechanisms over time.…”

“…For example, both case studies identified that over the past four decades, left-wing and egalitarian political parties have shown more political recognition and concern for HI (mechanism) than right-wing conservative political parties in the United Kingdom and in Barcelona, leading to more investments in HI research capacity (mechanism) and subsequently more production of HI research (outcome of interest). 30,32 Moreover, compelling evidence suggests that individual egalitarian values and ideologies have played a significant role in initiating and sustaining the production of HI research in both settings, which likely occurred via the activation of a sense of moral responsibility to act (mechanism) and to prove that HI existed to try to address them. The activation of this mechanism seems to have been particularly important during periods of struggles 41,42 or in "hostile socio-political and research environments".…”

“…10,22,[29][30][31] These include one study that identified inequalities in global HI research, 29 a conceptual model on the process, 20 and two novel realist explanatory case studies that established causal explanations for the significant production of HI in two high-income settings: the United Kingdom and the city of Barcelona. 30,32 While a few descriptive studies exist on social determinants of health (SDH) and HI research capacities in some low-and middle-income countries (LMIC; 11,[33][34][35][36][37][38][39] ), to the best of our knowledge, no other studies have attempted to apply this methodological approach to assess the HI research production process in other settings, and identify potential causal mechanisms involved.…”

“…Both the United Kingdom and Barcelona were identified as high producers of HI research, 29,31 and the two realist explanatory case studies were conducted with the intention of shedding light on how and why these two settings have been able to generate high volumes of HI research over the past four to five decades. 30,32 Interestingly, both studies found evidence to suggest that a combination of historical sociopolitical-institutional factors have activated many causal mechanisms over time, leading to the generation of a high volume of HI research in these two settings.…”