What (or who) causes health inequalities: Theories, evidence and implications?
What (or who) causes health inequalities: Theories, evidence and implications?
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DOI：
10.1016/j.healthpol.2013.05.021
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发表时间：
2013-12-01
期刊：
影响因子：
3.3
通讯作者：
Mackenzie, Mhairi
中科院分区：
文献类型：
--
作者：
McCartney, Gerry;Collins, Chik;Mackenzie, Mhairi
健康不平等是指在社会中担任不同职位的人群之间在健康方面的不公正差异。自1980年的布莱克报告以来，人们一直在努力了解是什么原因造成了这些问题，以便能够确定减少这些问题的行动。本文回顾和更新了已提出的理论，结合随后的流行病学研究对证据进行了评估，并强调了政治和政策的影响。布莱克报告就健康不平等的根本原因提出了四种理论(人工因素、选择、行为/文化和结构)，并认为结构理论提供了最好的解释。自那以后，这些理论被详细阐述，将智力和精英管理作为选择理论的一部分。然而，与所提出的因果途径有关的流行病学证据并不支持这些较新的阐述。它们可能对因果之间的机制提供了部分解释或见解，但结构理论仍然是对健康不平等的根本原因的最佳解释。论文引出了这一评估的至关重要的政治和政策含义。不能指望通过旨在改变健康行为的政策来大幅减少健康不平等，特别是在更广泛的公共政策不利于减少根本的社会不平等的情况下。此外，如果不对权力、收入、财富的分配或社会的监管框架进行必要的改变，政治上的花言巧语就有必要改变“文化变革”，这很可能会偏离必要的行动。(C)2013爱思唯尔爱尔兰有限公司。保留所有权利。
Health inequalities are the unjust differences in health between groups of people occupying different positions in society. Since the Black Report of 1980 there has been considerable effort to understand what causes them, so as to be able to identify actions to reduce them. This paper revisits and updates the proposed theories, evaluates the evidence in light of subsequent epidemiological research, and underlines the political and policy ramifications.The Black Report suggested four theories (artefact, selection, behavioural/cultural and structural) as to the root causes of health inequalities and suggested that structural theory provided the best explanation. These theories have since been elaborated to include intelligence and meritocracy as part of selection theory. However, the epidemiological evidence relating to the proposed causal pathways does not support these newer elaborations. They may provide partial explanations or insights into the mechanisms between cause and effect, but structural theory remains the best explanation as to the fundamental causes of health inequalities.The paper draws out the vitally important political and policy implications of this assessment. Health inequalities cannot be expected to reduce substantially as a result of policy aimed at changing health behaviours, particularly in the face of wider public policy that militates against reducing underlying social inequalities. Furthermore, political rhetoric about the need for 'cultural change', without the required changes in the distribution of power, income, wealth, or in the regulatory frameworks in society, is likely to divert from necessary action. (C) 2013 Elsevier Ireland Ltd. All rights reserved.