Dr Victoria J. McGowan (2025)
Social Science & Medicine
Abstract
Health inequities are avoidable and unjust differences in health arising from how society and the economy are structured. These inequalities are driven by vertical political and economic systems that prioritise economic growth over wellbeing. Yet, empirical research on health inequalities often focuses horizontally on people, places, and their inter-relationships. This research adopts a vertical lens to examine the structural processes driving geographical inequalities in health, framing housing as an extractive industry that contributes to ill-health and inequality. Drawing on comparative ethnography across four English coastal towns, Hartlepool, Blackpool, Hastings, and Torbay, where deprivation, health and social inequalities are among the most severe in the country, the research involved 4-6 weeks of immersive fieldwork in each site during 2023. Data collection involved in-depth interviews, walking interviews, and focus groups with 140 people living/working in these towns, supported by participant observation, field notes, documentary analysis, and photography. This paper will focus on participants discussions around housing as a major determinant of poor health and inequalities in their towns. Findings highlight vertical mechanisms such as ‘Right-to-Buy legislation, extractive wealth practices of private landlords, substandard housing conditions, financial strain, and housing insecurity in driving physical and mental ill-health. By highlighting the intersection of housing, the political economy, and health inequalities this study demonstrates the importance of ‘scaling-up’ our analyses to identify vertical processes which undermine horizontal efforts to reduce inequalities in health. Further examination of these dynamics, covering other determinants of health, is necessary to support the development of policies that go beyond mitigating health inequalities but also tackle the vertical structures that sustain them.
Dr Tim Price, Dr Victoria J. McGowan (2025)
Social Science & Medicine
Abstract
Health inequalities are a form of violence, produced and sustained by political, economic, and social structures that systematically disadvantage certain communities. Drawing on qualitative data from 194 participants in six English towns, this study develops the Cycle of Social Violence, a novel theoretical framework that conceptualises how structural, slow, and symbolic violence interact to create and perpetuate health inequalities. Participants' narratives illustrate how structural violence, driven by neoliberal economic policies creates the material conditions for poor health. These harms unfold over time as slow violence, extending their impacts and making their effects difficult to trace to specific causes. Symbolic violence then legitimises and obscures these injustices, reinforcing narratives that blame individuals rather than structural forces. The interaction of these three forms of violence produces a self-perpetuating cycle that deepens inequalities and erodes resistance to systemic harm. This study highlights how these dynamics manifest in deindustrialised and economically deprived communities, where declining public services, insecure work, and stigma reinforce poor health outcomes. Breaking the cycle of social violence requires policy interventions that incorporate the lived experience of people in affected communities and that go beyond surface-level regeneration to address the root causes of economic and social deprivation.
Dr Tim Price (2025)
Social Science & Medicine
Abstract
This paper examines how symbolic violence contributes to the persistence of geographic inequalities in deaths of despair (DoD), those from drug, suicide, and alcohol-specific mortality, in two deindustrialised towns in North East England. Although there is evidence that DoD are driven by structural determinants, such as economic policies, inadequate social safety nets, and poverty, less is known about how these determinants are ideologically obscured. Drawing on qualitative data collected from 30 residents of Middlesbrough and South Tyneside, two towns with above average rates of DoD, the analysis explores how symbolic violence, in the form of moralisation, stigma, and downstream interventions, frames behaviours as individual failings, downplays structural determinants, and sustains inaction while maintaining the appearance of intervention. By diverting attention away from the root causes of DoD, symbolic violence functions as a mechanism through which these inequalities are reproduced. By highlighting the cultural and ideological processes that allow structural determinants to go unaddressed, this study deepens our understanding of how inequalities in these deaths are sustained and legitimised in marginalised places. The findings point to the need for future interventions to not only improve material conditions but also critically engage with the symbolic forces that reinforce geographic disparities in DoD.
Dr Tim Price (2025)
American Journal of Men's Health
Abstract
This qualitative study explores the factors contributing to gender-based inequalities in “deaths of despair” (DoD) – those deaths from suicide, drug overdoses, and alcohol-specific causes – among men in two deindustrialised towns in North East England. Understanding gender-based disparities in these causes of death sheds important light on how social and economic factors intersect with certain facets of masculinity, such as stoicism and self-reliance, to drive vulnerability. Data were collected through semi-structured interviews and one focus group with 54 stakeholders – people whose work is related to DoD, such as mental health treatment and public health practice – and community members in Middlesbrough and South Tyneside, two towns with above average rates of DoD. Participants included both men and women, predominantly of middle-age or older, with most participants unemployed or retired. Data were analysed using Iterative Categorisation, with findings interpreted through thematic analysis. The study generated three key themes: industrial history and masculinity, masculinity and class, and masculinity as a barrier to help-seeking. The findings demonstrate that economic decline following deindustrialisation resulted in distress and created unique risk factors for substance use and self-harm for men. These results suggest that effective interventions to reduce DoD among men in post-industrial settings must avoid pathologising masculinity itself. Instead, strategies should focus on the broader structural forces that undermine men’s access to stable, fulfilling employment and offering forms of support that are compatible with masculine identity. By addressing these determinants, interventions can more effectively close gender-based inequalities and reduce the rate of DoD in deindustrialised areas.
