Scotland experiences higher mortality rates and larger health inequalities than other high-income countries, including the wider UK. The predominantly epidemiological evidence-base identifies deprivation, inequalities in wealth, deindustrialization, health behaviours and housing as important factors, while excess mortality has been attributed to a ‘political attack’ on the Scottish population in the late twentieth century. This paper synthesises 48 studies offering lay perspectives on the factors shaping health in Scotland, identified via systematic searches. The findings demonstrate that people with lived experience of disadvantage have a good understanding of the social determinants of health inequalities. We also identify five ways in which Scotland’s disadvantaged communities experience a sense of ‘attack’: the structural violence of poverty; disadvantageous national policies; ‘street level bureaucrats’ gatekeeping welfare support; local profiteers (e.g., unresponsive landlords); and interpersonal violence. We argue that these findings provide support for the ‘political attack’ hypothesis and that they suggest research and policy needs to better grapple with the depth of poverty, the intersectional nature of inequalities and the roles that history, narratives, crime, violence and policy implementation each play in shaping Scotland’s health outcomes. We call for research and policy responses that ground both diagnosis and future prescriptions in the experiential knowledge of those most negatively impacted.
Scotland is an important case study for health inequalities, having experienced higher mortality rates, lower life expectancy and larger health inequalities than most comparable high-income countries over the past four decades (Grant et al. 2023). This outlier status has stimulated a substantial, predominantly epidemiological, evidence-base, which identifies multiple causes of poor health outcomes, most of which coalesce in the outer layers of Dahlgren and Whitehead’s '(2007) widely reproduced 'rainbow model' of the determinants of health: 'General socio-economic, cultural and environental conditions' (the outermost layer) and 'Living and working conditions' (the second most outer layer). Analyses highlight rising poverty, persistently high inequalities in income and wealth, growing inequalities in educational attainment, differential access to decent housing, growing inequalities in drug and alcohol related deaths, the unequal impacts of austerity measures on social support and vulnerability to COVID-19, and inequalities in people’s health and social care access (Miall et al. 2022). In recent years, researchers have moved beyond these material factors to offer accounts of how policy decisions create the context for these inequalities. This paper builds on these recent explanations for Scotland’s unusually unequal health outcomes, employing a systematically-conducted review of qualitative evidence to consider how people’s accounts of life in Scotland might support, enrich, or contest research-led accounts.
Research has extensively explicated the factors that contribute to entrenched health inequalities. An international ‘umbrella’ review of the macroeconomic determinants of health and health inequalities found that employment, working conditions, welfare state generosity and the regulation of tobacco, alcohol and food all play an important role (Naik et al. 2019). A systematic review exploring the impact of political economy on population health identified public spending, fair trade policies, compulsory education provision, health and safety policies, healthcare access, and high-quality affordable housing as positive contributors (McCartney et al. 2019). A policy briefing produced by NHS Health Scotland (2015), informed by a larger review (Scott et al. 2013), maps social and material determinants to three ‘fundamental causes of health inequalities’: income (‘money received by individuals or groups over a specific time period’); power (‘the ability or capacity to do (or not to do) something and control, force or influence through a variety of means’); and wealth (‘accumulated material and capital assets which provides a reserve of financial resources and often provides an income stream’). Many of these factors are shaped by wider socio-economic, cultural and environmental conditions arising from policy decisions. For example, McCartney et al.’s (2019) review found social democratic welfare states were positively associated with health while neoliberal restructuring and higher income inequality were associated with poorer health outcomes.
The pathways connecting these high-level decisions to health outcomes in Scotland have been unpacked across multiple studies examining how macro-economic policies implemented in the 1970s-1980s negatively impacted on health (Collins & McCartney 2011, Garnham 2015, 2017, Mackenzie et al. 2017, McIvor 2019, Scott-Samuel et al. 2014). These studies document how UK policies in this era functioned to substantially increase unemployment in specific localities (which, in Scotland, were concentrated in the Greater Glasgow conurbation), while simultaneously reducing welfare safety nets via benefits reforms and reductions in social housing stock, and restricting trade unions’ ability to promote workplace safety and provide affected communities with political voice (e.g., heavily policing industrial disputes; see Kelliher 2021). Over the same period, analysis by Walsh and colleagues (2017) suggests that decisions taken by regional and local decision-makers in Glasgow led to urban planning decisions that resulted in poor-quality housing estates (which are larger than those of other UK cities and are often located in urban peripheries with limited amenities), lower investment in housing maintenance, and a greater emphasis on the kind of high-rise developments subsequently shown to negatively impact on mental health (Evans et al. 2003).
