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Issue 3, January 1999, pp.10-11.

Understanding health inequalities: the place of agency
Carol Thomas

Structure and agency

Men [and women!] make their own history, but they do not make it just as they please; they do not make it under circumstances chosen by themselves, but under circumstances directly encountered, given and transmitted from the past.
Karl Marx The Eighteenth Brumaire of Louis Bonaparte, 1851.(1)

Many readers are likely to regard Karl Marx's famous dictum as a statement of the obvious: we make our lives in and out of the circumstances we are given. Put in sociological terms, we both exercise agency and are constrained by structures (social, economic and cultural). This suggests that research seeking to understand why individual health (and health-related behaviour) is so strongly patterned by socio-economic status should be centrally concerned with how people experience and seek to act against the constraints of their daily lives. However, agency has not been a focus of health inequalities research in recent decades.

This article discusses some of the reasons why agency has been a neglected issue. Taking one project within the Health Variations Programme as an example, it goes on to describe how agency can be more fully incorporated into health inequalities research.

Agency reduced to 'lifestyle'
Since the Black Report(2) was published in 1980, explanations of socio-economic health inequalities have tended to polarise around materialist/structural explanations versus cultural/behavioural explanations.(3) In neither type of explanation does agency - what individuals think, know and do - receive much attention. This is because, on both sides of the debate aspects of agency were shredded up and reduced to health knowledge and behaviour: to whether or not individuals knew about and engaged in health-damaging behaviours like smoking, excessive alcohol consumption, eating a poor diet, failing to take physical exercise, or - later - engaging in 'unsafe sex'. For those who supported cultural/ behavioural explanations, the key questions were: what do individuals know about health-related behaviours? What behaviours do people engage in and what is the social patterning of these 'lifestyle factors'? How can knowledge/behaviour be changed in favour of healthy lifestyles? Changing these behaviours was promoted by governments of the day as the key policy pathway to improving the health of the nation.(4)

In this policy context, those researchers who supported materialist/structural explanations dug in, refined their methodologies, searched for new data sets and sharpened up their analyses of the impact of social deprivation and material disadvantage on health.(5,6) If agency was about a limited range of health-related knowledge and behaviours, then it was of little interest. This was because, from their perspective, behaviours were either mediating factors in the pathway between the real aetiological factors - like low income, poor housing, hazardous working environments - and poor health, or were simply 'markers' for such material determinants of health. More recently, the availability of longitudinal data sets and sophisticated statistical analyses has taken some researchers who support a materialist/structural model down the 'lifecourse' road (see the article by Paula Holland, Health Variations Programme Newsletter, Issue 3, pp.8-9). These researchers are studying the impact of accumulating health insults from conception, through infancy and onwards.(5,6) These studies have helped explain why health inequality exists right through the social scale: why, whatever one's position in the social hierarchy, the chances are that one enjoys better health than those below but worse health than those above.(5)

The rediscovering of agency?
Alongside these developments, there has been an important twist in the 'explaining health inequalities' story. Matters of agency - or at least, new aspects of what individuals think, perceive, feel or do - began to be seriously considered by some of those in the materialist/structural camp.

This engagement with agency has not, however, addressed the broad question of how, in Marx's words, men and women 'make their own history'. It has had a narrower focus on what are identified as psycho-social factors. For example, in his work on income distribution and population mortality, Richard Wilkinson(8,9) has turned to the explanatory role played by psycho-social factors, noting that there is a growing body of epidemiological findings which suggests that individual attributes and experiences - such as the presence or absence of a sense of control over one's life, high or low self-esteem, the occurrence of stressful life events, the degree to which people have social affiliations, social support etc. - can shape health outcomes in important ways. This in turn suggests that the quality of social relationships and the levels of social integration and cohesion in communities may be important influences on health inequalities, with concepts like 'social capital' and 'social cohesion' offering some purchase on the issues.(8,9,10) In brief, the Wilkinson idea is that where high degrees of relative deprivation exist such that wide income disparities are evident to all, then the quality of social relationships is threatened and the social cohesion of communities suffers, with the effect that the psycho-social well-being of individuals, particularly the disadvantaged, is undermined. All of this leads, either directly through psychosomatic (mind/body) mechanisms, or indirectly through the pathway of health-damaging actions, to poor health outcomes.(11)

. . . or not?
This and other psycho-social lines of inquiry are exciting and important, but one danger is that agency can be shredded up and reduced once again - this time to a new set of knowledge and behavioural factors. There is a risk that, rather than asking broad and open-ended questions about how individual agency mediates the impact of social structure, this new wave of research will again focus on atomised and measurable dimensions of people's knowledge and behaviour. For example, it will collect people's scores on scales designed to measure such items as envy, frustration, unfairness, disconnectedness, isolation, in order to factor this new set of variables into new and more sophisticated multi-level models. This trend may, however, be resisted: interestingly, Wilkinson and others are now recognising the importance of a broad and more qualitative engagement with the psycho-social: with agency. Broader and qualitative approaches to agency are a key feature of our project in the Health Variations Programme.(12)

'Worrying about how to pay also brings stress and anxiety. People with less money . . . can't afford to go to evening classes like keep fit or aerobics. [The] general area is in decline which is very worrying, like graffiti, crime and vandalism.'
Respondent in the Lancaster/Salford project

Developing a new conception of agency in the health inequality debate
Recognising the limited ways in which agency has been researched in the health inequalities field, we are taking a different starting point. Rather than reducing people's agency to a set of attributes (psychological, attitudinal, emotional, behavioural), we want to understand people's lived experience in all its richness and many-sidedness. We want, as far a possible, to get an insider's understanding of everyday life and the identities it sustains, to appreciate something of the complexity of people's world view - or their 'lay knowledge' - and its relationship to their health.