Dr Julija Simpson, Dr Viviana Albani, Dr Luke Munford, Professor Clare Bambra (2025)
Health & Place
Abstract
Geographical inequalities in health are substantial and increasing in many countries. In England, there is a life expectancy gap amongst the 20 % most deprived local authorities – between those in the northern regions and those in the rest of the country. We sought to quantify the size and evolution of this gap and to investigate potential contributing factors.
We used data from official national statistics covering years 2004–2020 for the 20 % most deprived local authorities in England, divided into north and rest of England. We conducted a Blinder-Oaxaca decomposition which quantified the size of the life expectancy gap for both men and women and identified the key contributing factors drawing on ‘deprivation amplification’ concept and other theories of health inequalities.
We have found that there is a long-standing and widening gap in life expectancy between local authorities in the north and the rest of England. The gap is greater for women than for men (11.7 vs. 7.0 months on average); the widening of the gap over the past two decades has also been greater for women. Our decomposition analysis indicates that regional differences in income are the main contributor to this gap for both men and women (explaining 69 % and 44 % of the gap, respectively), with behavioural factors such as smoking having no explanatory power.
Overall, our findings suggest that providing additional income-based resources to areas lagging behind in life expectancy may be an effective way of reducing place-based health inequalities both in England and in similar regionally imbalanced economies.
Dr Kate Bernard, Dr Victoria J McGowan, Professor Clare Bambra (2024)
Social Science & Medicine
Abstract
People in the North of England live shorter, less healthy lives than those in the South. Despite the significance of this ‘North South health divide’, regional health inequalities in England are under-researched qualitatively. Existing literature on geographical inequalities in health is largely confined to the neighbourhood level, is quantitative, and consists of very little lay knowledge. The current study is the first to examine lay perspectives of health inequalities on a regional level: exploring how people living in two urban areas of the North and South of England experience and perceive the North South health divide – including its causes and solutions. Using three focus group discussions with a total of 34 participants, and conducting participatory analysis, we identified three key themes: ‘inequalities of power’, ‘lack of control over lived environment’ and ‘communities under strain’. Findings align with existing research on lay perspectives of health inequalities at the neighbourhood level – identifying a network of material-structural and psychosocial factors. Participants across both regions discussed political and economic structures as central to understanding regional health inequalities, supporting calls to adopt a political economy approach in understanding health and place. Deindustrialisation, unemployment, loss of community facilities, and disengagement from politics were more present in Northern narratives than Southern. Findings add important ‘social meaning’ to emerging research on the North South health divide, reinforcing the urgency of public health professionals' recommendations for fair redistribution of power, wealth and resources to reduce regional health inequalities. In the context of government policy which diverges from public health evidence, this study sparks questions of how health inequalities research can intersect with wider social and political movements organising for systemic change.
Dr Tim Price, Dr Victoria J McGowan, Dr Shelina Visram, Professor John Wildman, Professor Clare Bambra (2024)
Health & Place
Abstract
The rise in mortality in high-income countries from drug, suicide, and alcohol specific causes, referred to collectively as ‘deaths of despair’, has received growing interest from researchers. In both the US and UK, mortality rates from deaths of despair are higher in deprived, deindustrialised communities. In this qualitative study, we sought to learn how stakeholders working with vulnerable populations in Middlesbrough, a deindustrialised town in North East England with above average mortality from deaths of despair, understand and explain the prevalence of deaths from these causes in their area. Participants identified a number of structural and socio-cultural determinants that they believe drive deaths of despair in their community, including the effects of austerity, deindustrialisation, communal identity, and collective trauma; we argue that these determinants are themselves a product of structural violence.
Dr Julija Simpson, Dr Viviana Albani, Dr Andrew Kingston, Professor Clare Bambra (2024)
Social Science & Medicine
Abstract
Regional health inequalities are rising globally. The case of German reunification offers a unique opportunity to explore how such inequalities can be reduced, or even eliminated: following reunification, a long-standing life expectancy gap between East and West Germany was closed for women and markedly reduced for men in less than 15 years.
We used data from official national statistics covering the period 1994–2020 for 15 regions in East and West Germany. Using fixed-effects models with an interaction term for regions in the East, we investigated whether within-region changes in key hypothesised factors (social security expenditure, healthcare improvements, changes in alcohol consumption, and life satisfaction), have had differential impacts on life expectancy at birth and at 65 years.
Our results show that increases in social security benefits in the East following reunification has been the most important factor for lowering inequalities between the two parts of Germany: for every 10% increase in social security benefits, life expectancy at birth increased by an additional 1.05 [0.68; 1.41] months for males and by 0.57 [0.18; 0.97] months for females in East relative to West Germany. We find the protective effect of social security benefits also for women at 65 years (additional 0.38 [0.06; 0.70] months) but not for men.
Our findings suggest that increasing social security expenditure could be an effective policy tool for reducing health inequalities across regions with different levels of economic development. This provides additional support for the materialist hypothesis and the political economy theory of the root causes of health inequalities.