These findings have informed an influential hypothesis that Scotland’s excess mortality (i.e., mortality over and above that which we would expect based on measures of socio-economic deprivation) may be partially explained by the concept of ‘political attack’ (McCartney et al. 2011, 2012). This idea is underpinned by three dimensions: 1) the UK’s specific experience of neoliberal policies from 1979 onwards; 2) Scotland’s particular vulnerability to these policies, especially in the West and specifically Glasgow areas; and 3) distinctive reactions to these policies based on Scotland’s ‘democratic deficit’, which repeatedly subjected the population to policies designed and implemented by political parties that the majority of Scottish citizens did not vote for (Wray et al. 2022). The hypothesis has attracted international attention from health inequalities researchers (Mackenbach 2012) but is harder to measure than more material social and commercial determinants of health. Nonetheless, McCartney and colleagues’ (2012) application of the Bradford-Hill criteria for causation to available evidence led them to conclude, just over a decade ago, that ‘the political attack hypothesis’ is the best placed explanation ‘to bring together the most likely behavioural, cultural and structural determinants of health into a coherent narrative’ to ‘explain the post-1980 mortality phenomenon’.
If the political attack hypothesis is true, it is reasonable to expect that a sense of being subject to political attack would be evident in ‘lay’ accounts of the social determinants of health and health inequalities in Scotland. Yet, these qualitative insights have been given limited attention in evidence reviews. This paper is (as far as we are aware) the first attempt to comprehensively address this gap. Our aim was to synthesise qualitative research to answer the following question: ‘What do qualitative accounts tell us about public understandings of health inequalities, the social determinants of health and excess mortality in Scotland?’
The first part of our findings aligns with a 2018 meta-ethnography, which synthesised qualitative studies from across the UK, and found that people generally, ‘have sophisticated understandings of the underlying causes of socioeconomic health inequalities, which closely mirror popular, research-informed theories about health inequalities’ (Smith & Anderson 2018). However, in reviewing lay accounts specifically in Scotland, we identify a clearer sense of communities who feel ‘under attack’ and we outline five distinct sources of attack. Somewhat surprisingly, in the context of 25 years of political devolution, studies report little differentiation in people’s accounts between decision-makers operating at local, national (devolved) and UK levels. In the concluding discussion, we consider the implications of these findings for research and policy.
We undertook three linked searches to identify relevant literature: two focused on academic literature (both in SCOPUS) and one on grey literature. Academic searches focused on identifying papers published since 2016, which were supplemented by papers included in the previous 2018 meta-ethnography that included relevant Scottish data (Smith & Anderson 2018). The grey literature search also started with publications from 2016, to aid comparability across the two strands. Since the meta-ethnography did not include grey literature, the exclusion of earlier grey literature is a limitation, as is the exclusion of long-form autobiographies (e.g. Barr 2014; McCormack 2009). This resulted in a data set of 48 publications: 37 academic publications and 11 grey literature reports (four studies were written up across two publications so this mapped to 44 distinct studies). See Appendix I for a full and detailed account of our methods and search terms.
Our analysis focused on identifying themes substantially evident across included publications. As such, we may not have fully captured diversity between included studies, though we were surprised by the consistency of many accounts and often found there was greater diversity between the experiences and perspectives of different social groups within studies (e.g., parents compared to children, or women compared to men) than between included studies.
The included studies (summarised in Appendix I Table II) are dominated by research focusing on the perspectives of socially-disadvantaged communities in Scotland’s central belt (particularly those living in urban areas). Only a handful of studies focus on the experiences of Scotland’s remote and rural populations (Bramley al. 2019, Lorimer et al. 2018, Macaulay et al. 2021). Methodological approaches vary but there is shift over time away from reliance on qualitative interviews towards more creative and participatory methods, especially in the grey literature, which includes innovative examples of socially-disadvantaged communities co-authoring reports.
Across studies, participants express sophisticated understandings of the multiple pathways through which social determinants shape health (aligning with Smith & Anderson 2018). As Tables 1 and 2 illustrate, people frequently described an interplay between material conditions (income, housing, neighbourhoods and employment opportunities), individual behaviours and social relations (both positive support networks and peer-pressure to engage in unhealthy behaviours, e.g., Copeland 2004).
|
Determinant |
Illustrative extract(s) |
|
Poverty, low income |
'Inability to cushion for (un)expected expenses also led to negative mental health outcomes and longer-lasting dissatisfaction with life for some, as shown by reports of stress, sleeplessness, feeling pressure from making difficult financial decisions. […] Many […] expressed feelings of shame and guilt if unable to provide for their children. This became so severe that some had suicidal thoughts.’ (Ibrahim et al. 2021) |
|
Poor quality housing and homelessness |
‘Participants highlighted problems of poor housing, cold and damp, which was often associated with respiratory conditions, particularly in children’. (Burningham & Thrush 2003) |
|
Unemployment / job loss |
“I’ve watched my son who is now twenty-two…I’ve watched him over a period of time having to go onto websites, having to apply for jobs, no’ getting any word back, no’ even getting notified whether he’s getting an interview, or whether he’s successful, or unsuccessful. You just watch the… sorta esteem just drain oot them.” (Alex, quoted in Mackenzie et al. 2017) |
These complex and layered accounts reflect researchers’ frameworks for understanding the social determinants of health and health inequalities (Dahlgren & Whitehead 2007). Multiple studies highlight determinants identified as important for population health in systematic reviews (e.g. Naik et al. 2019, McCartney et al. 2019). There is a recurrent emphasis on the negative impacts that unfair working conditions and a lack of employment can have on people’s self-esteem, confidence and mental health (Table 1 and Appendix I). Qualitative accounts are particularly effective at conveying the cyclical nature of these determinants, showing how struggling to secure decent employment can harm mental health (Table 1), and in turn make securing decent employment harder: “I have an interview tomorrow, and my anxiety is through the roof, I feel overloaded, I used to do this all the time, I feel like I can’t go back” (participant quoted in Yaqoob and Shahnaz 2021).