'Due to unemployment people's health isn't what it should be as they cannot afford to eat healthily. It's a case of having to buy cheap cuts of meat and no fresh vegetables'
Respondent in the Lancaster/Salford project

An important aspect of our approach is that as well as listening extensively to what people have to say about their day-to-day lives in our four study localities (two in Lancaster, two in Salford), we also want to undertake some ethnographic observation - to see agency in action. Along with the biographical information that we are collecting from our survey participants, these observational studies are highlighting how people express their lay knowledge through narrative. That is, lay knowledge is contained in, and told through, stories. Thus we are interested in the stories that people tell about themselves and others, about their pasts and presents. Understanding and working with narrative is a central and exciting challenge in our project.

So, our research is engaging with agency in a different way, drawing on a number of disciplinary traditions within sociology and anthropology to address key questions like:

• how do individuals living in the most materially disadvantaged areas of societies make sense of, and act upon, their environments?
• what are the consequences of these meanings and actions for their health and those they care for?

This emphasis on individual agency is tied to one which recognises the constraining effects of social structure. Like Karl Marx over a century ago, we are asking questions about the combined effects of social structures and individual agency on people's welfare.

'To take away the stresses of life would mean finding some way of treating poor people with the same care and attention to those with nice homes and gardens. They are already blessed with jobs while we are without any of those things. It wears you down trying to keep up with normal living on a quarter of the income.'
Respondent in the Lancaster/Salford project

While the project is still in progress, its findings are underlining the importance of the policy shift away from the 1980s and early 1990s focus on health education designed to change key lifestyle behaviours. It is endorsing the new policy emphasis on assisting people, both materially and through other community-based initiatives, to exercise their agency in favour of a better quality of life. This means investing resources in improving people's living conditions and listening to what local people have to say about the barriers to the achievement of good health. Lay knowledge on health inequalities, and how to overcome them, should at last be valued and acted upon.

Carol Thomas works in the Department of Applied Social Science, Lancaster University and is part of Lancaster and Salford Universities' research project: 'Understanding Health Variations: the interaction of people, place and time.' The full research team comprises: Jennie Popay, Sharon Bennett, Lisa Bostock, Anthony Gatrell, Carol Thomas and Gareth Williams.
A much expanded account of some of the ideas in this paper can be found in Popay et al (1998).(12)

References:
1. Marx, K. (1972) The Eighteenth Brumaire of Louis Bonaparte, Moscow : Progress Publishers.
2. Department of Health and Social Security (1980) Inequalities in Health: Report of a Working Group (The Black Report), London : HMSO.
3. Macintyre, S. (1997) 'The Black Report and beyond: what are the issues?' Social Science and Medicine, 44 (6) pp.723-745.
4. Department of Health (1992) The Health of the Nation: A Strategy for Health in England, London : HMSO.
5. Bartley, M., Blane, D. and Davey Smith, G. (1998) 'Introduction: Beyond the Black Report' in M. Bartley, D. Blane and G. Davey Smith (eds.) The Sociology of Health Inequalities, Oxford : Blackwell.
6. Blane, D., Brunner, E. and Wilkinson, R. (eds.) (1996) Health and Social Organization. London : Routledge.
7. Blane, D. (1985) 'An assessment of the Black Report's explanations of health inequalities'. Sociology of Health and Illness, 7 pp.423-445.
8. Wilkinson, R. (1996) Unhealthy Societies: the Afflictions of Inequality, London : Routledge.
9. Wilkinson, R., Kawachi, I. and Kennedy, B. (1998) 'Mortality, the social environment, crime and violence' in M. Bartley, D. Blane and G. Davey Smith (eds.) The Sociology of Health Inequalities, Oxford : Blackwell.
10. Putnam, R. D. (1995) 'Tuning in, tuning out: the strange disappearance of social capital in America' Political Science and Politics, 4 pp.664-83.
11. Elstad, L. L. (1998) 'The psycho-social perspective on social inequalities in health' in M. Bartley, D. Blane and G. Davey Smith (eds.) The Sociology of Health Inequalities, Oxford : Blackwell.
12. Popay, J, Williams, G., Thomas, C. and Gatrell, A. (1998) 'Theorising inequalities in health: the place of lay knowledge' in M. Bartley, D. Blane and G. Davey Smith (eds.) The Sociology of Health Inequalities, Oxford : Blackwell. (Also in Sociology of Health and Illness 20 (5) pp.619-644).