Theorising inequalities in health: the place of lay knowledge

This paper contributes to the development of theory and research on inequalities in health. Our central premise is that these are currently limited because they fail adequately to address the relationship between agency and structure, and that lay knowledge in the form of narrative has a significant contribution to make to this endeavour. The paper is divided into three sections. In the first section we briefly review the existing, largely quantitative research on inequalities in health. We then move on to consider some of the most significant critiques of this body of work highlighting three issues: the pursuit of overly simple unidimensional explanations within 'risk factor' epidemiology and the (probably inevitable) inability of this research tradition to encompass the full complexity of social processes; the failure to consider the social context of individual behaviour and, in particular, the possibility for, and determinants of, creative human agency; and, thirdly, the need for 'place' and 'time' (both historical and biographical) to be given greater theoretical prominence. In the final section of the paper the potential theoretical significance of 'place' and 'lay knowledge', and the relationship between these concepts, in inequalities research is explored. Here we suggest three developments as a necessary condition for a more adequate theoretical framework in this field. We consider first the need for the conceptualisation and measurement of 'place' within a historical context, as the location in which macro social structures impact on people's lives. Second, we argue for a re-conceptualisation of lay knowledge about everyday life in general and the nature and causes of health and illness in particular, as narratives which have embedded within them explanations for what people do and why - and which, in turn, shape social action. Finally, we suggest that this narrative knowledge is also the medium through which people locate themselves within the places they inhabit and determine how to act within and upon them. Lay knowledge therefore offers a vitally important but neglected perspective on the relationship between social context and the experience of health and illness at the individual and population level.