Qualitative studies are also effective in capturing the ways in which intermediary factors coalesce to shape health (Backett-Milburn et al. 2003, Davidson et al. 2006, 2008), with material, social and structural factors often cited as explanations of behavioural factors; the similarity with which people describe alcohol, illicit drugs, tobacco and unhealthy food is striking (Table 2). These accounts underline the importance of considering the material and social contexts of these behaviours as well as examining these behaviours collectively.
|
Behaviour |
Lay explanation |
||
|
‘Coping’ mechanism |
Accessibility |
Social networks |
|
|
Alcohol consumption |
‘Some Irish narratives suggested that in order to cope with working in Britain between the 1950s and 1970s, Irish men had adopted unhealthy lifestyles that included heavy alcohol and tobacco consumption,’ (Scanlon et al. 2006) |
‘The accessibility of alcohol (e.g., via pubs) was also identified as problematic, e.g.,: “At our end […] we have got teenagers burning bins, fire engines coming all the time. That’s because pubs allowing them to get alcohol at such a young age. Pubs here are a negative influence on our health.”’ (Kapilashrami & Marsden 2018) |
‘The peer researchers also felt that seeing alcohol, cigarette or drug related litter might normalise alcohol and drug taking behaviour. This means people might get used to seeing it happen and think it is ok to participate in it’ (Young Peer Researchers et al. 2020) |
|
Smoking |
‘The respondents in our study clearly indicated that in their lives there was a lack of substitutes for the habitual properties of smoking. Smoking helped them deal with circumstances in which high stress and boredom were ever-present facts of life.’ (Bancroft et al. 2003) |
‘Legal, illegal and informal sources were plentiful: “Every shop in Possil is designed for alcohol and cigarettes” “If you’re skint, you just take the coupons tae the van [mobile shop] an’ get fags” “The vans coming round” “And the smugglers” “Chap [knock] on someone's door—there's always someone selling fags, always—fags and drink”’ (Stead et al. 2001) |
‘The strength of the normative pressure to smoke was such that non-smokers described having needed a legitimate reason not to smoke as teenagers, such as asthma or a place in the school football team.’ (Stead et al. 2001) |
|
Consumption of unhealthy food and/or insufficient nutrition |
‘“people are always going to buy cakes, it's just the pills of life. They eat cakes and biscuits and sweets and so on, that taste nice so they make you think of different things” [FG6, inner city estate, lower SES, Greater Glasgow].’ (Davidson et al. 2008) |
“I do worry about fast food. Because they are so easily accessible, order on phone. And our children rely a lot on these. If you don’t find food at home, then just dial in a pizza.” (Kapilashrami & Marsden 2018) |
Describes few participants saying that they ate three meals a day and notes that this appeared to have been normalized for some: ‘Some viewed this pattern as their normal…’ (Douglas et al. 2020) |
|
Use of illicit drugs |
‘“I used them to escape but that just made more problems for me.” (Male J) “I was trying to escape reality... things in my head” (Female S)’ (Copeland 2004) |
‘The influence of their peers (friends) was the most common reason given by interviewees for starting to use drugs. One interviewee expressed clearly what others said too about the influence of friends: “People I was mucking about with got me into downers and I just sort of followed suit ... because they were my mates.”’ (Copeland 2004) |
|
Reflecting the cyclical nature of pathways connecting material circumstances to health, alcohol was cited as a contributor to “poverty and desperation (including hunger)” (Lorimer et al. 2018) as well as a ‘coping’ mechanism (Table 2). All of the behaviours listed in Table 2, with the exception of unhealthy food, were described as having negative health impacts on bystanders (e.g., being affected by the presence of alcohol and drugs - and associated violence - in their homes, schools, workplaces and neighbourhoods). The focus of these accounts is therefore much broader than individual decisions to engage in risky behaviours (or not); they capture the ripple effects of these behaviours when they are normalised in particular places and communities.
Having established that the ways in which research participants in Scotland talk about factors shaping their health aligns with research on the social determinants of health, we now consider the associated sense of feeling ‘under attack’. The most obvious source of feeling under attack is poverty; an inescapable feature of many accounts, with direct, material impacts. Some participants describe struggling to meet basic human needs (e.g., food, warmth, shelter) (e.g. Douglas et al. 2020, Garnham 2015, Ibrahim et al. 2021, Isaacs et al. 2020, Mackenzie et al. 2017). There are also multiple psychosocial pathways connecting poverty and mental health, ranging from the shame, embarrassment and stigma of poverty (e.g., contributing to social isolation, feelings of devaluation, low self-esteem and depression; Davidson et al. 2008, Inglis et al. 2019), to the fear, stress and anxiety arising from a belief that local neighbourhoods are unsafe (Burningham & Thrush 2003, Davidson et al. 2008; Egan et al. 2015, Kapilashrami & Marsden 2018, Rolfe & Garnham 2020, Shortt & Ross 2021, Watson & Douglas 2012, Wiseman & Watson 2021). While the links between poverty, deprivation and poor health are well recognised in Scotland, the extremes of poverty described by some participants suggest that current quantitative indicators and analyses dividing the population into quintiles, or even deciles, are insufficient (see Edmiston 2022, Timpson et al. 2023).
