Moving beyond individual choice in policies to reduce health inequalities: the integration of dynamic with individual explanations

N M Kriznik, A L Kinmonth, T Ling, M P Kelly

A strong focus on individual choice and behaviour informs interventions designed to reduce health inequalities in the UK. We review evidence for wider mechanisms from a range of disciplines, demonstrate that they are not yet impacting on programmes, and argue for their systematic inclusion in policy and research. We identified potential mechanisms relevant to health inequalities and their amelioration from different disciplines and analysed six policy documents published between 1976 and 2010 using Bacchi's 'What's the problem represented to be?' framework for policy analysis. We found substantial evidence of supra-individualistic and relational mechanisms relevant to health inequalities from sociology, history, biology, neuroscience, philosophy and psychology. Policy documents sometimes expressed these mechanisms in policy rhetoric but rarely in policy recommendations, which continue to focus on individual behaviour. Current evidence points to the potential of systematically applying broader thinking about causal mechanisms, beyond individual choice and responsibility, to the design, implementation and evaluation of policies to reduce health inequalities. We provide a set of questions designed to enable critique of policy discussions and programmes to ensure that these wider mechanisms are considered.