Reducing health inequalities in the UK has been a policy priority for over 20 years , yet, despite efforts to create a more equal society, progress has been limited . Some areas of inequality have widened , particularly during the Covid-19 pandemic . Considerable research on the existence and prevalence of UK societal and structural inequalities and their effects on mental and physical health outcomes has been reported. A survey of over 2,000 working-age adults found that 75 per cent within the lowest household income bracket experienced a mental health issue compared with 60 per cent in the highest .Socio-economic disadvantage and the chronic distress it causes for adults and children has negative effects on the body’s physiology [5,6,7]. Analysis of data from the English Longitudinal Study of Ageing showed that older people living in deprived neighbourhoods were significantly more likely to experience mobility difficulties than those in less-deprived neighbourhoods .
Research has recognised that health is a product of the interdependence between humans and environmental determinants ranging from ‘provision of the ecosystem services of food, water, and air, to more nuanced stress-reducing and social capital services, to the role of forests in mitigating the health threats posed by climate change’ [10:1006]. From an ecological viewpoint, researchers theorised that public health should address four dimensions consisting of ‘material’ referring to physical building blocks on which life depends; ‘biological’ involving bio-physiological processes including animal and plant species; ‘cultural’ concerning interpersonal relationships, community and family traditions; and ‘social’ related to institutions between people in terms of laws, social arrangements, conventions, and frameworks [11:3]. To explore underlying mechanisms linking urban environments to public health and social equity, four principles for an ecological public health model were proposed comprising ‘conviviality’, ‘equity’, ‘global responsibility’ and ‘sustainability’ [12:528].
The Commission on the Social Determinants of Health conjectured that health inequalities were caused by ‘unequal distribution of power, income, goods, and services, globally and nationally’ which resulted in ‘unfairness in the immediate, visible circumstances of people’s lives’ [13:1]. The chair of the Commission, Professor Sir Michael Marmot, examined the relationship between socioeconomic position and health in England and determined that two of the six principles for tackling health inequalities should be to ‘Create and develop healthy and sustainable places and communities’ and to ‘Strengthen the role and impact of ill health prevention’ with a focus on an asset-based approach [14:1]. A key report advocated a move towards transdisciplinary ‘health of the public research’ involving disciplines ‘that would not usually be considered to be within the public health field; an approach integrating aspects of natural, social and health sciences, alongside the arts and humanities, which directly or indirectly influence the health of the public’ [15:5].
The associations of engagement with cultural, community and natural assets, and societal and structural health inequalities, and the effects of Covid-19, are addressed in turn.
Engagement with cultural assets
Data gathered from over 15,000 UK respondents found that cultural engagement made the highest contribution to wellbeing in later life followed closely by physical activities and thinking skills . A review of 900 publications linking evidence from the arts to improved health and wellbeing identified two themes: ‘prevention and promotion’, in which the arts could ‘affect the social determinants of health’ and ‘encourage health-promoting behaviours’; and ‘management and treatment’, in which the arts could ‘help people experiencing mental illness’ and ‘help to support people with neurodevelopmental and neurological disorders’ [17:7–8]. A study conducted within deprived London communities found that, out of those engaged with the arts, 82 per cent enjoyed greater wellbeing, 79 per cent ate more healthily, and 77 per cent engaged in more physical activity . Arts engagement can also be effective in compensating for work-related stress ; a USA study of activity outside of work determined that organisations might ‘benefit from encouraging employees to consider creative activities in their efforts to recover from work’ [20:1]. A study exploring cultural interventions beyond the UK determined that ‘artists need to critically engage with the big issues of the day – ageing populations, social isolation, addictive behaviours, substance abuse, obesity and mental ill health – all of which are underpinned by inequality’, while questioning whether access to the arts could be increased ‘without resorting to models that perpetuate inequalities’ [21:186].
Depression and isolation follow the social gradient and, in addition to affecting adults, can impact negatively upon the lives of children . Several researchers have shown, however, that childhood engagement with the arts and literature can foster early physical, cognitive, linguistic, social and emotional development [22,23,24,25]. Findings show that arts engagement ‘helps to mitigate the effects of an adverse environment by: influencing maternal nutrition, perinatal mental health and childhood development; shaping educational and employment opportunities and tackling chronic distress; enabling self-expression and empowerment and overcoming social isolation’ [26:10]. A ten-week study of mothers singing with their babies showed faster recovery from postnatal depression, greater decrease in stress hormones, and more improvement in mother-infant bonding compared with controls using other forms of social interaction . An independent study for the Welsh Government acknowledged that arts engagement aided literacy and numeracy and helped to bridge the attainment gap, but that access to these benefits was unevenly distributed . An Australian study found that ‘arts education not only has intrinsic value, but when implemented with a structured, innovative and long-term approach, it can also provide essential extrinsic benefits, such as improved school attendance, academic achievement across the curriculum as well as social and emotional wellbeing’ [29:3].