Examples of neighbourhood deprivation were often attributed to decisions by ‘those in charge’, resulting in a visceral sense of not being cared for:
The participants noted that in the more deprived area, the presence of large piles of rubbish “makes it look like a bad area”. This also made people have negative feelings towards their own neighbourhoods, making them feel “horrible”.' […] They discussed how those in charge appear not to care, as bins are not provided. (Shortt & Ross 2021)
Terms such as ‘minging’, ‘minky’ and ‘disgusting’ were used to describe the aesthetics of the Area and how this made them feel. For example, one young person identified a lack of investment in the Area as making them look poor and boring, while graffiti was described as making them feel depressed (Watson & Douglas 2012)
This belief (which we return to below) appeared to exacerbate mental ill-health and was hard to escape; although some studies noted efforts by participants to resist neighbourhood stigmatization (Burningham & Thrush 2003, Fraser & Clark 2021), these efforts often appeared unsuccessful. Indeed, even leaving an area did not always enable participants to escape. In several accounts, participants describe feeling that the area they are from contributed to what Wacquant and colleagues (2014) call ‘territorial stigma’, that is, discrimination that impacted opportunities to access employment and services (including financial services). For example (see also Airey 2003):
Respondents in our study were acutely aware of being labelled and stigmatised because of their postcode. It was widely felt that employers regarded people from ‘the schemes’ as work-shy, unreliable and anti-social, and that the “wrong” address on job application forms could prejudice their chances. Several had been refused credit, such as catalogue selling or TV rental, because of their postcode: “You’re all tarred with the same brush’’. (Stead et al. 2001)
Viewed collectively, these accounts suggest that living in poverty and/or in areas of high deprivation in Scotland amount to ‘structural violence’ (Galtung 1969) since these experiences contribute to a myriad of pathways restricting people’s capacity to achieve their full potential. Although the definition of ‘structural violence’ is that individual arbitrators are not identifiable, this does not mean that there is an absence of blame; across many people’s accounts, there is a strong belief (discussed further below) that people with resources and power do not care about their communities (or, therefore, about them). This belief contributes to an ‘us/them’ dichotomy in Scottish society, evident in several studies, in which participants describe feelings of alienation (Davidson et al. 2008) and social division (Davidson et al. 2006, Lorimer et al. 2018), and of acquiring identities that ‘set them apart from the rest of society' (Copeland 2004). This, in turn, contributes to a sense of distrust, especially in those making decisions, which can mean that investments in disadvantaged areas are not necessarily viewed as ‘for’ the local communities. For example:
[With reference to new cultural facilities being built in Dundee]: “What's that for? It's no’ for us. That's no’ for us. It might benefit the city in general wi’ tourists and things, but when you come out o’ Dundee you’ll see it, it's a nice place, but behind that it's still Dundee. It's still the shithole that's here”. (Daniel, age 38, Dundee, Int2) (Lorimer et al. 2018)
As the section above about the structural violence of poverty suggests, despite 25 years of devolution and claims that Scotland has developed distinctive approach to policymaking centring on community empowerment (Cairney 2020), studies included in this review suggest that Scotland’s more disadvantaged communities do not feel well understood, represented, engaged with, listened to, or supported by politicians and policymakers (Box 1). In short, the causes of poverty and deprivation are consistently attributed to decisions by ‘government’ and ‘politicians’, with few distinctions between local, devolved or UK national policy arenas. Politicians are depicted as making decisions that have consequences for the communities affected, but also as not understanding or adequately caring for those communities (Garnham 2017, Watson & Douglas 2012). There is a persistent sense of powerlessness to change policies that are negatively impacting communities, to the extent that it seems plausible to consider this a key psychosocial pathway via which material experiences contribute to poor health in Scotland (e.g. Burningham & Thrush 2003).
