The Inequality Paradox, Equity Harms and Dark Logic Models Health interventions will often have unintended or adverse consequences which take a variety of forms. For example, continuously emphasising the benefits associated with a slim and toned body is liable to lead some people to develop eating disorders while it has also been shown that public health campaigns that stigmatised the HIV virus led to some gay men actively seeking to become infected with the virus in order to rebelliously claim a collective identity. On a smaller scale, there is a choking hazard involved in distributing condoms to school children for the purposes of sex education. Some of these adverse effects are inevitable and just have to be managed while others may just be unintended and could perhaps be avoided if the interventions were designed and implemented differently. Bonell et al (2014: 3) argue that currently these adverse effects are largely ignored and thus need far more attention directed towards them. These authors advocate developing models and theories which can be used to ‘anticipate the most plausible and most harmful unintended harmful impacts and associated mechanisms’ of health interventions and therefore to guard against them. They term these ‘dark logic models’. A central focus of my research is the impact that health policies and interventions have on health inequalities. Specifically, my main concern is how health policies and interventions influence the gap between more and less affluent groups in society: do they increase the ‘health gap’ or reduce it? Research has demonstrated that if interventions do not target and support specific vulnerable groups, e.g., unemployed, low income families, single parents, etc., they are likely to increase the health gap. This is known as the ‘inequality paradox’. In simplistic terms, it is a paradox because an intervention expected to have positive outcomes has a negative one by increasing inequality. A simple example would be an intervention designed to promote healthy eating by giving away free bananas at a supermarket. Research has shown that those most able and therefore likely to engage with such an intervention tend to come from more affluent sectors of society while the participation of vulnerable populations tends to be far more restricted. This means that as a result of this intervention it is likely that the health of more affluent groups increases (because they are eating more fruit) while the status quo is maintained within the vulnerable populations (because their situation has not changed). This is particularly problematic because vulnerable populations include those people most in need. Lorenc and Oliver (2014) describe these sorts of negative intervention outcomes as ‘equity harms’. They term them this because it is possible to argue that the intervention did not actually cause any direct harm: the health of more affluent people increased while the health of vulnerable populations stayed the same. However, they are harmful because by not recognising that some groups in society need more support than others in order to participate in health interventions they are liable to increase the health gap and thus reproduce the inequality paradox. The health interventions most likely to reproduce these harmful consequences are those which shift responsibility to the individual without offering adequate support, e.g., simply publicising the negative health effects associated with inactivity. I argue that we should no longer defend interventions that may have no negative health outcomes per se but increase health inequalities. This is because we now have convincing evidence demonstrating that the experience of living in an unequal society in and of itself has a detrimental effect on almost everybody’s health in that society: people living in more equal societies tend to experience better health relative to their level of wealth. Therefore, we need to ensure that suitable dark logic models influence the design of health interventions so that they do not reproduce the inequality paradox and thus create equity harms. If we do not achieve this goal then the nation as a whole is liable to suffer poorer levels of health.
DEADLINE: 29/1/16
CONTACT OLI: o.s.williams@bath.ac.uk