Engagement with community assets
Unequal access to community resources as a source of social stratification has long been recognised by sociologists , and the possibility that social inequalities are magnified and reinforced through differences in communities has become an important theme . A qualitative review of place and space across the life course highlighted that ‘development and perception of community has a role to play in individual and group wellbeing’ and ‘community broadly relates to the identification of and engagement in shared interests, experiences and activities’ [32:24]. It was further recognised that the poorer health of economically deprived communities could be explained by low social status but ‘offset by a sense of community, by a sense of identity’ [33:78]. The ‘role of boosting social relations between people in communities’ was described as a ‘key ingredient of both individual and community wellbeing’ [34:5]. The finding aligned with an asset-based, rather than deficit-based, model in which assets are regarded more broadly than at the level of an individual by local government . The importance of maintaining meaningful participation in later life ‘through social, creative or physical activity, work, or belonging to some form of community group’ was found to contribute more than 20 per cent of wellbeing [36:12]. Consequently, improving a sense of community, defined as the ‘measure of a person's integration and meaningful communication with their community, family and friends’ was seen to help to ameliorate social isolation .
Engagement with natural assets
The Marmot Review acknowledged the importance of the green infrastructure, proposing that ‘Access to good quality air, water, food, sporting, recreational and cultural facilities and green space all contribute to reducing inequalities as well as helping to create sustainable communities’ [14:26]. Areas of research examining the relationship between nature and health have included air quality, social cohesion, stress reduction and physical activity . A study of more than 345,000 people found that, after controlling for socioeconomic status, the prevalence of 11 disease categories was at least 20 per cent greater for those living in less green residential spaces than for those in greener areas . Green spaces have the potential to address long-term health conditions linked to chronic stress and lifestyle , with ‘greenness’ seen as protective against adverse mental health outcomes, cardiovascular disease, and mortality’ [41:131]. Even short physical engagements with nature appear to boost mood and self-esteem, which can be additionally enhanced by the presence of water . A review of seven UK studies [42,43,44,45,46,47,48,49] observed a statistical association between greater access to, or use of, green space and improvements in mental health outcomes . Regular weekly use of a natural environment was associated with a 43 per cent lower risk of poor general health, with each additional use per week appearing to lower the risk of poor mental health by six per cent . People who moved from less green to greener areas had significantly better mental health scores in the three years following the move than previously . People with a high amount of local green space appeared less affected by stressful life events than those with a low amount within the same 3Km radius . Gardening was found to promote relief from acute stress, as assessed by salivary cortisol . Although a number of explanations have been offered for the association of nature with health improvements, it seems plausible that being in green and natural environments enhances immune functioning .
As trees and other vegetation mitigate air pollution generated by road traffic and industry through carbon capture , it is interesting to note that the ‘most affluent 20 per cent of wards have five times the amount of parks or general green space (excluding gardens) per person than the most deprived ten per cent of wards’ [55:7]. Conversely, the most deprived urban communities tend to experience the poorest air quality , with increasing risk of cancer, asthma, heart disease, dementias, mortality, and hospital admissions . In addition to air pollution from traffic, noise pollution can also threaten human health , although well-designed urban green spaces can buffer noise and negative perceptions of it . Despite the perceived benefits of green space, people from deprived urban backgrounds appear to engage less with nature than those in more affluent areas . Furthermore, people from higher socioeconomic groups tend to be more physically active in their leisure time than lower socioeconomic groups . However, research shows a disproportionately positive association of engagement with natural resources and wellbeing for communities at the lower end of the socioeconomic gradient . A study of over 165,000 adults across England found a relationship between access to green space and walking in all socio-economic areas, whereas the relationship between green space and reduced mortality was only apparent in the most deprived areas . Income deprivation in England has a weaker association with all-cause and circulatory disease mortality among people living in areas with relatively large amounts of green space than for those in less green areas . Additionally, researchers found that ‘inner urban areas, which tend to have a lower quantity of green space, also tend to have a higher proportion of black and minority ethnic communities’, and recognised that ‘the results are intimately related to the circularity of disadvantage – black and minority ethnic communities are more likely to be living in areas of deprivation which have markedly less green space than average’ [64:14].