|
More historical
↓
Time
↓
More recent
|
‘Research participants from lower socio-economic groups […] talked eloquently about feeling that their communities were unheard and ignored. […] One man described his belief that whole sections of society were now seen as disposable ‘fling away people’, and another declared: ‘the government’s made us feel, as if we’re a carpet for [them] to wipe their feet on, and to be brushed aside. I’m talking about me personally, I feel rejected by the government, like I’ve been told, ‘we don’t need you, I mean, who cares about yous up there, right, we’ll just deal with people that’s in our category, with the suits.'’ Participants’ frustration at local neglect was often directed at government, local decision-makers and public services, who were often seen not to be doing anything to improve the situation, e.g.: ‘We’ve all been ignored all the time by the police and the government’. (Watson & Douglas 2012) Joan, oral history participant: 'They couldn't care less, north, as was said, of the Watford Gap. They're not even interested in the North England or anywhere, they're only interested in a little bit down there, they're not interested in anywhere else. And that's only by my experience of what I've seen. I've lost, I've really lost heart in politicians, I'm sick of all the, I mean come on! They're the biggest thieves out! The biggest thieves out! … So there's something sadly wrong with government, isn't there?’' (Garnham 2015, 2018) ‘A lack of trust in governments and politicians was prevalent across juries, with frequent expressions of cynicism concerning motives, competence, integrity and (lack of) concern for, or understanding of, ‘people like us’'. This 'informed a belief, evident across juries, that governments ‘waste’ money.’ (Smith et al. 2021) |
Analysed collectively, the included studies contain three recurrent examples of macro-level economic policies described as having been pursued at the expense of disadvantaged communities: (1) the closure of large industrial employers (especially coalmines) during Margaret Thatcher’s time as UK Prime Minister, which some participants viewed as a deliberate attempt to damage unions (Garnham 2017, Mackenzie et al. 2017, McGarrol 2020); (2) the combination of conditionality and austerity policies implemented by the Labour governments that were in power during 1997-2010 and the Conservative governments that were in power from 2010 onward (Garnham 2017, Mackenzie et al. 2017); and (3) policy decisions that enabled individuals working in financial services to accrue vast wealth, despite the 2008 global economic crash, at the same time as conditionality and austerity were being rolled out in disadvantaged communities:
They’d built up the financial services to such a strength that It outweighed manufacturing, it outweighed any other service in the UK. But they were the kings and everybody else was the minions…financial services I would say were the main cause of what has happened, the greed. And what gets up oor noses is that we still see bankers’ bonuses being paid, we still see the very rich getting tax breaks and we’re looking at people living in our community getting hit wi’ sixteen pound a week [benefit reductions]…there’s no a God, at this moment in time.' (Participant referred to as Alex, in Mackenzie et al. 2017)
Such accounts point to the importance of focusing on those who benefit from growing inequalities, as well as those who are most disadvantaged. Additionally, a study focusing on asylum seekers and refugees in Scotland identifies the UK’s ‘hostile environment’ policy as an ‘explicit example of structural violence' (Isaacs et al. 2020). A participant in Mackenzie et al.’s (2017) study highlights how media narratives and television shows can target particular social groups, concluding, “I think that’s Tory sponsored TV to be quite honest wi’ you…it’s like stigmatising full groups at a time.” (Mackenzie et al. 2017, p. 244). These studies highlight the importance of considering: 1) how national policies may be differentially experienced; 2) the necessity of considering multiple axes of inequality; and 3) the need to critically analyse the interplay between policy and media narratives. Despite 25 years of devolution, there is a notable absence within these studies of disadvantaged communities reporting a sense of improved political representation and voice. This is likely to reflect the continued impact of reserved policy areas (those that remain at UK parliamentary level) on reported experiences (especially social security until 2016, and immigration) and the more gradual development of community understanding of complex multi-level governance systems, as discussed next.
While the blame for the negative impacts of some policies was, therefore, commonly located with the UK government, lay accounts also draw attention to people’s experiences of how policies are implemented. Here, issues such as dignity, respect and responsiveness seem key. Crucially, community accounts make clear that the same policy can be implemented differently for different places/groups and can have varying consequences. For example, while the national policy context may appear to provide a particular combination of disability benefits, people with disabilities recount trying to avoid claiming benefits in what they perceived to be a hostile and stigmatising culture (Young 2021). Systemic complexity, a lack of transparency, and difficulty accessing good-quality advice and information, were all also identified as barriers to accessing benefits (Young 2021).
Another study identified a lack of confidence in core public services. This included accusations (in one older study) that councils and housing associations fail to adequately maintain housing stock, as well as claims that police ignore reports of crime and anti-social behaviour in some poorer neighbourhoods:
Participants characterised themselves as engaged in a constant battle to get the police and the council to do their job, recounting many occasions on which they had phoned one or the other about specific problems, to be met with what they considered an inadequate response. (Burningham & Thrush 2003).
The difficulties of accessing support were widely discussed (Table 3). Recent studies describe applying for welfare benefits as ‘a nightmare’ (Kapilashrami & Marsden 2018), the process of navigating support systems as ‘fearsome’ (Robertson 2020), and the challenges of meeting a requirement to ‘make three bids a week to an online index of available housing' as virtually impossible for people already experiencing homelessness (Kapilashrami & Marsden 2018).
|
Issue raised |
Illustrative extracts from Robertson (2020) |
|
Not knowing where to get support when it is needed |
‘“It’s not easy to find. […] It’s very stressful trying to, trying to even look for help and finding help and, it’s such an invaluable resource… so many didn’t even know about the Warm Homes Scheme. That’s something they keep real hidden.” (Sophie)’ |
|
Inadequate public service support provided when sought |
‘Sasha had applied for and had been waiting for a council property for 18 months. [W]orking 25 hours a week and caring for her child meant she struggled to fit in time for bidding for houses which she described as a constant process. She described “being very scared about the next winter” in her current flat because of the cold and her child’s health. Sasha had contacted the Council on several occasions to find out if she was any nearer to getting a property. Her frustration was clear here: “So I call them, they said, ‘meh, to be honest, you have like five hundred and something points. There’s people that has got four times the points that you have, and they’re still waiting’. Basically, they say you don’t have hopes to get nothing.”’ |
|
Concerns about the ways support is provided (e.g. treatment by staff, lack of staff knowledge) |
‘“It’s a fearsome process (the work capability assessment), like, I mean, if you havenae already got depression and anxiety, you will have after you’ve gone through that assessment thing, like, you know. It’s murder.” (John)’
“They don’t really care where you’re living, even you explain to them… In fact, even my key worker’s write some letters for the arrears that I had to show to the Jobcentre that I’m gonna be made homeless again because they have to do something with, I need some support. But I went there, they’re like “We can’t do nothing,” (Leo)’ |
In several accounts, the three issues highlighted in Table 3 combined, with people reflecting that uncertainties about how support services were supposed to operate, limitations in available support, and perceptions that front-line staff did not care, combined to cause mental and physical distress:
The Job Centre, that turns my stomach. I gotta go there every fortnight, it’s only every fortnight, but still, leadin’ up to that I can feel it in my stomach and my stomach turns and, y’know, it’s just not a pleasant experience for me … Well it’s called the job centre but I don’t think it actually tries to really get you a job. You go in there and they’ve got procedures and you’ve got to do what they want because they’ve got bosses on top of them and if they’re not seen to be doin’ what you’re supposed to be doin’ then they get intae trouble. I’ve got tae apply tae a job every week, but if I can’t find a job I’m told I’ve tae send a CV tae any company, which I do to keep them right. If I don’t do that then they get intae trouble … So that just physically upsets me, and mentally.” (Owen, photovoice participant, cited in Garnham 2015)
In sum, while multiple participants, across studies, provide compelling critiques of national policies, their accounts also identify problematic experiences with local actors, such as Job Centre staff, the kinds of people Lipsky (1980) refers to as ‘street-level bureaucrats’. An important exception to these accounts of public services is the way health services are discussed. In most studies, health services are not mentioned but, where health services and health professionals are discussed, they are often referred to positively (e.g. Douglas et al. 2020; Kapilashrami & Marsden 2018). In the small number of cases in which people raised concerns about health services, it related either to a sense that health professionals were not sufficiently aware of people’s life circumstances (e.g., giving advice that was not economically feasible; Douglas et al. 2020) or to a sense that health professionals could be judgmental of people’s circumstances and behaviours (Parkes et al. 2021).
Community accounts identify a range of ‘profiteers’, who extract resources from Scotland’s disadvantaged communities, with negative health impacts. It is important to acknowledge that some local businesses were described positively, including some fast food outlets that were described as providing safe and relatively affordable social spaces (Kapilashrami & Marsden 2018) as well as responsive housing providers (Garnham et al. 2022, Rolfe & Garnham 2020). However, there were also multiple negative examples. A recent study of people claiming Disability Assistance in Scotland noted multiple ways in which participants described private sector companies as extracting a ‘poverty premium’ from disabled people living in poverty, with examples including higher pre-payment meter energy rates, and the high cost of basic aids for independent living (Young 2021). Similarly, landlords were commonly described as prioritising profits over people, by leasing poor quality properties, ‘ripping off’ families, and taking advantage of marginalised communities (e.g., migrants) (Smith et al. 2021). Businesses involved in selling unhealthy products and services were often described as contributing to local problems. For example, businesses selling alcohol were frequently singled out as exacerbating a sense that particular local areas are unsafe, especially for women and children (Kapilashrami & Marsden 2018, McGarrol 2020).
Local profiteers perceived to cause health damage were not restricted to the formal sector; a recent study highlighted the importance of organised criminals and gangs in Scotland’s 'hidden economy' (Fraser & Clark 2021). Focusing on deindustrialized areas, these groups are described as exhibiting ‘a keen knowledge of vulnerabilities in the local area—debt, addiction, ill-health, lack of family support, and old age’ which they leverage ‘to build defensible fiefdoms' (Fraser & Clark 2021). While this can result in substantial financial rewards for some individuals involved, the fall-out for affected communities in terms of the availability of drugs and the fear of crime is substantial, and this is exacerbated by a sense that public sector actors (the ‘street level bureaucrats’ described above) step back, where organized crime takes hold (Fraser & Clark 2021).
Finally, some studies featured participants who described corporations that negatively impact on health more broadly by, for example, promoting unaffordable lifestyles (Davidson et al. 2006, Davidson et al. 2008), providing poor working conditions and low pay (McHardy et al. 2021), or undermining the public sector via tax avoidance (Smith et al. 2021). This suggests a need to broaden public health’s conceptualization of the ‘commercial determinants of health’ to better capture the range of profit-driven actors shaping people’s health.