Effects of Covid-19
Inequalities across the UK have been amplified by the impacts of Covid-19 on health and wellbeing that have ‘not been felt uniformly across society’ [65:7]. Furthermore, ‘many already deprived communities have faced even greater hardship and loss of assets and resources’ [4:1]. Covid-19 has exacerbated existing structural and social inequalities, with ‘particularly negative health outcomes for those already disadvantaged in society’ [65:7]. The pandemic has heightened awareness of chronic conditions associated with poverty and the greater likelihood of mortality from the virus, and ‘fallout from the pandemic threatens to expose – and widen – inequality in brutal fashion’ [66:4]. Analysis of Covid-19 data (April–July 2020) showed that ‘age-standardised mortality rate of deaths involving Covid-19 was 3.1 deaths per 100,000 population for the most deprived areas in England in July; this was statistically significantly higher than the 1.4 deaths per 100,000 population in the least deprived areas’ [67:16]. Risk of dying among those diagnosed with Covid-19 was also ‘higher in males than females; higher in those living in the more deprived areas than those living in the least deprived; and higher in those in Black, Asian and Minority Ethnic… groups than in White ethnic groups’ [68:4].
In the nationwide effort to reduce contact and to control the spread of Covid-19, the number of people experiencing loneliness as the ‘state of being without any company or in isolation from the community or society’ has inevitably increased [69:526]. Even in the absence of a pandemic, documented evidence shows that that long periods of isolation in custodial care or quarantine for illness has a detrimental effect on mental wellbeing . Additionally, loneliness has been shown to be an independent risk factor for sensory loss, connective tissue and autoimmune disorders, cardio-vascular disorders, and obesity . A UK survey in early lockdown (April 2020) found that 24 per cent of adults experienced feelings of loneliness compared with ten per cent before lockdown, with 44 per cent of younger adults (aged 18–24) feeling lonely during lockdown, compared with 16 per cent before lockdown, and more likely to experience loneliness than older age groups . Nationally representative survey data from more than 15,000 UK respondents documented a high prevalence of general psychiatric disorders (29.2%) and loneliness (35.86%) during the pandemic, and found that people with current or past Covid-related symptoms or disadvantaged socioeconomic backgrounds were at higher risk of general psychiatric disorders and loneliness .
There is growing pressure for research to tackle the wider social determinants of health across developed countries through the implementation of appropriate interventions [73:284], though there is an apparent lack of consensus among researchers as to which interventions are most likely to address health inequalities . A report outlining nine proposals from research experts, each recommending one intervention to reduce health inequalities at a local level, targeted the living wage; life chances in childhood; lower speed limits; health-related unemployment; participatory budgeting; further and adult education; health inequalities and ethnicity; conditions for public sector workers; age-friendly urban environments; and cost-effectiveness . The authors, however, did not consider consensus among the broader research community for these proposals. Other authors used a two-stage survey to determine policies to reduce UK health inequalities . In first stage, 41 respondents assessed the extent to which they believed 99 proposals taken from multiple sources would be effective; and, in the second stage, 92 respondents assessed 20 shortlisted proposals. Recommendation through expert opinion showed some consensus, including: taxation supporting those lower down the social gradient and reducing wealth inequalities; a minimum income for healthy living; greater investment for vulnerable populations, tackling long-term unemployment, primary care, and home-building. There were, however, differences between expert opinion and recommendations based on available evidence for interventions such as smoking cessation, alcohol pricing and speed limits.
Potential interventions have been categorised into four areas, from ‘strengthening individuals, to strengthening communities, to improving living and working conditions and associated access to essential services, to promoting healthy macro-policies’ . It is clear that ‘turning these demands for better evidence about interventions around the social determinants of health into action requires identifying what we already know and highlighting areas for further development’ [73:284]. The aim of the current study was to determine the most pressing inequalities in the UK and to consider future research priorities. A consultancy process involving a survey and workshop were conducted using expert opinion to investigate priority areas for future research into UK inequalities and to ascertain suitable methods for addressing these inequalities.