Studies exploring links between interpersonal violence and health inequalities in Scotland have tended to focus on gang-related violence, especially knife crime (e.g. Neville et al. 2015). Our findings suggest that interpersonal violence is more widespread, and that it is consistently linked with a toxic interplay of poverty, disaffection and addiction:
[W]e were struck by the shadow cast by poverty, drugs and violence, which appeared never to be far from the doorsteps of almost all participants, and for many it was an intrinsic part of negotiating everyday life. (Lorimer et al. 2018)
Multiple studies recount experiences, or fear, of violence and aggression (Bramley et al. 2019, Burningham & Thrush 2003, Copeland 2004, Egan et al. 2015, Fraser & Clark 2021, Garnham 2017, 2018, Lorimer et al. 2018, Marzetti et al. 2022, McGarrol 2020, Shortt & Ross 2021, Watson & Douglas 2012, Wiseman & Watson 2021). These accounts (which often also mention alcohol and/or drugs) suggest the health and wellbeing implications are profound:
Violence and drugs heavily present in participant accounts. […] Throughout interviews, it is clear that organized crime penetrates every level, with street-level crime intrinsically linked to local criminal markets, which also manifest through violence, intimidation, and financial pressure. (Fraser & Clark 2021)
Looking across studies, three types of inter-personal violence were commonly identified (Table 4).
|
Type of violence |
Illustrative example |
|
Youth and gang related violence |
‘Men who discussed their experiences of engaging in youth violence – commonly, but not exclusively, our Glasgow participants – gave a variety of reasons for this, from boredom to the acquisition of status, mirroring others’ findings […]. In these narratives, we read a mixture of choice (“Just dinnae [didn’t] feel coerced intae [into] it, just actively joined in”) and obligation (often even at different points in the same interview), suggesting that their violent behaviours were unavoidable and normalised in their community.’ (Lorimer et al. 2018) |
|
Violence against women and girls (‘domestic abuse’) |
‘We heard men talk about domestic abuse as a common feature of their communities, or personally witnessing domestic abuse. […] Of the 16 women interviewed, 13 said they had witnessed and/or been subject to personal experiences of domestic abuse.’ (Lorimer et al. 2018); 'Women reported experiences of sexual violence as children and adults.' (Wiseman & Watson 2021) |
|
Harassment and violence targeting minority groups (e.g. people with disabilities and people with LGBTQ+ or minority ethnic identities) |
‘Being subjected to violence was part of people’s everyday experiences throughout the life course and was experienced in various community settings such as schools, participants’ homes, public transport, and in care settings. Participants described trajectories of harassment and bullying that started from a young age. Schools were often the first space where participants experienced violence’. (Wiseman & Watson 2021) |
What is striking across all three forms of inter-personal violence featured in Table 4 is their depiction in participants’ accounts as normalized within affected communities. Unsurprisingly, in this context, a fear of violence also seemed pervasive, with negative consequences for mental health and physical exercise:
Walking was one of the few health-promoting practices that was considered financially accessible. However, an additional structural constraint – a sense of othering, reinforced by awareness of being audibly foreign, and visibly black, led to restrictions in terms of what ASR [asylum seeker and refugee] participants felt they could engage in outside of their home. Participants recounted racist experiences in their everyday interactions such as going to the local shops and travelling on buses. These encounters then shaped their willingness to partake in ostensibly free, healthy activities such as walking in their local area. Female participants in particular, sought to minimize time outside lest others became suspicious about them. (Isaacs et al. 2020)
Where participants described experiencing targeted harassment and violence in public, in situations where bystanders could have intervened but chose not to, this experience appeared to exacerbate the negative health impacts of violence, reinforcing a sense of being devalued and dehumanized (Wiseman & Watson 2021).
This review explores the contribution that lay accounts can make to understanding health inequalities, social determinants of health and excess mortality in Scotland. Although most qualitative studies are small-scale and focus on the views and experiences of specific communities, the literature has been growing rapidly. This means that, when synthesized, we have a large empirical foundation for understanding public views about – and experiences of – health inequalities and social determinants in Scotland, incorporating the perspectives of diverse social groups across income level, place, gender and age. Here, we outline six key conclusions based on this synthesis.
First, the review shows that members of the public, especially those who have experienced disadvantage, can provide visceral and sophisticated accounts of the interplay between material and social circumstances and health outcomes. These findings align with those of existing reviews of qualitative research from the wider UK (Smith & Anderson 2018) and beyond (Elliott et al. 2016). Yet, they remain important in the context of survey-based claims that there ‘is a mismatch between the public’s perceptions of what influences health (namely individual behaviour and access to care) and the clear evidence base demonstrating the significance of wider determinants of health’ (Kane et al. 2022). Different methodological approaches can reach opposing conclusions about public understanding of the social determinants of health and health inequalities. We therefore propose responding cautiously to calls to correct public misunderstandings by working to tell ‘a more powerful story about health inequalities’ (The Frameworks Institute & The Health Foundation 2022). Indeed, our review highlights the need for researchers and policy actors to do more to listen and learn from disadvantaged communities, including ny paying attention to existing qualitative research. For example, the internationally reproduced ‘rainbow model’ of the social determinants of health (Dahlgren & Whitehead 2007) mentions neither crime nor criminal justice, yet the pervasiveness of violence in people’s accounts of the factors shaing their health suggests these are all important social determinants of health in Scotland and warrant more consideration.
Second, the consistency with which intolerably deep poverty is described demonstrates the limitations of prevalent approaches to measuring poverty (Timpson et al. 2023), including population segmentation into deciles and quintiles. Indeed, our findings support Edmiston’s (2022) call to ‘re-think how we currently conceptualise poverty by better attending to internal heterogeneity within the broader analytical and methodological category of ‘the poor’’.
Third, and relatedly, many of the included studies drew attention to forms of disadvantage and discrimination that are not solely about poverty or deprivation; examples include migration status, ethnicity, gender and sexual identitiy, substance dependency and disability. This points to a need to expand the dominant focus on socio-economic and area-based health inequalities in Scotland. Indeed, some more recent studies are already demonstrating the value of acknowledging multiple, intersecting axes of inequalities (e.g., De Andrade 2016, Kapilashrami & Marsden 2018, Lorimer et al. 2018). There are also specific groups for whom research in Scotland is lacking, including: racialised minorities (in the 2011 census, minority ethnic groups accounted for 10-18% of the population in Scotland’s cities, where most health inequalities research focuses); people with disabilities (just under a third of the Scottish population and 43% of those in the most deprived quintile, according to the 2017 Scottish Health Survey); and people living in rural areas (around 17% of the Scottish population (Scottish Government 2021)).
Fourth, psychosocial explanations of health inequalities might be best understood as pathways connecting material factors to health outcomes. Scholars, not least in Critical Public Health (Green 2014) have argued that a focus on quantitative evidence in public health, especially from randomised controlled trials, can narrow debates on population health and focus attention on downstream interventions. We proposed a parallel risk that, if psychosocial pathways are presented as determinants, this may distract from underlying structural factors generating and entrenching inequalities.
Fifth, the findings support the idea that a sense of ‘political attack’ plays a role in Scotland’s poor health outcomes (McCartney et al. 2011, 2012) and we identify five contributing sources which we described above. Despite the intentions of many who work in public policy, the experience of political attack implicates macro-level policy decisions It is sobering to note that 25 years of political devolution appears to have done little to address a perceived lack of political representation within Scotland’s most disadvantaged communities. However, this sense of being ‘under attack’ is mediated by a broad range of other actors, including the ‘street-level bureaucrats’ who implement policies, and an array of individuals and organisations who are depicted as profiting from people’s desperation. Neither the concept of ‘political attack’ nor public health’s notion of ‘commercial determinants of health’ quite captures the diversity of inter-connected organisations and individuals that feature in people’s accounts. Researchers may need to move beyond national level policy analyses to examine those who work to influence policies and who benefit from policies with unequal impacts (Sayer and McCartney 2021), and to better understand local implementation experiences.
Sixth, across people’s accounts of how social determinants of health matter, the importance of history (of people and places) and narratives emerge; while historical experiences can cast a long shadow, via inter-generational trauma and privilege, narratives shape what people believe about themselves, about others, and about the past and the future. To better understand social determinants of health and to effect positive change, we need to examine the historical dimensions of places and communities, and design policies and interventions with historical trauma and cumulative disadvantage in mind. As well as critically engaging with narratives of blame and despair, we should also explore alternative narratives of hope. It is notable that people’s accounts of positive historical moments were often tied to a sense of opportunity, and effective political leadership within communities (Garnham 2015, 2017).
Rather than cast publics as audiences to be re-educated, this review demonstrates the value of grounding both diagnosis and prescriptions for a more equal future in the experiential knowledge of people living with experience of social and economic disadvantage. This involves researchers and policymakers working with the communities most negatively affected by Scotland’s poor health outcomes to better understand their experiences and to co-develop policies and interventions. This recommendation is not innovative; indeed, it aligns with existing high-profile policy reports in Scotland (e.g., Christie Commission 2011). Yet, it requires public health to relinquish an attachment to a hierarchy of evidence that pays low regard to qualitative research; it also requires responses that take serious aim at inequalities in wealth, power and political voice. Without such a shift, researchers and policymakers risk failing to adequately understand the experiences of Scotland’s disadvantaged communities, while unintentionally exacerbating inequalities in political voice.
The authors gratefully acknowledge work done by Dr Rosemary Anderson on the initial meta-ethnography published in 2018, and feedback received from members of the Expert Advisory Group of the 2022-2023 Health Foundation review of health inequalities in Scotland, as well as more detailed feedback from Professor Gerald McCartney and Dr David Walsh.
The University of Strathclyde School of Social Work received funding from The Health Foundation for the authors (KS & ES) to undertake a review of qualitative literature on health inequalities and the social determinants in Scotland. Both authors are also currently supported by funding from the UK Prevention Research Partnership (MR/S037578/1), the System-science Informed Public Health and Health Economic Research (SIPHER) Consortium. Smith is also supported by the UK Prevention Research Partnership SPECTRUM Consortium (MR/ S037519/1). The UK Prevention Research Partnership is funded by the British Heart Foundation, Cancer Research UK, Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Health and Social Care Research and Development Division (Welsh Government), Medical Research Council, National Institute for Health Research, Natural Environment Research Council, Public Health Agency (Northern Ireland), The Health Foundation and Wellcome Trust. Stewart is also supported by a Wellcome Trust Collaborative Award in Humanities and Social Science (219901/D/19/Z).
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Journal of Critical Public Health, Volume 1, Issue 2